Fractional laser resurfacing for acne scars: a review.

This review investigates the effectiveness of ablative and nonablative fractional photothermolysis (FP) lasers for treating facial acne scars. Twenty-six studies (13 ablative FP, 13 nonablative FP) published between 2003 and January 2011 were reviewed. Quantitative and qualitative data from each article were examined and analysed. Four studies were split-face randomized controlled studies. While the data analysed were all clinically relevant and significant, there were some methodological differences between the studies. Outcomes included subjective and objective assessment of scar appearance, pre- and postoperative treatment, side-effects and pain scores. A small number of studies used three-dimensional optical imaging profiling and histology for objective assessment. Even allowing for methodological variability, ablative FP had an improvement range of 26-83% whereas nonablative FP had an improvement range of 26-50%. Patients who underwent treatment with an ablative FP laser experienced erythema for 3-14 days which resolved by 12 weeks, whereas patients who opted for the nonablative FP laser experienced erythema for between 1 and 3 days and this resolved within a week. A higher proportion of patients (up to 92·3%) who underwent ablative FP experienced postinflammatory hyperpigmentation (PIH) than those who had nonablative FP (up to 13%). The maximum duration of PIH in ablative FP was up to 6 months whereas in nonablative FP it lasted for up to 1 week. The procedure with ablative FP was relatively uncomfortable compared with nonablative FP. The pain score with ablative FP ranged from 5·90 to 8·10 (scale 1-10) and with nonablative FP from 3·90 to 5·66 (scale 1-10).

Pseudoepitheliomatous, keratotic and micaceous balanitis after penile squamous cell carcinoma.

Pseudoepitheliomatous keratotic and micaceous balanitis (PKMB) is a rare form of balanitis, with only a handful of cases reported since the disease was first described. Although the condition has been described as benign, there is increasing evidence of its premalignant potential, with several of the reported cases progressing to verrucous or squamous cell carcinoma (SCC). We report a case of PKMB following penile SCC and discuss the literature on this rare condition.

Severe exacerbation of multiple self-healing squamous epithelioma (Ferguson-Smith disease) with radiotherapy, which was successfully treated with acitretin.

We describe the challenging case of a patient presenting with extensive, eruptive mid-facial squamous cell carcinomas (SCCs) and keratoacanthomas (KAs) consequent to radiotherapy. Our patient had a personal and family history of multiple KAs and SCCs. Multiple self-healing squamous epithelioma, otherwise known as Ferguson-Smith disease, was diagnosed. This case presented a therapeutic challenge to preserve tissue and avoid severe facial disfigurement. We found oral acitretin to be the treatment of choice.

Bexarotene therapy for mycosis fungoides and Sézary syndrome.

BACKGROUND: Bexarotene (Targretin) is a synthetic retinoid which is licensed for the treatment of advanced refractory cutaneous T-cell lymphoma (CTCL). OBJECTIVES: To summarize our experience with bexarotene for patients with CTCL with the aim of assessing efficacy and safety. METHODS: A retrospective study of 66 patients (44 male, 22 female) with mycosis fungoides (40 patients) or Sézary syndrome (26 patients) who were commenced on bexarotene prior to August 2007 was carried out. Nineteen patients had early-stage (IB-IIA) refractory mycosis fungoides and 47 patients had advanced-stage CTCL (IIB-IVB). RESULTS: Fifty-two out of 66 (79%) patients completed over 1 month of therapy with an intention-to-treat response rate of 44% (29/66). Of the patients, six (9%) had a complete response, 23 (35%) had a partial response, 15 (23%) had stable disease and eight (12%) had progressive disease. Median time to maximal response was 3 months (1-9 months). Median response duration was 8 months (1 to > 48 months). Median time to progression was 9 months (3-44 months). Fourteen patients (21%) did not complete a month of bexarotene therapy. Adverse effects of the whole group included central hypothyroidism in 100% (all grade II and managed with thyroid replacement) and hyperlipidaemia in 100% (all managed with lipid-lowering therapy +/- dose reduction). Responses were seen in all stages and were higher in advanced stages: 26% (five of 19) with early-stage and 51% (24/47) of advanced-stage disease. Responses were seen in skin, blood and lymph nodes. Twenty-eight out of 66 patients were treated with bexarotene monotherapy and the remainder were on one or more additional anti-CTCL therapies. CONCLUSIONS: Our data demonstrate that bexarotene is well tolerated in most patients and responses are seen in almost half of patients with all disease stages. However partial responses were not graded and would include any improvement seen in the skin, blood and lymph node.

Infliximab for severe, treatment-resistant psoriasis: a prospective, open-label study.

BACKGROUND: Infliximab, a mouse-human chimeric monoclonal antibody directed against tumour necrosis factor-alpha, has been shown to be effective for moderate to severe psoriasis, but there are few data published on its use in recalcitrant, treatment-resistant disease or in combination with other antipsoriatic therapies. OBJECTIVES: To report our experience with infliximab in the treatment of patients attending a tertiary referral service with severe recalcitrant disease. METHODS: All patients attending a tertiary referral service for severe psoriasis who were treated with infliximab between 2002 and July 2005 were entered into a prospective, open-label study. Details on disease phenotype, clinical course and adverse events were recorded together with measures of disease severity [Psoriasis Area and Severity Index (PASI), Dermatology Life Quality Index, clinical photography] at baseline, weeks 2 and 6, and then at 2-monthly intervals throughout the treatment period. RESULTS: Twenty-three patients were treated with infliximab during the study; one patient had pustular psoriasis and was therefore excluded from statistical analysis. All had severe disease (baseline PASI 26.5+/-6.7, mean+/-SD, n=22) and had received at least two systemic therapies for psoriasis in the past; 16 were taking one or more concomitant therapies at the time of treatment initiation. At week 10, 95% had achieved a 50% or greater improvement in baseline PASI (PASI 50), and 77% had achieved a 75% or greater improvement (PASI 75). Efficacy was sustained in the longer term, with eight of 10 patients on treatment for more than 11 months maintaining at least a PASI 50. Only one patient had treatment withdrawn due to lack of efficacy, two suffered severe systemic infections including extrapulmonary tuberculosis (splenic abscess) and cellulitis, and six have discontinued due to adverse effects including infusion reactions (two), severe thrombocytopenia (one), hepatitis (one) and malignancy (two). CONCLUSIONS: Data from this open-label study suggest that infliximab is a rapidly effective treatment for patients with severe, treatment-resistant disease, although approximately 25% of patients had to discontinue therapy due to the development of serious adverse effects. Long-term follow-up, continued pharmacovigilance, and further controlled comparative studies will be required to evaluate fully the risks associated with infliximab in the context of this already difficult to treat population.

Cutaneous bioassay of salicylic acid as a keratolytic.

Keratolytic efficacy of topical preparations containing salicylic acid was studied in humans utilizing adhesive tape stripping and quantifying SC removal by protein analysis. In combination with tape stripping, squamometry was used to evaluate the influence of salicylic acid on skin surface scaliness and desquamation. Furthermore, skin barrier perturbation and skin irritancy was recorded and related to the dermatopharmacological effect of the preparations. In contrast to squamometry, tape stripping combined with protein analysis was sensitive in detecting keratolytic effect of salicylic acid within hours of application. Importantly, whereas the pH of the preparations only minimally influenced efficacy, local dermatotoxicity was significantly increased at acidic pH. This indicates that the quest to increase the amount of free, non-dissociated SA is, in fact, counterproductive as the more acidic preparations resulted in skin irritation and barrier disruption.

Provocative use test of nickel coins in nickel-sensitized subjects and controls.

BACKGROUND: Consensus exists on levels of nickel release that are well tolerated in exposure to nickel-containing items in direct and continuous contact with skin (e.g. watches). The clinical relevance of nickel-containing coins eliciting nickel dermatitis associated with extensive occupational exposure (e.g. coins handled by cashiers) has not been determined. OBJECTIVES: To examine whether nickel-containing coins might be an elicitor of allergic contact dermatitis (ACD) in occupational settings with extensive exposure to coins (i.e. cashiers). METHODS: Eighteen subjects (10 nickel sensitized and eight non-nickel sensitized) completed this study after screening of history, physical examination and diagnostic patch testing (5% nickel sulphate). Each volunteer handled 10 coins (nickel-containing coins or non-nickel-containing coins) in a cross-over design at 5-min intervals (5 min handling followed by 5 min rest) for 8 h per day, for a total of 12 days excluding the weekend. One hand was gloved while the other was not during coin handling. Visual scoring and bioengineering measurements were recorded at each of four predetermined sites at baseline (day 1), end of day 5 and day 12 (last day of exposure). RESULTS: There were no statistical differences for either visual or bioengineering data comparing: (i) nickel-sensitized vs. non-nickel-sensitized subjects handling nickel-containing coins at day 1, day 5 and day 12; (ii) day 12 vs. day 1 (baseline) for nickel-sensitized subjects handling nickel-containing coins; (iii) handling of nickel-containing coins vs. non-nickel-containing coins by nickel-sensitized subjects at day 5 and day 12; (iv) gloved hand vs. ungloved hand of nickel-sensitized subjects handling nickel-containing coins at day 12. Limitations of the method and clinical extrapolation are detailed. CONCLUSIONS: Individuals handling these nickel-containing coins daily did not develop ACD, as judged by visual signs or bioengineering parameters.

Alefacept (Biogen).

Alefacept (B-9273) is an LFA-3-Ig fusion protein CD2 antagonist under development by Biogen for the potential treatment of autoimmune diseases, including psoriasis and transplant rejection [270267]. It is in phase III trials for psoriasis [349467]. In October 2000, the company reported that Amevive was on track for regulatory filing in the second half of 2001 [385250], with a possible launch in the second half of 2002 [395628]. The company began a pivotal phase III trial in the US in December 1999, involving patients with chronic plaque psoriasis [349467]. A second phase III trial has also been initiated [362199], [374040]. Results from both trials are expected in mid-2001 [396544]. In April 2001, SalomonSmithBarney confirmed that a regulatory filing was expected in Europe and the US in the second half of 2001 and stated that alefacept would be critical to the future earnings growth of the company [407796]. In June 1999, Merrill Lynch estimated product launch in 2001 [327145], [344773]. Sales in 2001 and 2002 were anticipated to be US $20 million and US $100 million, respectively [327145].

Physical and physiological effects of stratum corneum tape stripping.

BACKGROUND/AIMS: Tape stripping of human stratum corneum has been performed to measure stratum corneum mass, barrier function, drug reservoir and percutaneous penetration. However, the technique itself requires further development to facilitate interpretation. METHODS: In this study we quantified stratum comeum (SC) tape stripping and water kinetic parameters utilizing three types of adhesive tapes, in an in vivo randomized clinical trial. Stratum corneum was tape stripped, and the mass of SC removed by each tape was quantified utilizing a protein assay. Transepidermal water loss (TEWL) was measured and barrier disruption and SC water kinetics calculated. Three commonly utilized acrylate adhesive tapes were utilized and a comparison made between them. RESULTS: Each type of tape successfully stripped the stratum corneum, but the rayon tape did not induce SC barrier disruption. Neither the type of tape nor the site stripped significantly influenced the mass of SC removed. Water kinetic parameters did not differ significantly for the tapes that did induce barrier disruption. Individual variation in barrier disruption to water following tape stripping was demonstrated. CONCLUSION: The tapes utilized removed a similar amount of SC. The tapes have a different propensity to cause barrier disruption. Some individuals do not demonstrate increased TEWL despite an equivalent mass of SC being removed compared to those who do show a response.

Dermatology--24th Hawaii Seminar. 7-12 February 2000, Big Island, HI, USA.

At this seminar, several encouraging developments were demonstrated in various areas of dermatology practice. Much attention was focused on topical tacrolimus, the US approval of which, for the treatment of atopic dermatitis is much anticipated. The general consensus from trials was that the drug is safe and effective, and it is hoped that it will be of use in pediatric cases. Additional data were presented regarding the use of cyclosporin in psoriasis patients, with some evidence that low doses could be delivered safely with adequate monitoring. Safety was an issue in many of the sessions, reflecting the increasing involvement of potentially toxic therapies within dermatology. The debate regarding the use of topical tretinoin during pregnancy continues, and pharmacokinetic evidence was presented to demonstrate that systemic absorption of the drug is minimal. The range of diseases treated by topical imiquimod may be expanded with data suggesting that it may have benefits in the treatment of basal cell carcinomas. Surgical dermatology also featured heavily in the meeting, reflecting the more interventional approaches favored by dermatologists today.

Compound allergy. An overview.

This review defines the term "compound allergy" in the context of new findings, and discusses evidence that allergenic reaction products have been identified. Material was gathered by searching Index Medicus and the Science Citation Index, and reviewing several standard texts. Issues regarding the validity of patch test results are addressed and we introduce the term "pseudocompound allergy" to cover cases of false-negative patch tests. We present new theories regarding the mechanisms by which new allergens are formed and a means of classification.