Jason Emer

Complications of minimally invasive cosmetic procedures: prevention and management.

Over the past decade, facial rejuvenation procedures to circumvent traditional surgery have become increasingly popular. Office-based, minimally invasive procedures can promote a youthful appearance with minimal downtime and low risk of complications. Injectable botulinum toxin (BoNT), soft-tissue fillers, and chemical peels are among the most popular non-invasive rejuvenation procedures, and each has unique applications for improving facial aesthetics. Despite the simplicity and reliability of office-based procedures, complications can occur even with an astute and experienced injector. The goal of any procedure is to perform it properly and safely; thus, early recognition of complications when they do occur is paramount in dictating prevention of long-term sequelae. The most common complications from BoNT and soft-tissue filler injection are bruising, erythema and pain. With chemical peels, it is not uncommon to have erythema, irritation and burning. Fortunately, these side effects are normally transient and have simple remedies. More serious complications include muscle paralysis from BoNT, granuloma formation from soft-tissue filler placement and scarring from chemical peels. Thankfully, these complications are rare and can be avoided with excellent procedure technique, knowledge of facial anatomy, proper patient selection, and appropriate pre- and post-skin care. This article reviews complications of office-based, minimally invasive procedures, with emphasis on prevention and management. Practitioners providing these treatments should be well versed in this subject matter in order to deliver the highest quality care.

Review of ustekinumab, an interleukin-12 and interleukin-23 inhibitor used for the treatment of plaque psoriasis.

The pathogenesis of psoriasis is unknown, although it is generally accepted that this chronic inflammatory skin disorder is a complex autoimmune condition similar to other T-cell mediated disorders. Psoriasis imposes a heavy burden on the lifestyle of those affected due to the psychological, arthritic, and cutaneous morbidities; thus significant research has focused on the genetic and immunologic features of psoriasis in anticipation of more targeted, efficacious, and safe therapies. Recently, CD4+ T helper (Th) 17 cells and interleukins (IL)-12 and -23 have been important in the pathogenesis of T-cell mediated disorders such as psoriasis and has influenced the development of medications that specifically target these key immunological players. Ustekinumab is a monoclonal antibody belonging to a newly developed class of biological, anti-cytokine medications that notably targets the p40 subunit of both IL-12 and -23, both naturally occurring proteins that are important in regulating the immune system and are understood to play a role in immune-mediated inflammatory disorders. Ustekinumab’s safety and efficacy has been evaluated for the treatment of moderate-to-severe plaque psoriasis in 3 phase III clinical trials, 2 placebo-controlled (PHOENIX 1 and 2), and 1 comparator-controlled (ACCEPT) study which proved advantageous in patients who were treatment-naive, previously failed other immunosuppressive medications including cyclosporine or methotrexate, were unresponsive to phototherapy, or were unable to use or tolerate other therapies. Ustekinumab has also been investigated for other indications such as psoriatic arthritis, Crohn’s disease, and relapsing/remitting multiple sclerosis. We present a concise review evaluating the evidence that supports the use of ustekinumab in the treatment of plaque psoriasis and other conditions.

Female pattern alopecia: current perspectives

Hair loss is a commonly encountered problem in clinical practice, with men presenting with a distinctive pattern involving hairline recession and vertex balding (Norwood-Hamilton classification) and women exhibiting diffuse hair thinning over the crown (increased part width) and sparing of the frontal hairline (Ludwig classification). Female pattern hair loss has a strikingly overwhelming psychological effect; thus, successful treatments are necessary. Difficulty lies in successful treatment interventions, as only two medications – minoxidil and finasteride – are approved for the treatment of androgenetic alopecia, and these medications offer mediocre results, lack of a permanent cure, and potential complications. Hair transplantation is the only current successful permanent option, and it requires surgical procedures. Several other medical options, such as antiandrogens (eg, spironolactone, oral contraceptives, cyproterone, flutamide, dutasteride), prostaglandin analogs (eg, bimatoprost, latanoprost), and ketoconazole are reported to be beneficial. Laser and light therapies have also become popular despite the lack of a profound benefit. Management of expectations is crucial, and the aim of therapy, given the current therapeutic options, is to slow or stop disease progression with contentment despite patient expectations of permanent hair regrowth. This article reviews current perspectives on therapeutic options for female pattern hair loss.

Update on the management of rosacea

Refining diagnostic criteria has identified key characteristics differentiating rosacea, a chronic skin disorder, from other common cutaneous inflammatory conditions. The current classification system developed by the National Rosacea Society Expert Committee consists of erythematotelangiectatic, papulopustular, phymatous, and ocular subtypes. Each subtype stands as a unique entity among a spectrum, with characteristic symptoms and physical findings, along with an intricate pathophysiology. The main treatment modalities for rosacea include topical, systemic, laser, and light therapies. Topical brimonidine tartrate gel and calcineurin inhibitors are at the forefront of topical therapies, alone or in combination with traditional therapies such as topical metronidazole or azelaic acid and oral tetracyclines or isotretinoin. Vascular laser and intense pulsed light therapies are beneficial for the erythema and telangiectasia, as well as the symptoms (itching, burning, pain, stinging, swelling) of rosacea. Injectable botulinum toxin, topical ivermectin, and microsecond long-pulsed neodymium-yttrium aluminum garnet laser are emerging therapies that may prove to be extremely beneficial in the future. Once a debilitating disorder, rosacea has become a well known and manageable entity in the setting of numerous emerging therapeutic options. Herein, we describe the treatments currently available and give our opinions regarding emerging and combination therapies.

Emotional benefit of cosmetic camouflage in the treatment of facial skin conditions: personal experience and review

Background Recent studies highlighting the psychological benefits of medical treatment for dermatological skin conditions have demonstrated a clear role for medical therapy in psychological health. Skin conditions, particularly those that are overtly visible, such as those located on the face, neck, and hands, often have a profound effect on the daily functioning of those affected. The literature documents significant emotional benefits using medical therapy in conditions such as acne, psoriasis, vitiligo, and rosacea, but there is little evidence documenting similar results with the use of cosmetic camouflage. Here we present a review highlighting the practical use of cosmetic camouflage makeup in patients with facial skin conditions and review its implications for psychological health. Methods A search of the Medline and Scopus databases was performed to identify articles documenting the emotional benefit of cosmetic camouflage. Results Cosmetic camouflage provides a significant emotional benefit for patients with facial skin conditions, and this is substantiated by a literature review and personal experience. More clinical studies are needed to assess and validate the findings reported here. Conclusion Patients with visible skin conditions have increased rates of depression, anxiety, and decreased self-esteem. It is prudent for us to consider therapies that can offer rapid and dramatic results, such as cosmetic camouflage.

Assessment of safety and efficacy of a bipolar fractionated radiofrequency device in the treatment of photodamaged skin.

Abstract Background: A number of devices are available for skin rejuvenation and conventional devices include both ablative and non-ablative lasers. More recently, bipolar fractionated radiofrequency (RF) devices have been introduced. Objective: To evaluate the safety and efficacy of a novel 144 pin high density tip bipolar fractionated radiofrequency (RF) device for skin rejuvenation in Fitzpatrick skin types I-IV. Methods and materials: This single-center, prospective, study enrolled 25 female between the ages of 35–60 years, with mild to moderate wrinkling based on the Fitzpatrick Wrinkle Scale. The subjects were of Fitzpatrick skin types I-IV. Each subject underwent 3 full-face treatments with a 144 pin fractional bipolar RF device at 30-day intervals. All subjects underwent clinical evaluations during the study period to evaluate for any adverse events. Subsequently, all subjects were evaluated for improvement in rhytides, dyschromias and skin texture based on photographic evaluation by blinded investigators at 6 months following the final RF treatment. Results: A statistically significant improvement in rhytides, dyschromias and texture was noted. Adverse events were limited to mild erythema and swelling. Post-inflammatory pigmentary changes were not observed in any subjects. Conclusion: The novel 144 pin high density tip bipolar fractionated RF device is both safe and effective for facial skin rejuvenation in Fitzpatrick skin types I-IV.

Fatal Influenza A(H1N1) Respiratory Tract Infection in a Patient Having Psoriasis Treated With Infliximab

BACKGROUND The use of biologic agents represents a remarkable advance for patients with psoriasis and psoriatic arthritis who have experienced an incomplete response to other therapeutic modalities. Decreased mortality and improved quality of life have been reported in patients undergoing treatment with these agents. Increased risk of bacterial, viral, granulomatous, and opportunistic infections also has been associated with the use of these medications. Enhanced patient education, watchful monitoring to promote early detection of infections, discontinuation of the medication when clinical symptoms are identified, and immediate availability of supportive care are advised to balance the benefit of treatment with biologic agents against the potential risk of infection. Herein, we discuss the risk of infection and the monitoring and vaccination guidelines in patients having psoriasis treated with biologic agents. OBSERVATIONS A woman with obesity and psoriasis that had previously been successfully treated with efalizumab (Raptiva) for 3 years was started on a regimen of infliximab (Remicade) to treat a flare. She died 1 week after her first infusion of infliximab and was found to have had influenza A(H1N1). CONCLUSIONS We report the first case to date of a patient with psoriasis who died of influenza A(H1N1) respiratory tract infection while undergoing treatment with infliximab. Further observations are needed to make a causal association.

Botanicals and anti-inflammatories: natural ingredients for rosacea.

Rosacea is a chronic inflammatory skin condition characterized by cutaneous hypersensitivity. There are many therapeutic options available for the treatment of rosacea, but none are curative. Since the pathogenesis of rosacea remains elusive, it is not surprising that no single treatment is paramount and that many patients find therapies unsatisfactory or even exacerbating. Treatments are prescribed to work in concert with each other in order to ameliorate the common clinical manifestations, which include: papules and pustules, telangiectasias, erythema, gland hypertrophy, and ocular disease. The most validated topical therapies include metronidazole, azelaic acid, and sodium sulfacetamide-sulfur. Many other topical therapies, such as calcineurin inhibitors, benzoyl peroxide, clindamycin, retinoids, topical corticosteroids, and permethrin have demonstrated varying degrees of success. Due to the inconsistent results of the aforementioned therapies patients are increasingly turning to alternative products containing natural ingredients or botanicals to ease inflammation and remit disease. Additional research is needed to elucidate the benefits of these ingredients in the management of rosacea, but some important considerations regarding the natural ingredients with clinical data will be discussed here.

Treatment of Porokeratosis of Mibelli With Combined Use of Photodynamic Therapy and Fluorouracil Cream

A 45-year-old white man with a medical history that was remarkable for human immunodeficiency virus and AIDS complicated by Kaposi sarcoma presented with a 14-year history of a recurring scaly, pruritic lesion on the dorsal aspect of his left shin. The lesion was refractory to treatment with topical corticosteroids, tazarotene, salicylic acid, and various emollient and keratolytic creams. Recently, the lesion had become increasingly large, pruritic, painful, and cosmetically displeasing. Skin examination of the left dorsal shin area showed a thick, hyperkeratotic plaque with a distinct, raised annular border (Figure 1). A skin biopsy specimen revealed a broad-based parakeratotic column of cells traversing the stratum corneum (cornoid lamella), an underlying epidermis devoid of a granular layer, and dissolution of basal cells with shouldering acantholysis. A sparse, nonspecific, lymphocytic infiltrate was seen in the upper dermis (Figure 2). The clinical and histopathologic features supported a diagnosis of porokeratosis of Mibelli (PM). The patient was treated with a 4-week trial of imiquimod cream followed by an 8-week trial of fluorouracil cream, without success.

Biologics in the treatment of psoriasis and emerging new therapies in the pipeline

Correspondence: Jason J Emer Mount Sinai School of Medicine, Department of Dermatology, 5 East 98th Street, 5th Floor, New York, NY 10029, USA Tel +1 212 659 9530 Fax +1 212 348 7434 Email Jason.emermd@gmail.com Abstract: Elucidation of the immunopathogenesis of psoriasis has led to the discovery of novel biologic agents for the treatment of moderate-to-severe plaque psoriasis. There are currently five biologic agents approved by the US Food and Drug Administration for psoriasis which have proven to be quite efficacious in clinical trials and in post-marketing and clinical experience. As more details are uncovered about the immunologic pathways involved in initiation and maintenance of this disease, there will be an increasing development and marketing of novel therapeutics. It is crucial to understand the immunopathogenesis of psoriasis and the mechanisms of these novel agents in order to to treat the psoriatic population effectively and mitigate disease burden. This article reviews the currently approved biologics for the treatment of psoriasis, with emphasis on efficacy and safety. There are countless therapies currently in the research pipeline, with mechanisms ranging from receptor antagonism to signal transduction pathway inhibition. The initial trials and future studies involving these new agents are also reviewed. As therapeutics escalate through the research pipeline, the management and treatment of psoriasis will likely become more manageable for practitioners and patients.