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.

Management of Melanoma Patients by Non-Dermatologists in the Military Health System: A Retrospective Observational Study.

INTRODUCTION: Compared to their civilian counterparts, military personnel can have more exposure to sunlight and, as recent studies have shown, do have an increased incidence of melanoma. Given the inherent challenges service members may face in getting appropriate care whether because of operational tempo, deployments, and/or austere locations, many are initially diagnosed by specialties other than dermatology. In this study, we sought to determine if patients within the military health system were receiving appropriate follow-up management after biopsies by non-dermatologists led to the diagnosis of melanoma by pathology. MATERIALS AND METHODS: Using the Co-Path system, 1,000 patients were identified who had first time biopsies positive for melanoma. Of these, 73 were originally biopsied by non-dermatologists. Retrospective medical record review was performed to determine specialties of the non-dermatologists, staging of melanoma at diagnosis, referrals to specialists and dermatologists, and adherence to National Comprehensive Cancer Network guidelines. The study protocol was approved by the Walter Reed National Military Medical Center Institutional Review Board, protocol number WRNMMC-EDO-2017-0030, in compliance with all applicable federal regulations governing the protection of human subject research. RESULTS: Family medicine physicians made up the majority of non-dermatologists involved in performing biopsies that led to the diagnosis of melanoma in this study. Most patients were Stage I (pT1a), and the average time from initial biopsy to further wide excision biopsy was 18 days. Sixty-seven of the 73 patients biopsied by non-dermatologists received referrals to dermatologists, and 55 of the 67 patients followed through with being seen. Follow-up full body skin exams were performed on 55 of the 73 patients, with dermatologists conducting the majority of them. National Comprehensive Cancer Network guidelines were followed in 45 of the 73 patients, with an additional 24 patients having insufficient evidence to determine if guidelines were adhered to. CONCLUSION: Our study demonstrated that a number of different specialties outside of dermatology are involved in performing biopsies on patients in which melanoma is a concern. Although the results show that the majority of patients biopsied by non-dermatologists received appropriate follow-up care, there is still room to improve to ensure that all melanoma patients receive referrals to and are seen by dermatologists after a diagnosis of melanoma.

Management of Keratoacanthoma: 157 Tumors Treated With Surgery or Intralesional Methotrexate.

BACKGROUND: Keratoacanthomas (KAs) are common tumors of squamous cell origin that grow rapidly and may regress; however, differentiation from an aggressive squamous cell carcinoma is problematic. OBJECTIVE: To report the authors' experience in managing KA with intralesional methotrexate (MTX) or surgical excision. MATERIALS AND METHODS: The authors collected data on 157 tumors (136 patients) over 6 months from a single institution. RESULTS: There were 73 tumors (54 patients) treated with intralesional MTX. There were 9 tumors that did not resolve with intralesional MTX (88% cure). Nonresolving tumors were excised with no recurrences or complications. In all 9 cases, the nonresolving tumors were of the same size or smaller after MTX. Of the 73 tumors treated with MTX, 29 tumors (11 patients) were multiple KAs. All 29 tumors resolved (100% tumor clearance). There were no complications in any of the MTX-treated patients. Tumor clearance was defined by clinical resolution for a minimum of 6 weeks without a recurrence. There were 84 tumors (83 patients) treated with surgical excision. There were no complications and no recurrences (100% cure) with surgery. CONCLUSION: Intralesional MTX may be considered as the initial treatment for solitary KA, multiple KA, or in poor surgical candidates.

Amantadine-induced livedo reticularis in a child treated off label for neurobehavioral disorders.

We report the case of an 8-year-old boy who was taking amantadine off label for multiple childhood neurobehavioral disorders and subsequently developed livedo reticularis. Although this side effect is well-described in adult patients taking amantadine for Parkinson disease, it is now being seen in children as the off-label use of amantadine is expanded to this population.

Diffuse vesiculobullous eruption with systemic findings.

Drug induced linear IgA bullous dermatosis (LABD) is a rare blistering disease that has been shown to be associated with the use of various medications. Although rarely seen together, some of the medications associated with LABD can lead to the syndrome drug reaction with eosinophilia and systemic symptoms (DRESS), which presents with fever, cutaneous eruption, and multi-organ involvement. We present a patient who developed fever and a generalized vesiculobullous eruption after recently starting amlodipine and meloxicam. Initial laboratory tests demonstrated elevated liver function tests, leukocystosis, and eosinophilia. Histopathologic examination of the punch biopsy revealed a bulla with sub-epidermal split and numerous neutrophils. Direct immunofluorescence demonstrated broad deposition of IgA along the dermal-epidermal junction. These findings were consistent with an overlap between LABD and DRESS. Drug induced LABD and DRESS are independently both rare diseases. It is even more uncommon to see the two concurrently in the same patient. In this patient, these two conditions were thought to be triggered by either amlodipine or meloxicam. Given the high mortality rate associated with DRESS, it is important to recognize the presentation and initiate the appropriate treatment plan as soon as possible.

Lupus erythematosus tumidus of the scalp masquerading as alopecia areata.

Lupus erythematosus tumidus (LET) is a unique subset of chronic cutaneous lupus erythematosus (CCLE) that generally presents as urticarialike papules and plaques with induration and erythema on the face, trunk, and upper extremities. Lesions rarely present on the scalp or below the waist. We report a unique case of LET on the scalp of a woman that presented clinically as alopecia areata. Resistance to the standard treatment for alopecia areata prompted a biopsy that proved the diagnosis.

Dermestid Dermatitis in a 2-Year-Old Girl: Case Report and Review of the Literature.

Dermatitis from contact with carpet, larder, and hide beetles (family Dermestidae) is a seemingly uncommon or underrecognized hypersensitivity reaction to the specialized hairs on the larvae of certain dermestid beetles. The erythematous papulovesicular dermatitis that may result from such contact can be mistakenly construed as evidence of bites of bedbugs or other arthropods or infestation with scabies mites or can be the basis for a diagnosis of delusory parasitosis. We present a case of dermestid dermatitis in a 2-year-old girl and provide a review of the current literature.

Traumatic neuroma of the penis.

Traumatic neuromas are tumors produced by a reactive process to regenerate injured nerves that result in a disordered proliferation of nerve bundles. These tumors are usually related to previous surgery or trauma. We describe a case of traumatic neuroma on the penis of a 24-year-old man; the tumor was initially suspected to be a condyloma. A shave biopsy was both diagnostic and curative.