Philip Bekhor

Timolol Maleate 0.5% or 0.1% Gel‐Forming Solution for Infantile Hemangiomas: A Retrospective, Multicenter, Cohort Study

Abstract:  Therapeutic options for superficial infantile hemangiomas (IH) are limited. Recently, timolol maleate gel, a topical nonselective beta‐blocker, has been reported as a potentially effective treatment for superficial IH. This study is an extension of a previously published pilot study designed to further investigate the efficacy and safety and to identify predictors of good response of topical 0.5% or 0.1% timolol maleate gel‐forming solution. This was a retrospective cohort study including patients enrolled from five centers. Patients were included if they were treated with timolol maleate 0.1% or 0.5% gel‐forming solution and had photographic documentation of the IH and at least one follow‐up visit. Patients with concomitant active treatment using other IH treatments were excluded. The primary endpoint was change in the appearance of IH as evaluated using a visual analog scale (VAS). Data from 73 subjects were available for final analysis. Timolol maleate gel‐forming solution 0.5% was used in 85% (62/73) of patients, the remainder being treated with 0.1%. The median age at treatment initiation was 4.27 months (interquartile range [IQR] 2.63–7.21 mos), and patients were treated for a mean of 3.4 ± 2.7 months. All patients except one improved, with a mean improvement of 45 ± 29.5%. Predictors of better response were superficial type of hemangioma (p = 0.01), 0.5% timolol concentration (p = 0.01), and duration of use longer than 3 months (p = 0.04). Sleeping disturbance was noted in one patient. This study further demonstrates the efficacy and tolerability of topical timolol maleate and gradual improvement with longer treatment in patients with superficial IH.

Use of propranolol for treatment of infantile haemangiomas in an outpatient setting

Introduction:  Propranolol has recently emerged as an effective drug treatment for infantile haemangiomas. The side effect profile of the drug and the safety of administering propranolol in outpatient settings in this age group remain uncertain. We report our experience with 200 infants and children prescribed propranolol to treat infantile haemangiomas, including 37 patients considered to have a poor response to treatment.

Lichen striatus following solarium exposure

Two cases of lichen striatus occurring after solarium exposure are presented. Both patients were adult females who regularly attended a solarium prior to the development of their skin lesions. A 19‐year‐old woman attended the solarium twice weekly for 8 weeks prior to the appearance of lichen striatus on the chest and epigastrium. The condition resolved completely with the twice daily application of calcipotriol ointment for 6 months. The second patient, a 40‐year‐old woman, attended the solarium once weekly for 3 months before lichen striatus developed on the abdomen. She was treated with clobetasol propionate ointment, calcipotriol ointment and intralesional triamcinolone acetonide and the eruption cleared 7 months after onset. The histopathological picture in both patients supported a diagnosis of lichen striatus.

A case of PHACE syndrome

A young girl with PHACE syndrome presented with a posterior fossa malformation, a segmental telangiectatic right facial haemangioma, a novel aortic arch anomaly, a congenital right fourth cranial nerve palsy (not previously described in this syndrome) and Horners syndrome. Hydrocephalus was limited to the intrauterine period and detection of the cardiovascular anomalies was a direct result of recognition of this syndrome. She has received laser treatment for the haemangioma and is awaiting surgical correction of her cranial nerve palsy.

Lasers and laser-like devices: Part two: Clinical use of lasers in dermatology

Part two of this review series evaluates the use of lasers and laser‐like devices in dermatology based on published evidence and the collective experience of the senior authors. Dermatologists can laser‐treat a wide range of dermatoses, including vascular, pigmentary, textural, benign proliferative and premalignant conditions. Some of these conditions include vascular malformation, haemangioma, facial telangiectases, café‐au‐lait macules, naevi of Ota, lentigines, acne scarring, rhytides, rhinophyma and miscellaneous skin lesions. Photodynamic therapy with lasers and intense pulsed light is addressed, with particular reference to actinic keratosis and actinic cheilitis. A treatment algorithm for acne scarring based on scar morphology and severity is comprehensively outlined. Following from part one, the various devices are matched to the corresponding dermatological conditions with representative pictorial case vignettes illustrating likely clinical outcomes as well as limitations and potential complications of the various laser and light therapies.

Infantile Hemangioma with Minimal or Arrested Growth: Further Observations on Clinical and Histopathologic Findings of this Unique but Underrecognized Entity

Infantile hemangioma (IH) with minimal or arrested growth (IH‐MAG) is becoming increasingly recognized in the literature. It is important to be aware of their existence, because the correct diagnosis is essential for prognostication and treatment and, in the case of facial segmental lesions, the direction of further investigations if PHACE (posterior fossa abnormalities and other structural brain abnormalities; hemangioma(s) of the cervical facial region; arterial cerebrovascular anomalies; cardiac defects, aortic coarctation, and other aortic abnormalities; eye anomalies) syndrome or Sturge–Weber syndrome is suspected. Although the clinical and histologic characteristics of IH‐MAG resemble capillary malformations, positive GLUT‐1 status is a delineating feature.

Treatment of Minocycline-Induced Cutaneous Pigmentation With the Picosecond Alexandrite (755-nm) Laser.

Minocycline hydrochloride (minocycline)-induced pigmentation (MIP) is a rare but well-recognized adverse effect of the long-term use of doses above 100 mg daily, especially in those with advancing age. Pigmentationmay takemonths or years to resolve, but resolution may never be complete. Three types ofMIP have been reported (Table 1). The exact mechanism of laser-mediated pigment resolution is not completely understood. It is theorized that laser surgery may fragment the intracellular and extracellular pigment complexes trapped within the dermis, which are then cleared by macrophages.

The role of pulsed laser in the management of cosmetically significant pigmented lesions

Pulsed laser can be effective in the treatment of naevus of Ota, some cafe au lait macules, lentigines and junctional naevi. It is less useful for compound, intradermal or congenital naevi, chloasma, or post‐inflammatory pigmentation. Hydroquinone and broad spectrum sunscreen are routinely used after treatment.

Segmental haemangioma of infancy of the lower limb with skeletal overgrowth.

A female infant presented at 3 months of age with vascular lesions involving the left lower limb and left side of the vulva. At birth, the left leg was thinner than the right, but equal in length. She had macular, reticulate, bluish discolouration covering most of the skin of the involved leg with superimposed cherry‐red papules, most dense over the proximal portion. The macular component showed evidence of improvement within the first few months of life. Papular and nodular components over the leg and the vulva progressively increased in size and thickness until the age of 10 months. These elements had the appearance and behaviour typical of haemangioma of infancy. Regression of these lesions started at the age of 15 months. By the age of 6.5 months, the involved leg was no longer thinner than the right, but the left leg and foot had grown longer. Leg length discrepancy peaked at 2.4 cm at the age of 2 years. The most rapid phase of relative growth discrepancy of left and right leg bones was contemporaneous with the growth phase of the haemangioma. Radiological investigations and histopathology have been consistent with haemangioma of infancy. GLUT‐1 immunostaining of the lesion was positive.

Screening for Sturge-Weber syndrome: A state-of-the-art review

Infants with a high‐risk distribution of port‐wine stains are commonly screened for Sturge‐Weber syndrome using brain magnetic resonance imaging. There is no consensus about which port‐wine stain phenotypes to screen, optimal timing, screening sensitivity, or whether presymptomatic diagnosis improves neurodevelopmental outcomes. This state‐of‐the‐art review examines the evidence in favor of screening for Sturge‐Weber syndrome, based on its effect on neurodevelopmental outcomes, against the risks and limitations of screening magnetic resonance imaging and electroencephalography. A literature search of PubMed/MEDLINE was conducted between January 2005 and May 2017 using key search terms. Relevant articles published in English were reviewed; 34 articles meeting the search criteria were analyzed according to the following outcome measures: neurodevelopmental outcome benefit of screening, diagnostic yield, financial costs, procedural risks, and limitations of screening magnetic resonance imaging and electroencephalography. There is no evidence that a presymptomatic Sturge‐Weber syndrome diagnosis with magnetic resonance imaging results in better neurodevelopmental outcomes. The utility of electroencephalographic screening is also unestablished. In Sturge‐Weber syndrome, neurodevelopmental outcomes depend on prompt recognition of neurologic red flags and early seizure control. Small numbers and a lack of prospective randomized controlled trials limit these findings. For infants with port‐wine stain involving skin derived from the frontonasal placode (forehead and hemifacial phenotypes), we recommend early referral to a pediatric neurologist for parental education, counselling, and monitoring for neurologic red flags and seizures and consideration of electroencephalography regardless of whether magnetic resonance imaging is performed or its findings.