Clinical Insights About Onychomycosis and Its Treatment: A Consensus.

BACKGROUND: Recently, experience and knowledge have been gained using effective topical treatment for onychomycosis, a difficult-to-treat infection. METHODS: This project aims to help understand and improve patient-focused quality of care for fungal nail infections. A panel of dermatologists who treat onychomycosis convened on several occasions to review and discuss recent learnings in the treatment of onychomycosis. The panel developed and conducted a survey on diagnosis, treatment and prevention, discussed the results, and provided recommendations. RESULTS: The survey was sent out digitally to the Canadian Dermatology community. Ninety-two dermatologists completed the questionnaires, which were included in the analysis. The survey respondents and panel members agreed that the diagnosis of toe onychomycosis should be confirmed with a positive microscopic examination for fungus or a positive mycological culture when oral therapy and/or topical treatment is prescribed, except when it is not clinically feasible, in which case topical therapy could be started based on clinical presentation. The panel and survey respondents also agreed that treatment is to be based on percentage of nail involvement: less than 20%=topical efinaconazole; 20%-60%=topical efinaconazole±oral terbinafine (for greater than 3 nails); greater than 60%=oral terbinafine±topical therapy. CONCLUSIONS: The current treatment paradigm for onychomycosis may have shifted from mainly oral antifungals to topical treatment, improving patient-focused quality of care.

J Drugs Dermatol. 2018;17(3):253-262.

Current Concepts in the Use of Small-Particle Hyaluronic Acid.

BACKGROUND: Soft-tissue augmentation with hyaluronic acid (HA) fillers has become one of the most popular cosmetic procedures performed. HA fillers represent safe and commonly used fillers. Several different HA fillers are available. The differences lie in the manufacturing process, allowing for tailored uses. A small-particle HA with lidocaine (SP-HAL; Restylane Silk; Galderma, Uppsala, Sweden) was approved by the US Food and Drug Administration in June 2014 but has been available for many years in Canada as Restylane Fine Lines and in Europe as Restylane Vital. METHODS: Relevant articles were reviewed relating to the composition, effectiveness, and safety of SP-HAL. We also discuss the author's extensive clinical experience in the use of this product in Canada. RESULTS: SP-HAL has demonstrated proven benefits for lip fullness, augmentation, and treatment of perioral rhytides. Although off-label in the United States, SP-HAL is also well suited for the treatment of superficial fine lines, including periorbital, forehead, marionette, and smile lines. In addition, it has also been used in the tear trough region. A novel application for SP-HAL includes use as a skinbooster with intradermal micropuncture. In this technique, small aliquots of product are injected so as to gradually rejuvenate the skin in areas such as the face and hands. Side effects of SP-HAL were generally transient and mild. The most common side effects were swelling, tenderness, bruising, pain, and redness. CONCLUSION: SP-HAL is an effective and safe HA filler with varied clinical uses.

Burning mouth syndrome: patch test results from a large case series.

BACKGROUND: Burning mouth syndrome (BMS) is a burning or sore mouth in the absence of changes in the oral mucosa. It is often difficult to diagnose and treat. Numerous theories of the etiology have been suggested, including contact allergy. OBJECTIVE: To determine the clinical utility of patch testing in patients with BMS. METHODS: We retrospectively reviewed the charts of patients diagnosed with BMS who had patch testing performed between January 1, 2008, and July 31, 2012. RESULTS: Of 142 consecutive patients with BMS, 132 consented to patch testing; 89 (67%) had allergic patch test reactions. Of the patients with positive results, 66 (74%) had results that were deemed to have possible relevance. The most common allergens detected were nickel sulfate 2.5%, dodecyl gallate 0.3%, octyl gallate 0.3%, fragrance mix 8%, benzoyl peroxide 1%, and cinnamic alcohol 1%. CONCLUSIONS: Our findings suggest that contact allergy may be an etiologic factor in some patients with BMS. Patch testing is a useful investigation for BMS patients.

Periorbital surface anatomy for the dermatologist.

BACKGROUND: Optimal management of skin pathology demands accurate anatomic description, especially in the orbit and periorbital region. CASE REPORT: This brief article reviews the clinically important surface anatomy of the orbit and periorbital region for the dermatologist.

Cutaneous and respiratory symptoms among professional cleaners.

BACKGROUND: Occupational dermatitis is very common and has a large economic impact. Cleaners are at an increased risk for both work-related cutaneous and respiratory symptoms. AIMS: To compare the prevalence of occupational cutaneous symptoms among professional indoor cleaners to other building workers (OBW) and to determine associations with exposures and with respiratory symptoms among cleaners. METHODS: A questionnaire completed by indoor professional cleaners and OBW to compare rash and respiratory symptoms between these groups examined workplace factors such as training, protective equipment and work tasks. RESULTS: In total, 549 of the 1396 professional cleaners (39%) and 593 of the 1271 OBW (47%) completed questionnaires. The prevalence of rash was significantly higher in the cleaners compared to the OBW. For male cleaners, 21% (86/413) had a rash in the past 12 months compared to only 11% (13/115) of OBW (P < 0.05). The rashes experienced by the cleaners were more likely to be on their hands and worse at work. Cleaners washed their hands significantly more often than OBW. Cleaners with a rash were less likely to have received workplace training regarding their skin and were more likely to find the safety training hard to understand. Cleaners with a rash within the past year were significantly more likely to have work-related asthma symptoms than cleaners without a rash (P < 0.001). CONCLUSIONS: This study demonstrates a strong link between work-related symptoms of asthma and dermatitis among cleaners. Effective preventive measures, such as the use of protective skin and respiratory equipment, should be emphasized.

Successful treatment of complex aphthosis with colchicine and dapsone.

OBJECTIVE: To investigate the effectiveness of colchicine and dapsone, 2 corticosteroid-sparing anti-inflammatory agents, in the treatment of patients with complex aphthosis (recurrent oral and genital aphthous ulcers or severe, almost constant, multiple oral aphthae in the absence of Behçet syndrome). DESIGN: Retrospective review of medical records. SETTING: Tertiary care medical clinic. PATIENTS: Fifty-five patients with complex aphthosis evaluated and treated at Mayo Clinic between January 1, 1998, and July 31, 2007. All the patients were treated according to a therapeutic ladder, starting with colchicine and adding dapsone to treatment of patients who did not have a substantial response (>75% improvement) to colchicine or who discontinued colchicine use because of adverse effects. MAIN OUTCOME MEASURES: A substantial response to therapy with colchicine alone, dapsone alone, or colchicine and dapsone combined. RESULTS: Most patients (44 [80%]) had a substantial response to therapy and had no serious adverse effects. CONCLUSIONS: Colchicine and dapsone are effective, safe therapies for the treatment of complex aphthosis. Colchicine and dapsone, 2 established drugs also used for gout and leprosy, respectively, and for other dermatologic disorders, should be considered efficacious in the treatment of complex aphthosis.