Lance W. Chapman

Review of treatment for alopecia totalis and alopecia universalis

Alopecia areata (AA) is an autoimmune disease directed at the hair follicle. Although usually limited to patchy hair loss over the scalp (focalis), AA can present as total loss of scalp hair (totalis; AT) or as total loss of both scalp and body hair (universalis; AU). Management of AT and AU can be challenging, and although multiple treatment modalities have been explored, no therapy is currently FDA‐approved. This review focuses on the evidence for current treatment options for AT and AU. The PubMed database was searched from January 1, 2000, to September 1, 2016, for clinical trials, retrospective studies, and case reports of treatments for AT and AU. A total of 40 studies were retrieved and analyzed. Therapies studied for AT/AU included: topical immunotherapy, steroids, photodynamic therapy, immunosuppressive agents, TNFα inhibitors, and other therapies, such as sulfasalazine, bexarotene, JAK inhibitors, and simvastatin/ezetimibe. Although certain treatments showed significant hair regrowth, no treatment was completely effective. The most promising therapies with the highest quality data include diphenylcyclopropenone, squaric acid dibutylester, photodynamic therapy, steroids, and cyclosporine in combination with methylprednisolone. High‐quality randomized‐controlled trials with large sample sizes are lacking. Unified outcome guidelines are encouraged to facilitate the comparison of future studies.

Laser treatment of nongenital verrucae a systematic review

IMPORTANCE Although cutaneous warts are common lesions, full remission is not always achieved with conventional therapies. Laser modalities including carbon dioxide (CO2), erbium:yttrium-aluminum-garnet (Er:YAG), pulsed dye (PDL), and Nd:YAG have been investigated as alternative treatments for warts. OBJECTIVE To review the use and efficacy of lasers for treating nongenital cutaneous warts. EVIDENCE REVIEW Published randomized clinical trials (RCTs), cohort studies, case series, and case reports involving laser treatment of nongenital warts were retrieved by searching PubMed with no date limits. Quality ratings of studies were based on a modified version of the Oxford Centre for Evidence-Based Medicine scheme for rating individual studies. A higher emphasis was placed on RCTs and prospective cohort studies with large sample sizes and detailed methodology. FINDINGS There were 35 studies published between 1989 and 2015 that comprised an aggregate of 2149 patients. Simple and recalcitrant nongenital warts treated with lasers show variable response rates (CO2 laser, 50%-100%; Er:YAG laser, 72%-100%; PDL, 47%-100%; and Nd:YAG laser, 46%-100%). Current RCTs suggest that PDL is equivalent to conventional therapies such as cryotherapy and cantharidin. Combination therapies with lasers and other agents including bleomycin, salicylic acid, and light-emitting diode have shown some success. CONCLUSIONS AND RELEVANCE Lasers can be an effective treatment option for both simple and recalcitrant warts. The lasers most studied for this purpose are CO2, PDL, and Nd:YAG, and of these, PDL has the fewest adverse effects. Currently, use of lasers for wart treatment is limited by lack of established treatment guidelines. Future studies are needed to compare laser modalities with each other and with nonlaser treatment options, and to establish optimal treatment protocols.

Utilizing break-even analysis in a competitive laser market: Utilizing Break-Even Analysis in a Competitive

A break-even analysis (BEA) is often used in the business world to determine exactly when the business will be able to cover all of its expenses and generate profit. A BEA can be particularly useful when contemplating expansion and new purchases. Without consulting services, practitioners who utilize lasers can often find the notion of strategic planning and financial considerations overwhelming and not part of their acquired skillsets. However, with the increasingly competitive laser market, it is critical that a laser practitioner equip himself/herself with the basic business knowledge to be able to make an informed decision with respect to a major laser purchase. Here we detail the critical ingredients of a BEA for a fractional ablative laser device, specifically a 10,600nm ablative fractional CO2 laser, in order to educate practitioners on the financial considerations of laser acquisition. In order to perform a BEA as an educational tool for laser acquisition financial planning, we selected one publicly trading company that generated an annual revenue greater than

Awareness of Surgical Smoke Risks and Assessment of Safety Practices During Electrosurgery Among US Dermatology Residents

50million. The company provided its pro forma return on investment (ROI) projection for its 10,600nm fractional ablative CO2 laser. Laser device has been replaced with generic terminology to comply with ACCME guidelines. Break-even point (BEP) is the point in time in which total costs and total revenue are equal and one is able to generate profit thereafter. Laser revenue (R) is equivalent to the procedure fee (P) for each laser treatmentmultiplied by unit sales (X) (number of procedures performed for that particular laser treatment). Total costs include fixed costs (FC) and variable costs (VC). Fixed costs (FC) do not change with the volume of patients treated (laser purchase price, warranty, cost of operation such as overhead and cost of staff time, leasing, maintenance of certification). After a fixed warranty period is over (typically 1–2 years), practitioners often proceed with an annual maintenance contract (AMC) which generally includes all parts and maintenance and is estimated to be 22% of the invoice value [1]. Variable costs (VC) fluctuate with the number of patients treated and laser activity (cost of consumables/disposables (tips), and occasionally marketing expenses). Variable costs depend on each individual practice (academic vs. private), but can be estimated as approximately 10% of total revenue. Another useful concept in a BEA is contribution margin, which is essentially revenue minus variable costs. See Table 1 for our BEA for our selected 10,600 nm fractional ablative CO2 laser. Of note, the procedure fee in this example is the company’s “estimated fee” assuming a full-face fractional ablative treatment session. Procedure fees vary widely from practice to practice and between geographic locations and are driven by local and regional competition. BEA can be tremendously useful for laser practitioners in determining the number of treatment sessions needed to begin generating profit. AlthoughROI pro forma templates from companies are helpful in identifying several critical components of a BEA (in particular cost of ownership), each analysis will differ based on cost of operation (overhead and cost of staff time); therefore, fixed and variable costs will differ depending on the clinical context, the device utilized, and the indications being treated. We hope that this laser acquisition example illustrates the feasibility for practitioners to perform a BEA and make financially sound decisions with respect to purchase of a laser device. Lance W. Chapman MD, MBA Katherine Ferris MD Christopher Zachary MBBS, FRCP Department of Dermatology, UC Irvine Medical Center, Irvine, California

Classic autoimmune type 1 diabetes mellitus after a case of drug reaction with eosinophilia and systemic symptoms (DRESS)

This study assessed clinician awareness of surgical smoke risks and current safety practices during active electrosurgery among dermatology residents.

Laser treatment of cutaneous angiokeratomas: A systematic review

Author(s): Chiang, Audris; Shiu, Jessica; Elsensohn, Ashley N; Chapman, Lance W; de Feraudy, Sebastien; Smith, Janellen

Scrotal Melanoma: A Systematic Review of Presentation, Treatment, and Outcomes

Angiokeratomas can present therapeutic challenges, especially in cases of extensive lesions, where traditional surgical methods carry high risks of scarring and hemorrhage. Argon, pulsed dye (PDL), neodymium‐doped yttrium aluminum garnet (Nd:YAG), copper vapor, potassium titanyl phosphate, carbon dioxide, and erbium‐doped yttrium aluminum garnet (Er:YAG) lasers have emerged as alternative options. To review the use and efficacy of lasers in treating angiokeratomas. A PubMed search identified randomized clinical trials, cohort studies, case series, and case reports involving laser treatment of cutaneous angiokeratomas. Twenty‐five studies were included. Quality ratings were assigned using the Oxford Centre for Evidence‐Based Medicine scheme. Several laser modalities are effective in treating multiple variants of angiokeratomas. Vascular lasers like PDL, Nd:YAG, and argon are the most studied and of these, PDL offers the safest side effect profile. Nd:YAG may be more effective for hyperkeratotic angiokeratomas. Combination treatment with multiple laser modalities has also demonstrated some success. Lasers are a promising treatment option for angiokeratomas, but current use is limited by the lack of treatment guidelines. There are limited high quality studies comparing laser treatments to each other and to non‐laser options. Additional studies are needed to establish guidelines and to optimize laser parameters.

Quality of life outcomes associated with treatment of human immunodeficiency virus (HIV) facial lipoatrophy.

BACKGROUND Primary male genital melanomas are rare. Of these, scrotal melanoma is the least common, and is unfortunately often detected late in the disease course. OBJECTIVE To assess the clinical presentation, treatment modalities, and outcome of scrotal melanoma to aid clinician management. METHODS Systematic literature review of PubMed, yielding 23 cases, of which 20 met the inclusion criteria. RESULTS Although previously thought to have the best outcome of genitourinary melanomas, scrotal melanomas are associated with high mortality and late presentation. Scrotal melanoma presented as Stage I/II disease 18.75% of the time, Stage III 56.3% of the time, and Stage IV 25% of the time, whereas typical cutaneous melanoma presents as Stage I/II disease 84% of the time, Stage III 8% of the time, and Stage IV 4% of the time. Half of patients experienced recurrence of their disease. All patients who presented with metastases to distant organs died. LIMITATIONS Small sample size. Few cases described a Breslows depth making it difficult to draw conclusions on tumor thickness and survival outcome. CONCLUSION Scrotal melanoma is rare, aggressive, and is often caught late in the disease course. The authors encourage dermatologists to educate patients and destigmatize genital lesions to increase the likelihood of earlier detection and better patient outcomes.

Challenges to smartphone applications for melanoma detection

Facial lipoatrophy (FLA), characterized by a decrease in facial volume, has a high prevalence in patients with human immunodeficiency virus (HIV) infection treated with long‐term highly active antiretroviral therapy (HAART). The social stigmatization that results from such changes in facial appearance has led some HIV patients to discontinue HAART. The use of fillers is one method of restoring facial volume. A critical outcome of treatment concerns the patients quality of life (QoL). Although many studies have assessed patient satisfaction, as well as the social and psychological outcomes associated with the correction of HIV FLA, fewer studies have assessed QoL. We reviewed treatment options for HIV FLA with a specific focus on QoL outcomes. Our analysis revealed that the following treatments were associated with improvements in QoL: poly‐l‐lactic acid; calcium hydroxylapatite; hyaluronic acid; polyacrylamide gel; polyalkylamide gel; polymethylmethacrylate; silicone oil; and autologous fat transfer. The treatment of HIV FLA with these agents appears to improve QoL as assessed by various QoL instruments. Additional studies are required to identify a unifying QoL instrument to effectively assess longitudinal QoL outcomes and to compare treatment modalities.