James M. Spencer

Topical methyl-aminolevulinate photodynamic therapy using red light-emitting diode light for treatment of multiple actinic keratoses: A randomized, double-blind, placebo-controlled study

BACKGROUND The use of light-emitting diode light offers practical advantages in photodynamic therapy (PDT) with topical methyl-aminolevulinate (MAL) for management of actinic keratoses (AK). OBJECTIVE We sought to evaluate the efficacy of MAL PDT using red light-emitting diode light. METHODS We conducted a multicenter, double-blind, randomized study. A total of 49 patients with 363 AK lesions had 16.8% MAL cream applied under occlusion for 3 hours, and 47 patients with 360 AK lesions had vehicle cream similarly applied. The lesions were then illuminated (630 nm, light dose 37 J/cm2) with repeated treatment 1 week later. Complete lesion and patient (all lesions showing complete response) response rates were evaluated 3 months after last treatment. RESULTS MAL PDT was superior (P<.0001) to vehicle PDT with respect to lesion complete response (86.2% vs 52.2%, odds ratio 6.9 [95% confidence interval 4.7-10.3]) and patient complete response (59.2% vs 14.9%, odds ratio 13.2 [95% confidence interval 4.1-43.1]). LIMITATIONS The study population may not be representative of all patients with AK. CONCLUSION MAL PDT using red light-emitting diode light is an appropriate treatment alternative for multiple AK lesions.

Adverse effects of ultraviolet radiation from the use of indoor tanning equipment: Time to ban the tan

The incidence of melanoma skin cancer is increasing rapidly, particularly among young women in the United States. Numerous studies have documented an association between the use of indoor tanning devices and an increased risk of skin cancer, especially in young women. Studies have shown that ultraviolet exposure, even in the absence of erythema or burn, results in DNA damage. Countries and regulatory bodies worldwide have recognized the health risks associated with indoor tanning. In the United States, 32 states have passed legislation to regulate the indoor tanning industry, but there is an urgent need to restrict the use of indoor tanning devices at the federal level. The Food and Drug Administration is currently reviewing the classification of these devices. For all of these reasons, the Food and Drug Administration should prohibit the use of tanning devices by minors and reclassify tanning devices to at least class II to protect the public from the preventable cancers and other adverse effects caused by ultraviolet radiation from indoor tanning.

ASDS guidelines of care: injectable fillers.

S 1 1 5 Injectable soft tissue augmentation materials available for use in the United States have proliferated during the past 5 years. In addition to bovine collagen and autologous fat, physicians can now choose between numerous other options, including hyaluronic acid derivatives, poly-L-lactic acid, injectable calcium hydroxylapatite, injectable liquid silicone, polymethylmethacrylate microspheres, and human collagen. While these materials are generally safe and versatile, each has specific features that inform its best use. The guidelines presented herein are not intended to delineate the standard of care but rather to present how most injectors commonly use these materials in patients. These guidelines are a consensus document produced by the ASDS Guidelines of Care Task Force in conjunction with recognized experts in the field who have volunteered their time. While efforts have been made to maintain accuracy and timeliness at the point of submission, these guidelines will no doubt evolve over time and should be considered in the context of the patients’ individual needs. In the 1970s, research into collagen production led to a bovine formulation that could be placed in a syringe and injected. Because of bovine collagen’s temporary persistence, and requirement for skin testing, other fillers were developed and tested in Europe, Asia, and North America in the 1990s. Today, there are a number of fillers to choose from, each with its own strengths and drawbacks.

Tumors with Smooth Muscle Differentiation

BACKGROUND. In the classification of tumors of soft tissue, modern schemes describe tumors by the normal adult tissue type the tumor resembles. Thus, tumors are described as smooth muscle tumors if the cells are differentiating towards smooth muscle. We may infer that in fact the tumor arose from smooth muscle, but this is only an inference. Tumors showing differentiation towards smooth muscle include hamartomas, benign tumors, and malignant tumors. OBJECTIVE. This review article describes the clinical presentation and course, histology, and treatment recommendations for benign and malignant smooth muscle tumors. METHODS. An extensive literature review of tumors with differentiation towards smooth muscle. RESULTS Benign tumors exhibiting differentiation towards smooth muscle include smooth muscle hamartoma and leiomyoma. Myofibroma is a third tumor that some have argued is a smooth muscle tumor rather than a fibroblastic tumor. Characteristic fusiform shaped cells with a round central nucleus arranged in fasicles suggest smooth muscle differentiation. Special stains such as phosphotungenistic acid‐hemotoxilin, analine blue, and Massons trichrome are helpful in differentiating muscle from collagen. Immunohistochemical stains are also helpful in establishing a diagnosis. With solitary tumors, treatment for cosmesis or for painful leiomyomas is not a problem. Multiple leiomyomas, which may be painful or sensitive to cold or touch, are a therapeutic challenge, with reports of multiple medications being attempted in the literature. Leiomyosarcoma are malignant tumors of smooth muscle. They may be cutaneous and presumably arise from the arreclor pilorum muscle, or subcutaneous, where they are believed to arise from vascular smooth muscle. Cutaneous leiomyosarcomas frequently reoccur following excision, but rarely metastasize. Subcutaneous leiomyosarcomas frequently reoccur following excision and have a high metastatic rate. Several recent reports have documented an increased frequency of visceral leiomyosarcomas in immunasup‐pressed patients. These tumors have been found to contain the Epstein Ban virus. Treatment of leiomyosarcoma is wide excision. CONCLUSIONS. Smooth muscle tumors are rare neoplasms that may confront the dermatologic surgeon. While leiomyomas are benign, their frequent sensitivity or pain necessitates treatment. Leiomyosarcomas are malignancies with a high reoccurrence rate, and when deep, a high metastatic rate. The finding of an increased frequency of visceral leiomyomas and leiomyosarcomas in immunosuppressed patients may imply an increased frequency of cutaneous leiomyomas and leiomyosarcomas in this patient population.

Botulinum B treatment of the glabellar and frontalis regions: a dose response analysis

BACKGROUND: Botulinum toxin injections represent the most commonly performed cosmetic procedure in the US. There is an enormous reported experience documenting the efficacy of botulinum toxin A injections. There is very limited published information about the efficacy and appropriate dosage of botulinum toxin B injections. OBJECTIVE : The aim of this study was to evaluate the dosage response and side effect profile of botulinum toxin B injections. METHOD : Twenty-six subjects received botulinum B injections to their glabellar area. Eighteen subjects received botulinum B injections to their frontalis region. Three different dosages were used. In the glabellar treated subjects the low dose group received a total of 1875 units; the medium dose group received a total of 2500 units; and the high dose group received a total of 3125 units. In the frontalis treated group, the low dose group received a total of 2250 units; the medium dose group received a total of 3000 units; and the high dose group received a total of 3750 units of botulium B toxin. RESULTS: In the glabellar group, most subjects showed some evidence of paralysis at 2 months. Only in the high dose group did a significant cadre of treated subjects still show a significant response at 3 months after treatment. In the frontalis group, response was often still seen at 2 months. However, at 3 months most subjects showed no continued effect from botulinum B toxin. CONCLUSION: Botulinum B toxin injections represent an alternative to botulinum A treatment for glabellar and frontalis hyperkinetic wrinkles. At the doses utilized in this study, the effect does not generally appear to last as long as has been reported with botulinum A injections. However, the onset of action may be sooner with botulinum B injections.

Bednar tumor (pigmented dermatofibrosarcoma protuberans) occurring in a site of prior immunization: Immunochemical findings and therapy

Bednar tumor is a rare pigmented variant of dermatofibrosarcoma protuberans (DFSP). Because of its rarity, information is lacking regarding the optimal therapy and potential utility of immunohistochemistry in diagnosis. We report a case of Bednar tumor in which the diagnosis was aided by immunohistochemistry for CD34, an antigen known to be expressed in DFSP but not previously reported in Bednar tumor. Our case was also striking because it represents the first reported appearance of a Bednar tumor at a site of prior immunization, a phenomenon previously noted in some cases of DFSP. The patient was treated effectively with Mohs surgery and is without recurrence at 9 months.

Pilot study of imiquimod 5% cream as adjunctive therapy to curettage and electrodesiccation for nodular basal cell carcinoma

BACKGROUND Curettage and electrodesiccation (C&D) is a widely used method to treat nodular basal cell carcinoma (BCC). However, residual tumor is present immediately after the procedure in approximately 20 to 40% of cases. Imiquimod, a topical immune response modifier that targets Toll-like receptor 7, is currently approved for superficial BCC. OBJECTIVE In a double-blind, vehicle-controlled study, the administration of imiquimod after C&D was investigated to determine if the combination regimen would reduce the frequency of residual tumor compared with C&D alone in patients with nodular BCC. METHODS Twenty patients received three cycles of C&D followed by imiquimod 5% or vehicle cream once daily for 1 month as adjunctive therapy. The primary end point was the frequency of residual tumor. The secondary end points included the time to heal and cosmetic appearance. RESULTS Twenty patients were randomized to imiquimod (n = 10) or vehicle (n = 10) treatment group. At 8 weeks, the proportion of patients with residual tumor was substantially decreased with imiquimod therapy (10%) compared with vehicle (40%). Wounds in the vehicle group healed more quickly than those in the imiquimod group, although by 8 weeks, all excision sites were healed. The majority of scars in the control group were atrophic and hypopigmented, whereas most scars in the imiquimod group were flat and slightly pink. CONCLUSION Imiquimod 5% cream once daily for 1 month as adjunctive therapy after C&D substantially reduced the frequency of residual tumor and improved the cosmetic appearance compared with C&D alone. These preliminary results suggest that further studies to investigate imiquimod adjunctive therapy are warranted.

Surgical myths in dermatology.

Throughout medical training and clinical practice, many of our surgical tenets and practices are deep seated and believed to be evidence based. Numerous current surgical practices are actually not based on randomized controlled studies but rather on experience. Developing strong clinical studies in

Understanding actinic keratosis: Epidemiology, biology, and management of the disease

T his supplement on actinic keratosis (AK) presents information that is current and relevant, such that the clinician will gain insight into the alterations in biological pathways that lead to development of AK, aswell as understand the clinical options and strategies for its management. The supplement was initiated by a steering committee of advisors who identified the key clinical topics that address the development and therapeutic management of AK in photodamaged skin. In the first article, Drs Rosen and Lebwohl review the epidemiologic landscape to capture updates in the demography and burden of AK. The authors describe the variability in the clinical presentation of AK, which contributes to the challenge in enumerating and classifying these common skin lesions. The presence of AK indicates an increased risk for both squamous cell carcinoma and probably basal cell carcinoma as well. A multifaceted approach is needed to reduce the prevalence and progression of AK. In the second article, Drs Berman and Cockerell present an important review of the mutagenic and immunomodulatory effects of ultraviolet (UV) radiation, which together lead to photocarcinogenesis by UVA and UVB radiation. Although this article is not intended to exhaustively review the mediators implicated in pathogenesis of AK, it does provide a framework for understanding the keymechanisms in AK pathologies and their relationships. The authors of the third article, Drs Rigel and Stein Gold, point out that patient attitudes contribute to delays in the identification and treatment of AK. Although it is not possible to identify which specific AK lesions will progress, certain characteristics are associated with an increased risk of invasive squamous cell carcinoma. AK is a disease that reflects the field cancerization effects of UV radiation. Histopathologic analysis remains the gold standard

Prevalence of methicillin-resistant Staphylococcus aureus in the setting of dermatologic surgery.

BACKGROUND The prevalence of methicillin‐resistant Staphylococcus aureus (MRSA) in the postoperative setting of dermatologic surgery is unknown. Such data could influence the empirical treatment of suspected infections. OBJECTIVE To examine the period prevalence of MRSA infections in the postoperative setting of dermatologic surgery. METHODS We performed chart reviews of 70 patients who had bacterial cultures taken from January 2007 to December 2007. In the 21 postsurgical cases, we analyzed age, risk factors, sites of predilection, method of repair, and pathogen of growth. RESULTS The mean age of the overall study population was 57, with the mean age of postsurgical MRSA‐positive cases being 75.5. Of the 21 postsurgical cultures taken, 16 cultures grew pathogen, and two of the 16 (13%) pathogen‐positive cultures grew MRSA. LIMITATIONS This is a retrospective chart review of a relatively small sample size in one geographic location. Our patient population is known to contain a large number of retirees. CONCLUSION The increasing prevalence of MRSA skin and soft tissue infections and recommendation to modify empirical antibiotic therapy have been well documented in particular patient populations, but we caution against the empirical use of MRSA‐sensitive antibiotics in the postoperative setting of dermatologic surgery. We advocate culturing all infectious lesions upon presentation and reserve empirical use of MRSA‐sensitive antibiotics for high‐risk patients or locations. The authors have indicated no significant interest with commercial supporters.