Deede Liu

Ensuring that injectable bicarbonate-buffered lidocaine-epinephrine complies with 2015 United States Pharmacopeia (USP) compounding provisions.

L idocaine’s rapid onset and relatively short duration make it a popular choice in dermatology practice. Because it is pregnancy category B, lidocaine can safely be used in most patients, including children and pregnant women. Epinephrine is often added at 1:100,000 or 1:200,000 to constrict blood vessels, thus prolonging the duration of anesthesia. Because epinephrine is stable only in acidic environments, pH of lidocaineepinephrine is lowered to 3.5 to 5.5 via acidic preservatives. This can cause injection site pain, and delay anesthesia onset. ‘‘Buffering’’ by adding 1 part 8.4% sodium bicarbonate to 10 parts lidocaineepinephrine can raise pH to address both pain and delay. Other less commonly used local anesthetics such as bupivacaine and mepivacaine can also be buffered. Combining 2 medicines, such as lidocaine-epinephrine1 bicarbonate, in a single syringe, is considered to be ‘‘compounding,’’ defined as combining, mixing, or altering ingredients of 2 or more drugs to create a medication tailored to the needs of an individual patient. Because epinephrine activity declines at 25% per week in alkaline or neutral environments, standard texts recommend that it be used within 1 to 2 weeks after initial preparation. Because infections from in-office compounding of lidocaine-epinephrine 1 bicarbonate have not been reported, textbook guidelines are based on the loss of epinephrine activity rather than the potential infection risk.

Treating gingival pemphigus vulgaris with cotton balls soaked in topical steroid ointment

SOLUTION We describe use of a cotton ball technique for applying topical steroid ointment to gingival pemphigus vulgaris lesions. Topical steroid ointment is applied to the cotton ball, after which the cotton ball is inserted adjacent to the desired gingival treatment area, and left in place for 1 hour. This increases duration of contact between topical steroid and lesion, without the discomfort and bleeding risks associated with intralesional steroid injections and carrier trays.

Mitigation or prevention of mild hair dye contact dermatitis after pretreatment with clobetasol foam

SOLUTION For patients with early, mild hair dye dermatitis, clobetasol propionate foam 0.05% is applied to the affected areas twice a day for 3 days before coloring. This application has minimal or no effect on cosmetic outcome. Hair dyes are typically reapplied every 6-10 weeks, and clobetasol foam pretreatment can be repeated before each subsequent coloring session. Pretreatment with clobetasol foam carries a lower risk for side effects than typical prolonged postcoloring use of potent topical steroids.

Skin Cancer in the Immunocompromised

Skin cancer in organ transplant recipients (OTRs) and other immunosuppressed populations is a significant health care concern. The more than two million American OTRs have a dramatically increased risk for developing squamous cell cancer, as well as a variety of other skin cancers, including basal cell cancer, melanoma, Merkel cell carcinoma, and Kaposi sarcoma. Skin cancer risk is also increased among patients receiving immunosuppressive treatment for various autoimmune diseases such as rheumatoid arthritis, inflammatory bowel disease, and psoriasis, and also patients infected with the human immunodeficiency virus. Management of cutaneous neoplasia in these at-risk populations includes topical therapies, photodynamic therapy, systemic retinoids, surgical excision, as well as multidisciplinary care involving patient education and frequent dermatological examinations. In OTRs and autoimmune patients the revision of immunosuppression is also a key treatment consideration for aggressive skin cancers.