Understanding botulinum toxin. Surgical anatomy of the frown, forehead, and periocular region.

BACKGROUND: Cosmetic denervation of hyperfunctional facial lines using botulinum toxin (Botox, Allergan, Inc., Irvine, CA) has gained growing popularity over recent years. Understanding the clinical use and effects of botulinum toxin requires a thorough understanding of the muscular anatomy of the treatment areas. OBJECTIVE: The purpose of this article is to review the anatomy of the frown, forehead, and periocular regions. Function of individual muscles is discussed to understand proper injection technique. CONCLUSIONS: The anatomy of the frown, forehead, and periocular regions is complex. Individual muscles are tightly intertwined and treatment of one anatomic region may affect many different muscles. A complete understanding of the anatomy of the upper face is essential to ensure proper injection technique, safe and predictable results as well as anticipating complications.

Long-term low-dose cyclosporine therapy for severe psoriasis: effects on renal function and structure.

BACKGROUND: The effectiveness of cyclosporine in the treatment of severe psoriasis is well known. OBJECTIVE: We evaluated the efficacy and toxicity of systemic cyclosporine in patients with severe psoriasis, observing short-term (12 weeks) and long-term (3 to 5 years) effects. METHODS: To further elucidate efficacy and safety, 42 patients with severe psoriasis were treated initially with cyclosporine 5 to 6 mg/kg per day for 12 weeks. A subset of 14 patients continued maintenance treatment for 3.5 years to study the long-term effects of cyclosporine on renal function and structure. Renal biopsies were performed after 2.5 years and 3.5 years of treatment. Renal histologic findings were correlated with renal function. RESULTS: By weeks 8 and 12, 64% (n = 27) and 86% (n = 36) of patients, respectively, were rated clear or almost clear of the psoriasis. However, a subpopulation of 15 patients did not respond to 5 mg/kg daily but improved when the dose was increased to 6 mg/kg daily. Clearance or near clearance was achieved in 67% of this subpopulation after 4 weeks. For the 29 patients whose glomerular filtration rate (GFR) was measured, mean GFR fell by 7% from baseline to week 4 (p < 0.05). This change was reversible when dosage was reduced by 1 mg/kg per day in each of these patients. Patients older than 45 years of age experienced significant elevation of mean diastolic blood pressure and had reduced GFR and increased serum creatinine. After 2.5 years, of the 14 patients who continued maintenance treatment, two had biopsy specimens that showed moderate interstitial fibrosis and tubular atrophy. The remainder showed only minimal to mild structural damage. After 3.5 years of cyclosporine treatment, repeat renal biopsy specimens revealed slight increases in structural changes in nine subjects. These changes correlated with increasing age and drug-induced hypertension. CONCLUSION: We conclude that 5 mg/kg of cyclosporine daily is usually an effective initial dose for psoriasis. Patients who do not respond will often benefit from elevation of the dose to 6 mg/kg daily. Older patients experience cyclosporine-induced hypertension and changes in renal function and structure more frequently than do younger patients.

Low doses of repetitive ultraviolet A induce morphologic changes in human skin.

Repetitive exposure of skin to sunlight is known to result in dermatoheliosis, characterized by photoaging and carcinogenesis. It has been demonstrated previously that relatively large amounts of ultraviolet (UV) A can produce photodamage and it is believed that UVB plays a major role in the induction of photodamage and photocarcinogenesis. The study reported here determines the cutaneous effects of minimal erythemal amounts of solar-simulated UV radiation as well as suberythemal and minimal erythemal doses of UVA. Previously non-sunexposed human skin was irradiated twice weekly for 24 weeks. Biopsies were obtained 12, 24 and 36 weeks after the initial irradiation and assessed for both epidermal and dermal alterations. Dermal elastic tissue content was measured via computerized image analysis. All UV treatment regimens produced observable epidermal and dermal changes. These alterations were observed after only 12 weeks of twice-weekly irradiation and were still evident 12 weeks after the final irradiation. Interestingly, UVA irradiation produced a decrease in elastic tissue content whereas solar-simulated UV produced a slight increase. Most notable were the changes produced by the suberythemal dose of UVA. Surprisingly, this relatively low UVA dose produced a reduction in elastic tissue content. The results of this investigation demonstrate that small amounts of UVA or solar-simulated UV are capable of producing cutaneous photodamage. These findings suggest that even suberythemal doses of repetitive UVA may lead to photoaging of the skin and that there is a need for daily broad spectrum UV protection.

Systemic retinoids for psoriasis.

This article reviews the use of systemic retinoids in the treatment of psoriasis. Various retinoids are discussed in the treatment of generalized pustular psoriasis, exfoliative psoriasis, and plaque psoriasis, both in combination therapy and monotherapy. Dosing outlines, side effects, and recommended monitoring guidelines are reviewed.

Infraorbital pigmented skin. Preliminary observations of laser therapy.

BACKGROUND: The presence of infraobital dark skin, often known as dark circles under the eyes, is a frequent cosmetic concern. There has been little reported on therapy of this condition. One group of patients was determined to have dermal melanin deposition, which we treated with a Q-switched ruby laser. OBJECTIVE: Our study evaluated the clinical and histological appearance of infraobital skin pigment in 17 patients with dermal melanin deposition treated with a Q-switched ruby laser. METHODS: Seventeen patients with melanin deposition were treated with the Q-switched ruby laser (694 nm) with a pulse width of 28 nanoseconds and fluences of 7.5 J/cm2. Response to treatment was assessed by an independent investigator with patient and photograph evaluation. Skin Biopsies were obtained in nine of the 17 patients. RESULTS: Of those patients treated with one Q-switched ruby session, 23.5% achieved a greater than 50% response. Of those treated twice, 88.9% achieved greater than 50% response. In postreatment skin biopsies there was reduction of dermal melanin deposition. CONCLUSIONS: Patients with infraobital pigmented skin due to dermal melanin deposition may be considered candidates for Q-switched Ruby laser treatment.

Nevus of Ota: treatment with high energy fluences of the Q-switched ruby laser.

BACKGROUND: The nevus of Ota is a benign dermal melanocytic lesion that has previously proved difficult to treat. Recently, the Q-switched ruby laser has been reported to be successful in treating benign pigmented lesions and tattoos. OBJECTIVE: Our study evaluates the treatment of 16 patients with nevus of Ota with the Q-switched ruby laser (694 nm). METHODS: Sixteen patients with nevus of Ota were treated with the Q-switched ruby laser with a pulse width of 28 nsec and energy fluences ranging from 7.5 to 10 J/cm2. Response to treatment was assessed by an independent investigator with photographs. RESULTS: The average number of treatments was 3.8 per patient. After two treatments, 44% of patients showed a 50% or greater improvement. After three treatments, 85% of patients showed a 50% or greater improvement; after four treatments, 100% of patients showed 50% or greater improvement. No patients had permanent textural changes or scarring. CONCLUSION: High-energy fluences of the Q-switched ruby laser lead to significant improvement without scarring of nevus of Ota after a few treatments.

Lichen myxedematosus treated with chlorambucil.

BACKGROUND: Chemotherapy with various alkylating agents has been reported to be successful in the treatment of lichen myxedematosus. However, serious toxicities have accompanied such use. OBJECTIVE: To report a case of treatment of lichen myxedematosus with chlorambucil. RESULT: There was a favorable response using chlorambucil as an alternative therapeutic agent.