Mesotherapy With Dutasteride for Androgenetic Alopecia: A Retrospective Study in Real Clinical Practice.

BACKGROUND: 5-alpha inhibitors are an effective treatment for androgenetic alopecia. Mesotherapy with dutasteride has been proposed as an effective method to improve hair loss and reducing systemic absorption. OBJECTIVE: The main objective was to describe the safety profile of mesotherapy with dutasteride in real clinical practice in a large cohort of patients with androgenetic alopecia. A secondary aim was to describe the effectiveness of this treatment. METHODS AND MATERIALS: A multicentric retrospective study was designed. Patients treated with at least 6 months of follow-up were included in the study. Side effects and response to the treatment were analyzed. RESULTS: A total of 541 patients were included. The commonest approach during the first year was to perform the treatment every 3 months. Response to the mesotherapy in monotherapy could be assessed in 86 patients (15.9%) after one year. Most of them presented clinical improvement, being a marked improvement in 33 patients (38.4%). Pain was the most frequent side effect of the treatment (246 patients, 45.5%). No serious or sexual adverse events were detected. CONCLUSION: Mesotherapy with dutasteride was effective in male and female hair loss in real clinical practice. Side effects related to the treatment were mild and self-limited. This therapy may be an effective option for select patients wishing to avoid oral treatment. J Drugs Dermatol. 2022;21(7):742-747. doi:10.36849/JDD.6610.

Needle Manufacturing, Quality Control, and Optimization for Patient Comfort.

INTRODUCTION: There is an increasing rise of cosmetic injectables. We sought to understand the manufacturing, quality control process, and needle selection of hypodermic needles for fillers. OBJECTIVE: To understand the process of manufacturing and quality control of hypodermic needles and the relevance to an aesthetic clinician. METHODS: We conducted a search of the internet and contacted medical device companies to understand the manufacturing process. We then collaborated with the Executive director of global pharmaceutical technology from Abbvie as well as the packaging and device engineer at Galderma and summarized our findings. Finally, we reviewed the literature and summarized existing recommendations on techniques to minimize pain related to injection. RESULTS: Hypodermic needles undergo an extensive manufacturing and regulatory process. Many considerations are taken into account in needle manufacturing as well as the selection process with commercially available hyaluronic acid filler products. Needle manufacturers are held to universal standards though the International Organization for Standardization (ISO). Filler companies perform their own testing to evaluate suitability of needles for their product including leakage force, penetration force, extrusion force, etc. Finally, parameters such as needle length, needle diameter, and wall thickness are considered for selection of needle/hub with individual filler viscosity. CONCLUSION: There is extensive consideration that goes into needle manufacturing, quality control, and optimization for hyaluronic acid filler. Understanding the technical process helps inform the clinician and guide patient care for maximum comfort. J Drugs Dermatol. 2021;20(1):44-48. doi:10.36849/JDD.5591.

Ablative fractional laser treatment of hypertrophic burn and traumatic scars: a systematic review of the literature.

Hypertrophic scars (HTS) following burns and other trauma and are associated with significant functional and psychosocial impairment. Ablative fractional lasers (AFLs) are increasingly being applied in the treatment of HTS supported by a rapidly expanding multidisciplinary base of literature. The multidisciplinary authors sought to evaluate existing literature, provide context and identify gaps, and make recommendations for a path forward. A systematic review was conducted to identify literature pertinent literature through September 2019. Retrospective cohort, randomized controlled trials, quasi-randomized controlled trials, observational prospective cohort, or case series with five or more subjects with hypertrophic scars incurred from burns and related trauma were considered. Twenty-two of the 23 evaluated studies documented statistically significant and/or meaningful qualitative improvements in nearly all outcome measures. Adverse events were generally infrequent and minor. Significant heterogeneity was observed among the studies included in this systematic review, precluding metaanalysis of pooled data. There is abundant existing literature on the use of AFLs in the management of HTS but study heterogeneity limits generalizability. Future studies should prioritize standardized protocols including assessments of function and quality of life.

Cutaneous Photoaging: A Notable Pattern of Distribution of Lentigines on the Face.

Importance: Facial lentigines are a common patient complaint encountered in general and cosmetic dermatology practices. Lentigines are a marker of photoaging and understanding their distribution will provide insight into the aging process in order to better counsel patients. Objectives: To compare the relative distribution of lentigines in facial cosmetic subunits. Methods: We reviewed clinical photographs of patients receiving Alexandrite laser treatment for facial lentigines during the time period 11/1/2017-12/1/2018. Individual lentigines were plotted for each patient into one of 21 aesthetic units. A "heat map" was created to compare the relative density of these lesions. Results: Grouped peripheral cosmetic subunits contained more lentigines compared to grouped central cosmetic units. The mean number of lentigines in the central units was 0.60 and in the peripheral units was 0.85. This finding was statistically significant with a p value of 0.0001. J Drugs Dermatol. 2020;19(7): doi:10.36849/JDD.2020.5193.

Recurrence of Herpes Zoster Infection in the Setting of Topical Immunosuppression for Erosive Pustular Dermatosis of the Scalp.

We present a unique patient with erosive pustular dermatosis of the scalp (EPDS) with several unique features: (1) a rare case of EPDS occurring after herpes zoster (HZ) infection and (2) the first reported case of recurrence of HZ induced by topical immunosuppressive therapy (clobetasol 0.05% cream and tacrolimus 0.01% cream) in a patient with underlying EPDS. Based on our patient, we recommend to exercise caution with the prolonged use of potent topical steroids in areas previously affected by herpes zoster.

Successful Treatment of Cosmetic Eyebrow Tattoos in Fitzpatrick III-IV With Picosecond (1,064, 532-nm) Neodymium-Doped Yttrium Aluminum Garnet Laser With a Perfluorodecalin-Infused Patch: A Pilot Study.

BACKGROUND AND OBJECTIVES: Nanosecond Q-switched lasers have been used for the removal of traditional and cosmetic tattoos. Picosecond lasers utilize pulse durations of 10-12 and provide more efficient clearance of tattoos. Safe and effective removal of tattoos is especially important in cosmetically sensitive areas such as the face. We report four patients with skin types (III-IV) who have had successful removal of eyebrow tattoos with the picosecond (1,064-, 532-nm) laser using a perfluorodecalin-infused patch (PFD). STUDY DESIGN/MATERIALS AND METHODS: Patients with eyebrow tattoos underwent treatment with dual-wavelength picosecond Nd:YAG laser at 1,064-nm with a 3 mm spot size and fluence of 4-4.6 J/cm2 . The 532-nm wavelength was also used during treatment #1 (patient 2 only) with a 4 mm spot size and fluence of 0.5 J/cm2 . Patient 1 had a total of three treatments (6-8 weeks apart). The remaining patients, each had only one treatment. Patients were photographed prior to treatment and subsequently at each follow-up. RESULTS: Immediately following each laser treatment, only mild and transient localized erythema and edema was observed. Some epidermal crusting was noted for 3-5 days following each treatment. Eyebrow hair growth was not affected and no adverse events were reported. There was 75% clearance in patient 1 after three treatments over a period of 2.5 months, 75% clearance in patient 2 after one treatment, 90% clearance in patient 3 after one treatment, and 100% clearance in patient 4 after one treatment. CONCLUSIONS: The 532- and 1,064-nm wavelength of the picosecond Nd:YAG laser was safely used to clear brown and black ink eyebrow tattoos in four patients, three of whom were skin type IV, and one of whom underwent eyebrow tattoo via microblading, a novel and popular technique for cosmetic tattoos. The use of picosecond laser provides several treatment advantages to Q-switched laser when treating eyebrow tattoos. In our experience, it required less number of treatments and lower fluences. This, along with use of the perfluorodecalin-infused patch resulted in excellent outcomes for our patients with no significant side effects. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Trichoscopy of Scalp Metastases.

A 69-year-old woman with invasive ductal breast cancer (BC) presented multiple asymptomatic alopecic areas of the scalp. Trichoscopy revealed peripheral black dots (BDs) and an atypical vascular pattern. Histopathology confirmed the diagnosis of BC metastases. Cutaneous and scalp metastases are a possible sign of advanced and widespread BC, and the diagnosis may be challenging. The trichoscopy of scalp metastases has never been described. BDs and an atypical vascular pattern in our case were a diagnostic clue.

Treatments of Primary Basal Cell Carcinoma of the Skin: A Systematic Review and Network Meta-analysis.

Background: Most interventions for basal cell carcinoma (BCC) have not been compared in head-to-head randomized trials. Purpose: To evaluate the comparative effectiveness and safety of treatments of primary BCC in adults. Data Sources: English-language searches of MEDLINE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Embase from inception to May 2018; reference lists of guidelines and systematic reviews; and a search of ClinicalTrials.gov in August 2016. Study Selection: Comparative studies of treatments currently used in adults with primary BCC. Data Extraction: One investigator extracted data on recurrence, histologic clearance, clinical clearance, cosmetic outcomes, quality of life, and mortality, and a second reviewer verified extractions. Several investigators evaluated risk of bias for each study. Data Synthesis: Forty randomized trials and 5 nonrandomized studies compared 18 interventions in 9 categories. Relative intervention effects and mean outcome frequencies were estimated using frequentist network meta-analyses. Estimated recurrence rates were similar for excision (3.8% [95% CI, 1.5% to 9.5%]), Mohs surgery (3.8% [CI, 0.7% to 18.2%]), curettage and diathermy (6.9% [CI, 0.9% to 36.6%]), and external-beam radiation (3.5% [CI, 0.7% to 16.8%]). Recurrence rates were higher for cryotherapy (22.3% [CI, 10.2% to 42.0%]), curettage and cryotherapy (19.9% [CI, 4.6% to 56.1%]), 5-fluorouracil (18.8% [CI, 10.1% to 32.5%]), imiquimod (14.1% [CI, 5.4% to 32.4%]), and photodynamic therapy using methyl-aminolevulinic acid (18.8% [CI, 10.1% to 32.5%]) or aminolevulinic acid (16.6% [CI, 7.5% to 32.8%]). The proportion of patients reporting good or better cosmetic outcomes was better for photodynamic therapy using methyl-aminolevulinic acid (93.8% [CI, 79.2% to 98.3%]) or aminolevulinic acid (95.8% [CI, 84.2% to 99.0%]) than for excision (77.8% [CI, 44.8% to 93.8%]) or cryotherapy (51.1% [CI, 15.8% to 85.4%]). Data on quality of life and mortality were too sparse for quantitative synthesis. Limitation: Data are sparse, and effect estimates are imprecise and informed by indirect comparisons. Conclusion: Surgical treatments and external-beam radiation have low recurrence rates for the treatment of low-risk BCC, but substantial uncertainty exists about their comparative effectiveness versus other treatments. Gaps remain regarding high-risk BCC subtypes and important outcomes, including costs. Primary Funding Source: Agency for Healthcare Research and Quality. (PROSPERO: CRD42016043353).

A Pilot Study Characterizing Factors in Adherence to Cutaneous Lupus Treatment.

Cutaneous lupus erythematosus (CLE) is an autoimmune skin disease that manifests as scarring, dyspigmentation, erythema, and pain. Topical corticosteroids are a mainstay of treatment. Irritation, messiness, and tediousness may deter use. Thus, nonadherence, rather than nonresponse, can result in treatment failure. Prior adherence studies were limited to systemic lupus erythematosus. We performed a single-center, open-label pilot study to assess adherence to topical medication in patients with CLE. CLE adherence to topical medications is suboptimal and declines over time. Shorter treatment duration and greater patient perception of disease severity may contribute to higher adherence. Improving adherence to existing treatments could be as or more valuable than new therapies for the disease.

Cardiovascular Disease Outcomes Associated with Three Major Inflammatory Dermatologic Diseases: A Propensity-Matched Case Control Study.

INTRODUCTION: Inflammation is an established component of cardiovascular disease (CVD) and an underlying factor of several dermatologic conditions including rosacea, atopic dermatitis, and psoriasis. Identifying potential associations between these dermatologic and cardiovascular diseases can better inform holistic healthcare approaches. The objective of this study was to determine whether rosacea, psoriasis or atopic dermatitis are independent risk factors for CVD 1 year following diagnosis. METHODS: Using a large commercial claims database of 21,801,147 lives, we employed a propensity-matched logistic regression to evaluate the association between diagnoses of rosacea, psoriasis, or atopic dermatitis and a 1-year risk of being diagnosed with cardiovascular disease. Control patients were matched based on health-care utilization, age and overall health status as defined by a modified Deyo-Charlson comorbidity index. RESULTS: The analysis included 2105 rosacea, 622 atopic dermatitis, 1536 psoriasis, and 4263 control patients. Compared to propensity-matched controls, the adjusted odds of cardiovascular disease were not higher in patients with rosacea (odds ratio: 0.894, p = 0.2713), atopic dermatitis (OR 1.032, p = 0.8489), or psoriasis (OR 1.087, p = 0.4210). In univariate analysis, the unadjusted odds of cardiovascular disease was higher in patients with psoriasis (OR 1.223, p = 0.0347). CONCLUSIONS: Limitations of this study include the short follow-up period and inclusion of only commercially insured patients limit the generalizability of these findings. In this large study of patients with rosacea, atopic dermatitis, and psoriasis, we did not detect an increased 1-year risk of cardiovascular disease after adjusting for confounders.

Prevalence of rosacea in community settings.

BACKGROUND: The prevalence of rosacea is poorly characterized. Because selection bias may affect prevalence estimates, there is a need to characterize the prevalence of rosacea outside the clinic setting. OBJECTIVE: To assess the prevalence of rosacea in community settings. METHODS: A clinical research fellow and a medical student stood in public places (a mall, the Department of Motor Vehicles, a grocery store) and examined consecutive individuals who passed by ≤ 2 yards away. They tallied demographic and descriptive data on the subject and included the subject in one of three categories: clearly rosacea, possible rosacea, and definitely no rosacea. Subanalyses by perceived gender, age, race, and rosacea subtype were also performed. Comparisons between groups were made using the Fisher exact test. RESULTS: Considering the prevalence of rosacea among all observed individuals in the community setting, 5.4% (95% CI 3.6-7.8) of individuals had "possible" rosacea and 6% (95% CI 4.1-8.5) of individuals had "definite" rosacea. Older, white individuals with fairer skin types (Fitzpatrick skin types I, II, and III) were more likely to have rosacea. There was no gender predisposition. LIMITATIONS: Distance from subjects made it difficult to assess patients with mild rosacea or a few telangiectasias, as well as ocular rosacea. The study could not assess those individuals who were too embarrassed by their rosacea to be in the public settings observed. Additionally, some subjects may have applied significant makeup in an effort to conceal their rosacea, making assessment difficult. CONCLUSIONS: Based on direct observation of individuals in community settings, rosacea is more common than previously reported in the United States.

Systemic treatment of papular dermatitis: A retrospective study.

BACKGROUND: Papular dermatitis is an intensely pruritic eruption that is often refractory to conventional therapy. AIM: The aim of this study was to evaluate the efficacy of different non-steroidal systemic therapies for long-term control of disease in patients with papular dermatitis. METHODS: This was a single center, retrospective study involving a chart review of patients with a diagnosis of papular dermatitis who were prescribed systemic therapy between 1 January 2002 and 31 December 2012. RESULTS: Fourteen patients were identified that were treated with a systemic agent. Median duration of treatment was 25 months. Methotrexate was used first line in 12 patients, with control of disease achieved in eight patients with a dose between 2.5 and 10 mg weekly. Azathioprine and mycophenolate mofetil also provided control of disease when used as first-line therapy in the remaining two patients. While azathiopurine was effective in patients who failed methotrexate, gastrointestinal side effects limited its use long term. CONCLUSIONS: Low dose weekly methotrexate, as well as, azathioprine and mycophenolate mofetil are long-term treatment options for patients with papular dermatitis refractory to other therapies.

A model for predicting gastrostomy tube placement in patients undergoing surgery for upper aerodigestive tract lesions.

IMPORTANCE: Identifying high-risk patients in the preoperative period can allow physicians to optimize nutritional status early for better outcomes after head and neck cancer resections. OBJECTIVE: To develop a model to predict preoperatively the need for gastrostomy tube (G-tube) placement in patients undergoing surgery of the upper aerodigestive tract. DESIGN, SETTING, AND PARTICIPANTS: This retrospective medical record review included all adult patients diagnosed with head and neck cancers who underwent tumor resection from 2007 through 2012 at Wake Forest Baptist Health, a level 1 tertiary care center. Records were screened for patient demographics, tumor characteristics, surgical treatment type, and postoperative placement of G-tube. A total of 743 patients underwent resection of head and neck tumors. Of these, 203 were excluded for prior G-tube placement, prior head and neck resection, G-tube placement for chemoradiotherapy, and resection for solely nodal disease, leaving 540 patients for analysis. MAIN OUTCOMES AND MEASURES: Placement of postoperative G-tube. RESULTS: Of the 540 included patients, 23% required G-tube placement. The following variables were significant and independent predictors of G-tube placement: preoperative irradiation (odds ratio [OR], 4.1; 95% CI, 2.4-6.9; P < .001), supracricoid laryngectomy (OR, 26.0; 95% CI, 4.9-142.9; P < .001), tracheostomy tube placement (OR, 2.6; 95% CI, 1.5-4.4; P < .001), clinical node stage N0 vs N2 (OR, 2.4; 95% CI, 1.4-4.2; P = .01), clinical node stage N1 vs N2 (OR, 1.6; 95% CI, 0.8-3.3; P = .01), preoperative weight loss (OR, 2.0; 95% CI, 1.2-3.2; P = .004), dysphagia (OR, 2.0; 95% CI, 1.2-3.2; P = .005), reconstruction type (OR, 1.9; 95% CI, 1.1-2.9; P = .02), and tumor stage (OR, 1.8; 95% CI, 1.1-2.9; P = .03). A predictive model was developed based on these variables. In the validation analysis, we found that the average predicted score for patients who received G-tubes was statistically different than the score for the patients who did not receive G-tubes (P = .01). CONCLUSIONS AND RELEVANCE: We present a validated and comprehensive model for preoperatively predicting the need for G-tube placement in patients undergoing surgery of the upper aerodigestive tract. Early enteral access in high-risk patients may prevent complications in postoperative healing and improve overall outcomes, including quality of life.

Rosacea: new and emerging treatments.

Rosacea is a chronic inflammatory skin condition that negatively impacts patients' quality of life. We sought to review important aspects of the pathogenesis of rosacea and the role of new treatment options in its management. New, emerging treatments show promise; however, quality randomized controlled trials for many of these drugs are lacking. Brimonidine tartrate is an effective newly approved treatment for erythematotelangiectatic rosacea. Topical oxymetazoline has potential for the treatment of erythematotelangiectatic rosacea, with efficacy described in case reports and randomized controlled trials currently underway. Both oral and topical ivermectin have been studied for the treatment of papulopustular rosacea, both showing benefit; however, only topical ivermectin 1 % cream has been studied in randomized controlled trials. As our understanding of the etiology of rosacea continues to evolve, so will our options for therapeutic interventions. Further studies need to be performed to assess the long-term safety and efficacy of these treatments.

Subcutaneous sarcoidosis without systemic involvement.

Subcutaneous sarcoidosis is a rare variant of cutaneous sarcoidosis, which typically presents as single or multiple, indurated, ill-defined plaques, typically on the upper extremities. Granulomas consisting of macrophages with multinucleated giant cells and sparse lymphocytic inflammation are confined to the subcutaneous tissue, rather than to their usual location within the dermis in typical lesions of cutaneous sarcoidosis. An association between subcutaneous sarcoidosis and systemic involvement has been reported, although response to treatment and prognosis remain good. We report a case of a middle-aged woman with subcutaneous sarcoidosis, with negative work-up for systemic involvement of sarcoidosis. Interestingly, family history was significant for a son who died from complications of pulmonary sarcoidosis. The patient was successfully treated with a tapering course of oral prednisone in combination with hydroxychloroquine.