Brian J. Simmons

Acute and Chronic Cutaneous Reactions to Ionizing Radiation Therapy

Ionizing radiation is an important treatment modality for a variety of malignant conditions. However, development of radiation-induced skin changes is a significant adverse effect of radiation therapy (RT). Cutaneous repercussions of RT vary considerably in severity, course, and prognosis. When they do occur, cutaneous changes to RT are commonly graded as acute, consequential-late, or chronic. Acute reactions can have severe sequelae that impact quality of life as well as cancer treatment. Thus, dermatologists should be informed about these adverse reactions, know how to assess their severity and be able to determine course of management. The majority of measures currently available to prevent these acute reactions are proper skin hygiene and topical steroids, which limit the severity and decrease symptoms. Once acute cutaneous reactions develop, they are treated according to their severity. Treatments are similar to those used in prevention, but incorporate wound care management that maintains a moist environment to hasten recovery. Chronic changes are a unique subset of adverse reactions to RT that may develop months to years following treatment. Chronic radiation dermatitis is often permanent, progressive, and potentially irreversible with substantial impact on quality of life. Here, we also review the etiology, clinical manifestations, pathogenesis, prevention, and management of late-stage cutaneous reactions to radiotherapy, including chronic radiation dermatitis and radiation-induced fibrosis.

An update on photodynamic therapies in the treatment of onychomycosis

Onychomycosis is a common fungal infection of the nails that is increasing in prevalence in the old, diabetics and immunocompromised. Onychomycosis presents a therapeutic challenge that can lead to significant reductions in quality of life leading to both physical and psychological consequences. Current treatment modalities are difficult to implement due to the poor penetration of topical treatments to the nail bed, the slow growing nature of nails and the need for prolonged use of topical and/or oral medications. Standard of care medications have cure rates of 63–76% that leads to a high propensity of treatment failures and recurrences. Photodynamic therapy (PDT) offers an alternative treatment for onychomycosis. Methylene blue dye, methyl‐aminolevulinate (MAL) and aminolevulinic acid (ALA) have been used as photosensitizers with approximately 630 nm light. These modalities are combined with pre‐treatment of urea and/or microabrasion for better penetration. PDT treatments are well tolerated with only mild transient pain, burning and erythema. In addition, significant cure rates for patients who have contraindications to oral medications or failed standard medications can be obtained. With further enhancements in photosensitizer permeability, decreased pre‐treatment and photosensitizer incubation times, PDT can be a more efficient and cost‐effective in office based treatment for onychomycosis. However, more large‐scale randomized control clinical trials are needed to access the efficacy of PDT treatments.

Use of radiofrequency in cosmetic dermatology: focus on nonablative treatment of acne scars

Acne is a common affliction among many teens and some adults that usually resolves over time. However, the severe sequela of acne scarring can lead to long-term psychological and psychiatric problems. There exists a multitude of modalities to treat acne scars such as more invasive surgical techniques, subcision, chemical peels, ablative lasers, fractional lasers, etc. A more recent technique for the treatment of acne scars is nonablative radiofrequency (RF) that works by passing a current through the dermis at a preset depth to produce small thermal wounds in the dermis which, in turn, stimulates dermal remodeling to produce new collagen and soften scar defects. This review article demonstrates that out of all RF modalities, microneedle bipolar RF and fractional bipolar RF treatments offers the best results for acne scarring. An improvement of 25%–75% can be expected after three to four treatment sessions using one to two passes per session. Treatment results are optimal approximately 3 months after final treatment. Common side effects can include transient pain, erythema, and scabbing. Further studies are needed to determine what RF treatment modalities work best for specific scar subtypes, so that further optimization of RF treatments for acne scars can be determined.

Exogenous Ochronosis: A Comprehensive Review of the Diagnosis, Epidemiology, Causes, and Treatments

Exogenous ochronosis (EO) can be an unintended psychologically troubling condition for patients who are already being treated for longer-term hyperpigmentation disorders such as melasma. Early diagnosis is key in order that the offending agent can be stopped to prevent further disfiguring discoloration. EO can be diagnosed in the right clinical setting with the aid of dermatoscopy, which can assist in early diagnosis and may negate the need for a biopsy. Laser modalities using Q-switched lasers of longer wavelengths and combination laser dermabrasion treatments have shown the most significant results with minimal adverse events. However, further large-scale studies are needed to determine optimal treatment modalities. Although considered uncommon, the incidence of EO will likely continue to increase with the growth of immigrant populations and the use of skin-lightening agents above the FDA’s recommended over-the-counter concentrations, without the guidance of a dermatologist.

Light and laser therapies for the treatment of sebaceous gland hyperplasia a review of the literature

Sebaceous gland hyperplasia (SGH) is a benign cutaneous condition that presents primarily on the face and increases with UVB exposure and ageing. These lesions are a common cosmetic concern but are difficult to treat, as the entire sebaceous gland needs to be destroyed to prevent recurrence. Traditional methods of treatment include: cryosurgery, electrodessication, curettage, shave excision and topical trichloroacetic acid. These methods have an increased risk of skin discoloration and scarring to the area of treatment that may lead to inferior cosmetic outcomes. Alternatively, oral isotretinoin can treat SGH, but is a known teratogen in pregnancy and has high relapse rates with discontinuation. A systematic review of the literature was performed to look at photodynamic therapy (PDT) and laser treatment for SGH. According to the results of this study, PDT, lasers and combinations of the two treatments were found to offer alternatives to the more conventional techniques with better outcomes. In particular, the use of wavelength‐specific laser for the sebaceous gland of 1720 nm were found to have better outcomes and provide minimal damage to surrounding tissues. Additionally, combination PDT with aminolevulinic acid and pre‐treatment with carbon dioxide laser ablation or pulse‐dyed laser offered higher cure rates over stand‐alone laser or PDT treatments in a shorter number of sessions with similar transient side‐effects. However, further large‐scale prospective studies with adequate follow‐up are required to confirm these findings and those for sebaceous gland‐specific lasers.

Treatment of Acne Keloidalis Nuchae: A Systematic Review of the Literature

Acne keloidalis nuchae (AKN) is a chronic inflammatory condition that leads to fibrotic plaques, papules and alopecia on the occiput and/or nape of the neck. Traditional medical management focuses on prevention, utilization of oral and topical antibiotics, and intralesional steroids in order to decrease inflammation and secondary infections. Unfortunately, therapy may require months of treatment to achieve incomplete results and recurrences are common. Surgical approach to treatment of lesions is invasive, may require general anesthesia and requires more time to recover. Light and laser therapies offer an alternative treatment for AKN. The present study systematically reviews the currently available literature on the treatment of AKN. While all modalities are discussed, light and laser therapy is emphasized due to its relatively unknown role in clinical management of AKN. The most studied modalities in the literature were the 1064-nm neodymium-doped yttrium aluminum garnet laser, 810-nm diode laser, and CO2 laser, which allow for 82–95% improvement in 1–5 sessions. Moreover, side effects were minimal with transient erythema and mild burning being the most common. Overall, further larger-scale randomized head to head control trials are needed to determine optimal treatments.

1064 nm Q-switched Nd:YAG laser for the treatment of Argyria: a systematic review

Argyria is a benign skin disease characterized by blue to slate‐grey discoloration that is caused by deposition of silver granules in the skin and/or mucus membranes as a result of long‐term ingestion of ionized silver solutions or exposure to airborne silver particles. The skin discoloration can be generalized or localized and is exacerbated by sunlight. The skin discoloration is usually permanent, and until recently, there has been no effective treatment for argyria. Over the past 6 years, a number of case reports and one case series have described cases of argyria that were successfully treated with a 1064 nm Q‐switched (QS) neodymium‐doped yttrium aluminium garnet (Nd:YAG) laser; however, a review of these studies has never been reported in the dermatologic literature. To review the use of the 1064 nm QS Nd:YAG laser for the treatment of argyria. A search of the National Library of Medicines PubMed Database and the SCOPUS Database was performed to find articles that detailed the treatment of argyria with 1064 nm QS Nd:YAG laser. Six articles were selected for inclusion in this review. Each article was reviewed and summarized in a table. A 1064 nm QS Nd:YAG laser offers a novel and effective treatment for argyria. A systematic review of the dermatologic literature revealed a limited number of case reports and case series using this treatment. However, the results gleaned by the authors from the literature review provide important information to the clinician. For patients with argyria, a single pass of the 1064 nm QS Nd:YAG laser offers immediate, effective and sustained pigment clearing without any long‐term adverse effects.

An evaluation of the value of plastic surgery mission trips in resident education by attending physicians

The Journal of Cranio are needs of developi A s the health c ng countries increase, surgicalmissiontripshavebecomemorecommon.Assuch, residents will have increased opportunity to incorporate such surgicalmissions into their overall educational experience. Although the motivation to participate may primarily be a humanitarian desire, residents can simultaneously gain an invaluable learning experience. This should lead to improvement of technical skill, professional development, and global awareness. In addition, the patient populations on medical missions provide unique and challenging cases that may be scarce in the United States. However, allmedicalmission tripsarenotequivalent.Martiniuketal concluded in a literature review that there is significant scope for improvement in mission planning, monitoring, and evaluation as well as global and/or national policies regarding foreign medical missions. To promote optimum performance by mission staff, training inareas such as crosscommunication and contextual realities of mission sites should be provided. With the large number of missions conducted worldwide, efforts to ensure efficacy, harmonization with existing government programming, and transparency are needed. Existing inconsistencies among medical missions impact the available training opportunities afforded to residents. In the past, surveys of residents who have attended surgical mission trips demonstrate strong support for inclusionofmedicalmissions into resident trainingowingto increased ‘‘awareness of global health care and cultural competence.’’ However, such surveys generally provide a subjective resident perspective of their experience, without specifically addressing aspects of surgical missions that should be improved to ensure homogenized training experiences and proper patient care. There have also been several studies that highlight some of the shortcomings of surgical medical mission trips. For example, several studies suggest that postsurgical follow-up and on-site resources are frequently lacking. These deficiencies can impact resident training and diminish the quality of care provided to patients. In addition, data suggest that there remains a need for feedback on and critical evaluation of the quality of mission trips to improve the outcome of surgical procedures. To standardize resident education and improve quality of care, the Accreditation Council for Graduate Medical Education (ACGME) has outlined a set of guidelines. These guidelines mandate overseas programs to have local authority approval as well as adequate supportive units such as anesthetic and laboratories, critical care infrastructure, proper follow-up care, and certified on-site staff. Thus, the guidelines strive to create an educational experience, but at the

Cells to Surgery Quiz: August 2015.

QUESTIONS 1. A 50-year-old man underwent Mohs micrographic surgery for removal of a basal cell carcinoma on the nasal dorsum/sidewall. The resulting full-thickness wound pictured above elicits which of the following? a. Innate immune response. b. Adaptive immune response. c. Antigen presentation by dendritic cells. d. All of the above. e. None of the above. Cells to Surgery Quiz: August 2015 Mohammad-Ali Yazdani Abyaneh1, Brian J. Simmons1, Fleta N. Bray1, Mohammed Alsaidan1 and Keyvan Nouri1 Journal of Investigative Dermatology (2015) 135, e16. doi:10.1038/jid.2015.215

Cryotherapy—As Ancient as the Pharaohs

In cryotherapy, also known as cryosurgery, cold temperatures are used to treat a wide variety of skin disease in modern dermatology. However, cryotherapy has its humble roots as far back as the Egyptians in 3000 BCE, when cold compresses were used to treat the inflammation of infected wounds. In the fifth century BCE, Hannibal’s Carthaginian mercenaries experienced the hemostatic and destructive tissue effects of the cold while crossing the Alps en route to Rome. In the Napoleonic times, cooling was used for anesthesia and amputation. It was not until the mid-1800s when modern use of cryotherapy was born. James Arnott, deemed the “father of modern cryosurgery,” was the first to use salted solutions with crushed ice to freeze cancers of the breast and cervix. The temperatures reached −18°C to −24°C, which was enough to freeze the tumors and lead to a reduction in size of the lesions and improved pain management. Eventually, Arnott used his cryosurgical device on acne and neuralgia. However, the device did not get cold enough for complete tissue destruction. It was not until after the industrial revolution when temperatures of −190°C could be reached to produce and harness liquid air, marking the beginning of the dermatologic cryosurgery era. New York physician Campbell White successfully used this to treat a myriad of skin diseases, from nevi, warts, varicose leg ulcers, and chancroids to herpes zoster and epitheliomas. While this approach was still unachievable at most institutions, solid carbon dioxide became the mainstay of treatment because the temperatures required were half that of liquid air. However, the method was limited to treating superficial skin conditions less than 1 to 2 mm deep. The post–World War II era further expanded the field by making liquid nitrogen readily available. To fix the problem of inadequate penetration of tissue freezing with available techniques, solid copper discs cooled by submersion in liquid nitrogen became widespread practice. In the mid-20th century, the dermatologists and innovators Douglas Torre and Setrag Zacarian created the first handheld cryosurgery device and brought the first commercial device to market. These pioneers, along with a handful of others, established the field of dermatologic cryosurgery as it is known today. From the early observations of the Egyptians and Greeks to the practice of cryotherapy using the handheld devices today, the field of cryosurgery has come a long way. The techniques are sound and have been effective in treating a wide array of benign, premalignant, and cancerous lesions. Thus, the ancient technique of cryotherapy will continue to play a role in the modern field of dermatology for years to come.