Treatment of palmar hyperhidrosis with botulinum toxin.

Excessive sweating of the palms, axillae, and soles can be managed with intradermal injections of botulinum toxin as an alternative to more aggressive surgical therapies such as sympathectomy and less effective techniques including topical antiperspirants. The dosage and injection techniques can be optimized to provide several months of freedom from this troubling disorder.

The restricted cellular host range of human herpesvirus 8.

DESIGN: A selection of primary and transformed cell types were evaluated for their susceptibility to infection with human herpesvirus 8 (HHV-8)/Kaposi's sarcoma-associated herpesvirus. METHODS: Sources of HHV-8 included Kaposi's sarcoma lesion punch biopsies that were either cocultured directly with target cells or that were first cocultured with human lymphocytes to derive HHV-8-containing fluids that were inoculated onto target cells. HHV-8 was also obtained from primary effusion lymphoma-derived cell lines. Techniques to detect infection included the PCR, immunofluorescence assays and in situ hybridization. RESULTS: Susceptible cells included human umbilical cord blood mononuclear cells (UCMC), adult CD19 B cells, macrophages and certain endothelial cells of human and animal origin, including some that are transformed with human papilloma virus type 16 E6 and E7 genes. The infection of lymphocytes did not yield established lymphoblastoid cell lines (LCL) and virus infection persisted for only 4-7 days. However, long-term HHV-8 infection of UCMC could be achieved by coinfection with Epstein-Barr virus. HHV-8 could also infect UCMC LCL recently derived by Epstein-Barr virus transformation, but long-established LCL could not be infected with HHV-8. CONCLUSIONS: These data provide further biological evidence in cell culture for the limited cellular host range of HHV-8 to CD19 B cells, macrophages, and certain endothelial cells.

Autologous fat grafting: comparison of techniques.

BACKGROUND: Despite more than a century of reporting in the medical literature, controversy still surrounds both the efficacy and longevity of autologous fat transplantation in subcutaneous soft tissue augmentation. OBJECTIVE: To summarize the existing literature relating to the effectiveness of this procedure and to highlight differences in technique that may play a role in reported treatment successes and failures. METHODS: Review of the literature and reporting of authors' observations and results. CONCLUSION: Autologous fat transplantation can be a gratifyingly effective treatment for subcutaneous augmentation that may produce permanent results in some cases. This article aims to clarify some of the differences in technique employed by doctors in this field and aims to enable the reader to better see the subtle, but sometimes important differences in methods used.

The risk of progression to invasive disease.

BACKGROUND: Actinic keratoses occasionally progress to invasive skin cancer. The clinician-dermatologist ideally would like to know which lesions are at individual risk. Various investigators have attempted to answer this problem through a variety of clinical research applications including counting individual lesions in populations at risk, in the general population, and by examining insurance claims data and extrapolating incidence figures. OBJECTIVE: The purpose of the study was to ascertain the range of risks for progression of actinic keratoses to invasive skin cancer. RESULTS: Five clinical research studies were reviewed that covered a period from 1988 to 1998. Published risk of progression of actinic keratoses to invasive squamous cell carcinoma for individual lesions ranged from 0.025% to 16% per year. Extrapolation from these clinical studies suggests a rate of risk of progression of actinic keratoses to invasive squamous cell carcinoma of approximately 8% taken as an average among the cited statistical rates in the studies reviewed. CONCLUSION: Although the rate of progression of actinic keratoses to invasive squamous cell carcinoma statistically occurs at a low percentage rate ( approximately 10%), the problem for the clinician is that the risk over a broad population does not aid in determining the risk factor for the individual lesion. Hence the decision to treat is made on related clinical factors such as history of persistence, age of patient, discomfort, extent of coexisting photodamage, tolerance for morbidity of therapy, and history of skin cancer.

Botulinum A neurotoxin for axillary hyperhidrosis. No sweat Botox.

BACKGROUND: Axillary hyperhidrosis causes considerable emotional stress and is associated with extraordinary costs and limitations in clothing. Existing topical and surgical therapies are either ineffective or associated with unacceptable morbidity and sequelae. Botulinum A neurotoxin (Botox) has been shown to decrease sweating in normal skin and in palmar hyperhidrosis. OBJECTIVE: The current study was undertaken to demonstrate the utility of using Botox in the treatment of axillary hyperhidrosis. METHODS: Twelve patient with axillary hyperhidrosis underwent intradermal injection with 50 units of Botox in the axillary skin bilaterally. RESULTS: All patients enjoyed relatively complete anhidrosis of the axillary skin in periods ranging from 4 to 7 months. Repeat injections produced similar results. CONCLUSION: Botulinum A neurotoxin (Botox) is an elegant and simple treatment for axillary hyperhidrosis.

Physiologic and structural changes associated with aging skin.

The spectrum of photoaging in human skin shows a recognizable progression from subtle to profound, reflecting the various anatomic and structural changes that appear with aging skin. Qualification and quantification of these changes on both the macroscopic and microscopic levels enable the physician to select and evaluate appropriate therapeutic approaches to the problem of chronic solar damage. Comparative studies remain to be done that will further refine our abilities to match the right solutions to the recognized problems.

Aesthetic and anatomic analysis of the aging skin.

One of the most interesting medical conditions that now afflicts the baby boomer generation is photoaging. Clinical signs of photoaging of the skin include rhytids, lentigines, keratoses, telangiectasia, loss of translucency, loss of elasticity, and sallow color. A systematic classification of patient photoaging types has been developed by the author: type I, "no wrinkles"; type II, "wrinkles in motion"; type III, "wrinkles at rest"; and type IV, "only wrinkles." The intent is to organize the discussion of therapies for photodamaged skin to permit rational comparisons of therapies and clinical results.

Chemical peels. Trichloroacetic acid and phenol.

Chemical peeling is the most widely used modality for treating photoaged skin. The classification, indications, techniques, complications, and histology of two of the most widely used peeling agents, trichloroacetic acid and phenol, are presented.

Wood's lamp for superficial chemical peels.

BACKGROUND: Superficial chemical peels are being used with increasing frequency in the treatment of photoaging. OBJECTIVE: Our purpose was to develop a marker to indicate when all areas of skin have been treated and avoid reliance on a map or operator recall. METHODS: With a Wood's lamp (maximum output 365 nm) and addition of salicylic acid and fluorescein sodium, solutions that are readily available, the progress of the superficial chemical peel can be visualized. RESULTS: Wood's lamp accentuates epidermal pigment and therefore highlights dyschromia that will respond to a superficial chemical peel. Similarly, salicylic acid and fluorescein sodium fluoresce when viewed under Wood's lamp examination. CONCLUSION: When fluorescent compounds are incorporated into a superficial chemical peel, then fluorescence can accurately locate skip areas, minimize inadvertent overlayering, and thereby avoid deeper penetration.

6-Thioguanine treatment of psoriasis: experience in 81 patients.

BACKGROUND: Despite recent innovations a considerable number of patients with psoriasis cannot be successfully treated by current therapies. OBJECTIVE: Our purpose was to summarize our 18-year experience with the antimetabolite 6-thioguanine in the management of patients with psoriasis. METHODS: We retrospectively studied 81 patients who were treated with 6-thioguanine. A variety of schedules were used to find the optimal schedule. Forty-eight percent of the patients either had been treated with methotrexate or were excluded from receiving methotrexate because of liver or kidney disease. RESULTS: Forty-nine percent of patients with plaques were effectively maintained with 6-thioguanine for a median of 33 months. Four of five patients with palmoplantar pustular psoriasis experienced substantial benefit. The most common side effect was myelosuppression. CONCLUSION: 6-Thioguanine is an effective therapy for psoriasis and should be considered for patients who have failed to respond to other systemic agents.

Dermatologic surgery and human immunodeficiency virus disease.

In summary, the statistically greater risk of disease among health care workers who suffer occupational needle sticks or similar exposure to contaminated blood remains hepatitis. Routine vaccination of health care workers who are at risk for exposure to hepatitis B, combined with common-sense implementation of risk management behaviors should reduce the chances of occupationally acquired blood-borne disease to levels of acceptable risk. The practice of medicine has never been without risk to the health care worker who is engaged in direct patient care, and the present epidemic is no exception. Collective action to minimize the impact of HIV disease continues to be the prudent and compassionate course of action.