Anna Chacon

Intralesional Treatment for Keloids and Hypertrophic Scars: A Review

BACKGROUND Although differing in clinical presentation and prognosis, keloids and hypertrophic scars are generally characterized by abnormally proliferative scar tissue and are extremely debilitating. Several intralesional therapies have been studied in attempts to find a universally safe and effective modality, of which there are currently none. OBJECTIVE To provide a comprehensive review of current intralesional treatment modalities for keloids and hypertrophic scars. METHODS AND MATERIALS A PubMed search was performed for literature pertaining to intralesional treatment modalities for keloids and hypertrophic scars. References from retrieved articles were also considered for review. RESULTS AND CONCLUSION Many intralesional therapies for keloids and hypertrophic scars are currently available to physicians and patients. Mechanisms of action and side effect profiles vary between these agents, and new approaches to keloids and hypertrophic scars are frequently being explored. Randomized controlled trials are needed to assess these new and promising modalities fully.

Laser and light therapy for onychomycosis: a systematic review.

More than just a cosmetic concern, onychomycosis is a prevalent and extremely difficult condition to treat. In older and diabetic populations, severe onychomycosis may possibly serve as a nidus for infection, and other more serious complications may ensue. Many treatment modalities for the treatment of onychomycosis have been studied, including topical lacquers and ointments, oral antifungals, surgical and chemical nail avulsion, and lasers. Due to their minimally invasive nature and potential to restore clear nail growth with relatively few sessions, lasers have become a popular option in the treatment of onychomycosis for both physicians and patients. Laser or light systems that have been investigated for this indication include the carbon dioxide, neodymium-doped yttrium aluminum garnet, 870/930-nm combination, and femtosecond infrared 800-nm lasers, in addition to photodynamic and ultraviolet light therapy. This systematic review will discuss each of these modalities as well as their respective currently published, peer-reviewed literature.

Pulsed dye laser-resistant port-wine stains: mechanisms of resistance and implications for treatment.

Port‐wine stains (PWS) are among the most common congenital vascular malformations. Unlike capillary haemangiomas, these lesions do not involute spontaneously but rather become progressively more disfiguring as the patient ages. While benign in nature, the cosmetic deformity and attendant psychological and emotional distress prompt the majority of those afflicted to seek treatment. The pulsed dye laser (PDL) has long been considered the treatment of choice for these vascular lesions; however, very few patients achieve total clearance with PDL therapy and a significant number of lesions fail to respond at all. In order to address these recalcitrant cases, the mechanisms that contribute to treatment resistance must be understood and novel laser and light therapies must be employed. This review will address what is currently known about lesion‐specific characteristics of PDL‐resistant PWS as well as discuss current and future treatment options.

Carbon dioxide laser for the treatment of microcystic lymphatic malformations (lymphangioma circumscriptum): a systematic review.

Background Lymphangioma circumscriptum (LC) is a rare, superficial, cutaneous lymphatic malformation. Management is difficult because of high recurrence rates, regardless of the treatment modality chosen. The carbon dioxide (CO2) laser may offer a less‐invasive option than surgery that provides satisfactory functional and cosmetic results. Objectives To systematically review the efficacy and safety of the CO2 laser for the treatment of LC. Methods The terms “lymphangioma circumscriptum” and “microcystic lymphatic malformation” were combined with “treatment,” “laser,” and “carbon dioxide” during separate searches in the PubMed database. The articles retrieved were then evaluated based on set criteria. Results We identified 16 studies (11 case reports, 5 case series) with a total of 28 separate patients who had been treated for LC using a CO2 laser. Eight patients remained disease free from 4 months to 3 years, 10 experienced partial recurrence, and two experienced complete recurrence. Various laser parameters were reported, and adverse effects were generally minor and infrequent, such as dyspigmentation and mild scarring. Conclusions Available evidence indicates that the CO2 laser is a safe and efficacious option for the treatment of LC, particularly in large lesions that may not be amenable to surgical intervention.

Pyschodermatology: a trip through history

The interaction between the mind and diseases of the skin has been the study focus for many researchers worldwide. The field of Psychodermatology, or Psychocutaneous Medicine, is the result of the merging of two major medical specialties, psychiatry and dermatology. Although the history of Psychodermatology is rather old and interesting, the field has only recently gained popularity. Since ancient times, philosophers, surgeons, dermatologists and psychiatrists have reported the presence of psychocutaneous diseases in various scenarios. In this article, the authors describe curious and remarkable facts in the history of Psychodermatology.

From flint razors to lasers: a timeline of hair removal methods.

Today, most do not go a day without practicing or hearing about new hair removal methods. However, little is discussed about the history of hair removal and the development of most hair removal methods since the period of cavemen. Avoiding decapitation and fitting in with society are two of many reasons for the development of this now normative practice. Knowledge of the hair growth cycle is vital in understanding the efficacy of various hair removal methods as well as the difference between epilation and depilation. While laser hair removal (LHR) is one of the most common cosmetic procedures practiced in the world, according to the FDA, the only current permanent form of hair removal is electrolysis. These two methods as well as various other ones are discussed in this article. Further developments are being made every day to better treat the removal of blonde and white hair as well as to diminish the pain of hair removal. With these developments, dermatologists will better understand the advancement of hair removal methods and the reasons why patients may seek treatment.

Coma blisters in two postoperative patients.

Coma blisters are self-limited cutaneous bullae that occur in the setting of loss of consciousness because of a drug, illness, or accident, with the most common settings being barbiturate overdose and neurological disorders. The etiology behind coma blisters is poorly understood and is not related to underlying infections or autoimmune conditions. The clinical presentation consists of bullae, erosions, and violaceous plaques usually involving sites of pressure. The skin lesions usually occur within 48-72 hours of the start of a coma and resolve within 2-4 weeks. We present one case of a 5-month-old infant with severe valvular disease who required surgical repair. He was placed on extra corporeal membrane oxygenation and developed multiple tense coma blisters during the course of therapy. Skin biopsy revealed a noninflammatory subepidermal blister with necrosis of the overlying epidermis and necrosis of the eccrine ducts. We also present a second case of an 18-year-old female patient who underwent surgical resection of a benign mandibular tumor. She subsequently developed bullae on both arms 4 days after surgery. The skin biopsy showed a necrotic epidermis, a subepidermal blister, and diffuse necrosis of the eccrine coils.

Cutaneous aspergillosis masquerading as Sweet's syndrome in a patient with acute myelogenous leukemia.

To the Editor, Aspergillosis may present as primary cutaneous lesions or as secondary cutaneous emboli.1 The former typically appear as plaques with black crust, while the latter consists of necrotic papules and plaques, often with ulceration and rapid progression. Pulmonary disease with multiple, bilateral cavitating infiltrates and nodules may appear in those with disseminated cutaneous emboli.1 In hosts with neutropenia or an immunocompromised status, such as our patient, the fungus can disseminate widely. Here we present a case of a 68-year-old male with newly diagnosed acute myelogenous leukemia (AML) who developed multiple pink Sweet’s-like papules; the tissue stained positive with Gomori methenamine silver (GMS) stain, consistent with aspergillosis. A 68-year-old male with newly diagnosed AML status post-induction chemotherapy presented with a 2-day history of multiple, painful skin lesions that were indurated and erythematous. The lesions were distributed on his right finger, right neck, right foot and left cheek and spread to his left leg, left neck and occiput. Over the next few days, he developed left eye pain, periorbital swelling, decreased visual acuity and left-sided nasal congestion. Associated symptoms included recent neutropenic febrile episodes, night sweats, chills, shortness of breath and progressive fatigue. Physical examination at this time revealed rounded, well-defined pink papules with central pustules that were tender to palpation (Fig. 1). Two lesions had a blackish, eschar-like appearance in the center surrounded by an erythematous base (Fig. 2) and one lesion contained a central Fig. 1. Discrete erythematous papule and macule on the left posterior thigh.

Post-kala-azar dermal leishmaniasis in HIV-infected patients with AIDS: a report of two cases diagnosed in the USA

Post‐kala‐azar dermal leishmaniasis (PKDL) is an uncommon complication of visceral leishmaniasis (VL) but is emerging as an increasingly frequent and serious complication of acquired immunodeficiency syndrome (AIDS). It manifests as a macular, morbilliform, or nodular eruption in a patient who has recovered from VL.

Letter to the editor: Application of dapsone 5% gel in a patient with dermatitis herpetiformis.

Dermatitis Herpetiformis (DH) is a rare, blistering skin disease described by Duhring in 1884.[1] DH is strongly associated with the HLA-DQ2 phenotype, a gateway in which dietary gluten reaches inflammatory cells and stimulates an autoimmune process. The etiopathogenesis involves IgA anti-endomysial antibodies directed against tissue transglutaminase (TG); the presumed skin autoantigen is epidermal TG. IgA/TG immune complexes form locally within the papillary dermis leading to neutrophil chemotaxis and degranulation (which forms neutrophilic abscesses), proteolytic cleavage disrupting the lamina lucida, and blister subepidermal blister formation.[2] Current standard-of-care for DH is oral dapsone and a gluten-free diet. We describe a teenage patient in whom resolution of lesions was achieved with adjuvant use of topical dapsone 5% gel (aczone), the first case in the literature. A 14-year-old male had been suffering recurrent eruptions of blisters on his chest and arms for 16 months. He had been diagnosed with direct immunofluorescent proven DH based on granular IgA deposition in the upper papillary dermis. Though distinguishing LABD (linear IgA bullous dermatosis) from DH is often clinically impossible, the finding of IgA in a granular pattern at the dermoepidermal junction with accentuation in the dermal papillae was specific for DH in our patient. Upon an exacerbated eruption of blisters on the chest and shoulders, the patient presented to our clinic. On physical examination he presented with multiple, welldefined, pink keratotic papules, plaques and diffuse, hypopigmented macules and patches on the chest and shoulders, equally distributed on the left and right side. Primary lesions were counted before treatment and numbered 33 on the left side and 34 on the right side of the chest, respectively. The patient did not maintain a gluten-free diet and was receiving daily oral dapsone (25 mg). Twice daily application of topical dapsone (Aczone gel, 5%) was initiated on the right side of the patient’s chest and Aquaphor ointment to the left. Two physicians were blinded to which side received the medication. The patient was asked to follow up in four weeks. Over the following three days the patient’s skin lesions did not improve on either side of the chest. The oral dosage of dapsone was modified to 25 mg and 50 mg on alternating days. The patient continued to apply the topical products unilaterally as originally prescribed. On a follow-up visit four weeks later, the blinded physicians observed improvement of the lesions on the right side of his chest in comparison to the left. Physical exam demonstrated two remaining ulcerated vesicles on the right chest and five on the left without signs of erosion. It was also noted that relative to the left side, the skin on the right side was significantly smoother. The patient was then allowed to expand usage of topical dapsone to all affected areas and had similar improvements. There have been no reports on treating dermatitis herpetiformis using topical dapsone and the current standard-ofcare remains oral dapsone. Most clinical remissions are related to dietary gluten restriction, however, the gluten-free diet is inconvenient and unacceptable to some patients. Oral dapsone (diaminodiphenylsulfone) is the current treatment and the most effective sulfone but many physicians would prefer a non-systemic treatment choice. Though patients intolerant to dapsone may consider therapy with sulfapyridines, there is significant risk for nephrolithiasis and some patients may not respond at any dose. Although this patient had received oral and topical dapsone simultaneously, he only applied topical dapsone 5% gel to the right side, the same side which demonstrated significant improvement of the lesions. The left side where aquaphor was applied did not show the same level of improvement at four-week follow-up. High doses of oral dapsone simply increase toxicity while providing minimal benefit. The main side effects associated with oral dapsone may be classified as toxic/pharmacologic or idiosyncratic/allergic; these range from hemolytic anemia, the most common complication within 2 weeks after starting therapy, to nephritis and renal failure, precluding the need for strict monitoring of renal function tests.[3] Hemolytic anemia occurs in virtually every patient on oral therapy and may even occur in breastfed infants since dapsone is secreted in breast milk. A notable complication, especially in patients with glucose-6-phophate dehydrogenase (G6PD) deficiency, is hemolysis and methemoglobinemia due to oxidative stress from the hydroxylamine metabolite.[4] Adverse effects of dapsone are generally dose-dependent and are more commonly observed in patients with comorbid conditions such as anemia and cardiopulmonary disease.[3] Other rare complications include agranulocytosis early on, as well as a systemic drug hypersensitivity syndrome, a serious complication that requires medication withdrawal and systemic corticosteroid administration.[5] Regular follow-up visits and routine laboratory monitoring of blood counts are needed for patients receiving treatment with oral dapsone, especially during the first 3 months.[5] Dapsone is clinically useful in diseases containing neutrophilic infiltrates. Dapsone inhibits neutrophil myeloperoxidase, decreasing the damage from the neutrophil respiratory burst pathway mediated by this enzyme. The anti-inflammatory properties of topical dapsone benefit patients with acne and could also hinder the immunologic cascade and accompanying inflammatory process that occurs in DH. We attribute the efficacy of topical dapsone to a local inhibition of neutrophil chemotaxis to N-formyl-methionyl-leucyl-phenylalanine and interference of the CD11b/CD18-mediated neutrophil binding that induces chemoattractant signal transduction and inhibits leukotrienes. IgA adherence may also be inhibited though it remains to be proven.[5] Concerning our review of the literature, we conclude that there is therapeutic explanation for the moderate therapeutic effects seen from use of topical dapsone in DH. Using topical dapsone alone or in combination with a lower dose of oral dapsone is preferable to high doses of oral dapsone. Additionally, facial disease may prove refractory to oral dapsone therapy; topical dapsone gel may provide a more tolerable alternative than breaking facial vesicles and applying a potent corticosteroid gel. In order to further study the utility of topical dapsone in DH, a more extensive trial of topical dapsone is warranted. In summary, aczone appears to be a promising therapeutic agent for patients with dermatitis herpetiformis who are refractory to oral therapy and noncompliant with a gluten-free diet.