Pinzas para garrapatas...

Using Tweezers Most Effective Technique To Remove Ticks, Study Says.

Healio (5/25, Thiel) reports, "Using tweezers was the most effective technique to remove ticks when compared with three commercial removal devices," research published online in the Journal of the American Academy of Dermatology suggests. Tweezers beat out "commercial devices based on freezing (Tickner, Laboratory Tickner AG), lassoing (Trix Ticklasso, Innotech), and card-detachment (Zeckenkarte, SafeCard Aps)."

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

4000-1054

2208-8206

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Si un alimento se asocia con dermatitis atopica, una dieta restrictiva total puede inducir reacciones más severas si se expone accidentalemente a este alimento posteriormente

Kids With Food-Triggered Eczema Are at Risk for Developing Life-Threatening Food Allergy

Mayo 24, 2016

CHICAGO -- May 24, 2016 -- Elimination of the food that triggers atopic dermatitis is associated with increased risk of developing immediate reactions to that food, according to a study published in the Journal of Allergy and Clinical Immunology. 

Immediate reactions to the culprit food range from hives to life-threatening anaphylaxis.

"Our findings suggest that families of children diagnosed with food-triggered atopic dermatitis should be prepared to respond to a full-blown food allergy reaction if the child is accidentally exposed to the food in question," said senior author Anne Marie Singh, MD, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois. "These children need an emergency action plan and an injectable epinephrine to keep them safe."

The study followed 298 patients with food-triggered atopic dermatitis. A total of 19% of these patients, who had no history of immediate food reactions, developed food allergy after being placed on an elimination diet. Nearly one-third of the new immediate food reactions included anaphylaxis.

Foods are a trigger in up to 30% of patients with moderate-to-severe atopic dermatitis, mostly in infants and children aged younger than 5 years. While these children typically are instructed to avoid the triggering food completely, this recommendation might need to be modified.

"Given that in our study strict elimination diets as management for atopic dermatitis clearly increased the risk of immediate reactions, more research is needed to see if children may benefit from keeping tolerable amounts of the food allergen in their diet," said Dr. Singh. "Families should work with an allergist to determine the optimal treatment course for their child."

More research is needed to establish if letting children with atopic dermatitis eat tolerable amounts of allergenic food would prevent the development of immediate reactions to that food.

SOURCE: Ann & Robert H. Lurie Children's Hospital of Chicago

Benjamin Hidalgo-Matlock
Skin Care Physicians of Costa Rica
4000-1054
2208-8206
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Cirugía de Mohs es efective en el Carcinoma Basocelular periocular.

Recurrence Rates of Periocular Basal Cell Carcinoma Following Mohs Micrographic Surgery

TAKE-HOME MESSAGE

• This retrospective study investigated the recurrence rate of periocular basal cell carcinoma (BCC) after Mohs micrographic surgery (MMS). Of 480 patients who underwent Mohs surgery for periocular BCC during the study period, 390 were eligible for inclusion. Of the lesions identified, 80.2% were primary BCCs and 19.7% were recurrent. Overall, based on a mean of 30 months of follow-up, 6 recurrences (1.5%) were identified. Of the recurrences, 1 (0.3%) was in a patient from the primary BCC cohort and 5 (6.5%) were in the patients from the recurrent BCC cohort

• According to this study, MMS is an effective treatment for periocular BCC with a low recurrence rate.

– Anna Wile, MD

Alopecia Androgenetica y la utilidad del tratamiento con plasma rico en plaquetas.

SINOPSIS ANALÍTICA

Alopecia androgenética: ¿es eficaz la aplicación de plasma rico en plaquetas en el cuero cabelludo? Ensayo aleatorizado, controlado con placebo, en doble ciego de la evaluación del plasma rico en plaquetas aplicado en la mitad de la cabeza para el tratamiento de la alopecia androgenética. ARTÍCULO ORIGINAL: RANDOMIZED PLACEBO-CONTROLLED, DOUBLE-BLIND, HALF-HEAD STUDY TO ASSESS THE EFFICACY OF PLATELET-RICH PLASMA ON THE TREATMENT OF ANDROGENETIC ALOPECIA Rubina Alves, MD y Ramon Grimalt, MD, PhD.. Dermatol Surg. 2016 Apr; 42(4):491-7.. INTRODUCCIÓN La alopecia androgenética es una miniaturización progresiva, no cicatrizal del folículo piloso con un patrón de distribución típico, en hombres y mujeres genéticamente predispuestos. Hasta el presente solamente están aprobados para esta indicación minoxidil tópico y finasteride oral. Estos tratamientos son al momento actual de limitada efectividad. El plasma rico en plaquetas (PRP) es una preparación de plaquetas autólogas en un concentrado de plasma, que contiene una concentración plaquetaria superior a la basal. Cuando los gránulos alfa plaquetarios son activados liberan numerosos factores de crecimiento, entre ellos factor de crecimiento derivado de plaquetas, factor de crecimiento transformante beta, factor de crecimiento del endotelio vascular, factor de crecimiento epidérmico, y factor de crecimiento tipo-insulina. Estos factores de crecimiento estimulan la proliferación y diferenciación celular. El PRP demostró efectos beneficiosos en el injerto óseo, en cirugía maxilofacial, ortopédica, y cardiovascular. Recientemente, hubo interés en la aplicación de este producto en dermatología para la regeneración de los tejidos, y en la curación de heridas, entre otras indicaciones. Además, el PRP fue postulado como un tratamiento nuevo para la alopecia androgenética. Una serie muy limitada de estudios investigaron el rol del PRP en el tratamiento de la pérdida del cabello en la alopecia androgenética. A pesar de estos estudios el mecanismo preciso por el cual este producto promueve el crecimiento del cabello, no está del todo comprendido. El objetivo de este ensayo fue evaluar la eficacia del tratamiento con PRP en la alopecia androgenética entre 3 y 6 meses y el basal, y determinar si el PRP podría considerarse como un nuevo tratamiento efectivo para esta entidad. DISEÑO Ensayo clínico, aleatorizado, en doble ciego, controlado con placebo, de la mitad de la cabeza, en grupos paralelos. CONTEXTO Este ensayo se realizó en una clínica privada subsidiaria de la "Universitat Internacional Catalunya", España entre enero y noviembre del 2014. P ACIENTES Se incluyeron hombres entre 18 y 65 años, con un Hamilton-Norwood Patterns II a V y mujeres de la misma edad, estadío I a III de acuerdo con la clasificación de Ludwig. Se excluyeron los pacientes que utilizaran alguna medicación tópica (como el minoxidil o cualquier otra solución para el crecimiento del cabello), medicación oral (finasteride, dutasteride, o anti-andrógenos), terapia láser, o quimioterapia en los últimos 12 meses, diátesis hemorragíparas, síndrome de disfunción plaquetaria, recuentos plaquetarios menores a 150.000/μl, tratamiento anticoagulante o con anti-inflamatorios no esteroideos en los últimos 15 días, embarazadas o en período de lactancia. También se excluyeron los pacientes con una patología crónica activa del cuero cabelludo diferente a la alopecia androgenética, o con antecedente de trasplante de cabello. INTERVENCIÓN Los pacientes fueron distribuidos al azar en una proporción 1:1 a recibir en la mitad de la cabeza tratamiento con PRP y en la otra mitad placebo (solución salina). Los pacientes fueron divididos en dos grupos (A y B): el grupo A recibió tratamiento con PRP en la mitad derecha de la cabeza y placebo en la mitad izquierda, mientras que el grupo B recibió tratamiento con PRP en la mitad izquierda de la cabeza y placebo en la mitad derecha. Para preparar el PRP se extrajeron 18 ml de sangre periférica, los cuales fueron transferidos a un tubo con 2 ml de citrato de sodio al 3,8%. La sangre citratada (20 ml) fue centrifugada a 460g durante 8 minutos. El centrifugado permitió separar los componentes sanguíneos de acuerdo a sus densidades específicas. El PRP representa la capa intermedia. Aproximadamente tres cuartas partes del sobrenadante se descartan, y la suspensión remanente es utilizada como PRP (3 ml) con un recuento plaquetario 3 veces superior al sanguíneo. La fracción de PRP fue separada y activada con 0,15 ml de una solución de cloruro de calcio el 10% inmediatamente antes de la aplicación, y aplicada en 4 áreas seleccionadas del cuero cabelludo, en una cantidad de 0,15 ml/cm2 con una aguja de 30-G aplicada una vez al mes durante 3 meses. Como control se utilizó una solución salina con 3 ml, la que fue inyectada en el lado opuesto del sitio experimental. Debido a las diferentes características entre el placebo y el PRP no se pudo mantener el ciego en el médico tratante. Los evaluadores de los resultados mantuvieron el ciego, al igual que los pacientes. Al final del estudio todos los pacientes recibieron 3 tratamientos con PRP en la mitad de la cabeza no tratada (área de placebo).

MEDIDAS DE EVOLUCIÓN

Las principales medidas de evaluación fueron: el recuento de los cabellos (medido como el número de cabellos/0,65 cm2), la densidad del cabello, la densidad terminal del cabello, el porcentaje de cabellos anágenos, el porcentaje de cabellos telógenos, y la razón entre los cabellos anágenos/telógenos. La evaluación comparativa se hizo en los distintos puntos de tiempo, y entre la mitad de la cabeza con tratamiento activo y con placebo. A nivel basal se eligieron 2 áreas circulares (una frontal y otra occipital) en ambas mitades de la cabeza (4 áreas circulares), las que fueron marcadas con un tatuaje. Las áreas elegidas fueron simétricas, de acuerdo a la densidad del cabello de cada área. Los criterios de evaluación fueron establecidos por fotografía y fototricograma.

PRINCIPALES RESULTADOS

-En total se incorporaron 25 pacientes, 12 hombres y 13 mujeres con alopecia androgenética, de los cuales 22 pacientes completaron el estudio y 3 se perdieron en el seguimiento.
-La mediana de edad de los participantes fue de 39 años.
-Los parámetros de crecimiento del cabello fueron evaluados al tercer y sexto mes, y comparados con el basal, y entre las áreas de tratamiento y las áreas de control.

-A nivel basal, no se observaron diferencias significativas en el recuento de los cabellos, densidad, densidad terminal, y porcentaje de cabellos anágenos y telógenos entre las áreas de tratamiento y las áreas de control.
-Se observó que la administración de PRP determinó un incremento estadísticamente significativo en la mediana de cabellos anágenos, telógenos, en la densidad de los cabellos, y densidad terminal del cabello luego de 3 y 6 meses cuando se comparó con el basal.
-La mediana de la densidad total del cabello en las áreas de tratamiento, luego de 3 meses evidenció un incremento de 14,8 ± 32,1 cabellos/cm2, comparados con el basal, mientras que las áreas de control evidenciaron una mediana de descenso de 0,7 ± 32,7 cabellos/cm2 (diferencia control versus tratamiento; p<0,05).
-Con respecto al recuento total de cabellos, no se observó una diferencia significativa entre las áreas tratadas
con PRP y las áreas con placebo, exhibiendo un leve incremento en el número total de cabellos en las áreas tratadas comparadas con el grupo de control. -El tratamiento con PRP demostró una correlación estadísticamente significativa de la mediana de la densidad total del cabello en hombres con una edad menor o igual a 40 años, con un comienzo de la caída del cabello a los 25 años o mayores, con un antecedente familiar positivo, y con más de 10 años de evolución de la alopecia androgenética cuando fueron comparados con el placebo.

CONCLUSIÓN

Este ensayo demuestra una mejoría estadísticamente significativa en la mediana de pelos anágenos, telógenos, en la densidad del cabello y en la densidad terminal a los 3 y 6 meses, comparados con el basal cuando se administró PRP. Sin embargo, al compararse con el área de control, la zona tratada con PRP solamente demostró un incremento significativo en la mediana total de la densidad de los cabellos. Por lo tanto, este ensayo avala la aplicación de PRP como un tratamiento complementario y seguro para la alopecia androgenética.

FUENTES DE FINANCIAMIENTO

No presenta financiamiento externo.

CONTACTO

Dirigir correspondencia a: Rubina Alves, MD, Universitat Internacional de Catalunya, Estrada Monumental, 364 3F, Funchal, Portugal 9000-100, or e-mail: rubinaalves@gmail.com

COMENT ARIO

Los autores relatan que el mecanismo por el cual la administración de PRP induce a efectos positivos en la alopecia androgenética no son conocidos. En los estudios en modelos animales (murinos) se observó que la aplicación de PRP induce a una transición telógeno a anágeno más rápida que en los controles. Según los autores, este estudio es el primero en encontrar una correlación entre el pelo anágeno y los pacientes mayores de 40 años, con un inicio de la alopecia androgénica a la edad de 25 años o mayores. También remarcan una serie de limitaciones, como ser un seguimiento de sólo 6 meses. Relatan además, que al utilizar al mismo paciente con áreas tratadas y con placebo se pueden corregir algunos posibles sesgos relacionados con el sexo y el grado de pérdida de cabellos que podrían afectar los resultados. 

No recomiendan el uso de ketoconazol oral.

Oral Ketoconazole Shouldn't Be Given for Skin and Nail Fungal Infections

By Kelly Young

Edited by André Sofair, MD, MPH, and William E. Chavey, MD, MS

The oral antifungal ketoconazole (Nizoral) should not be used to treat skin and nail fungal infections, the FDA cautioned on Thursday. The drug, which is not approved to treat those conditions, is associated with increased risk for liver damage, adrenal gland abnormalities, and adverse interactions with other drugs.

In 2013, the skin and nail fungus indications were removed from ketoconazole's label, but the FDA has learned that clinicians are still prescribing the drug for such infections. Since the label change, one patient died after taking ketoconazole to treat a nail fungus infection.

The FDA reminds clinicians that oral ketoconazole tablets should only be used for serious fungal infections when no alternatives are available.

FDA MedWatch safety alert (Free)

Background: Physician's First Watch coverage of 2013 ketoconazole label changes (Free)

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

4000-1054

2208-8206

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Infecciones incrementan en pacientes con Psoriasis.

Serious infections are increasing among psoriasis inpatients

SCOTTSDALE, ARIZ. – From enterocolitis to MRSA, serious infections are on the rise among inpatients with psoriasis, and psoriasis is an independent risk factor for serious infections, according to findings from large retrospective studies from the United States and the United Kingdom.

Inpatients with psoriasis in the United States also were at greater risk of serious infections, compared with nonpsoriatic inpatients at every time point studied, and serious infections were associated with increased hospital costs, length of stay, and risk of mortality, reported Derek Hsu, a medical student at Northwestern University, Chicago, and his associates. "Research is needed to determine how to reduce the risk of serious infections in patients with psoriasis," the investigators emphasized. 

Psoriasis affects some 7 million adults in the United States. Biologics, which are transforming the treatment landscape for moderate-to-severe psoriasis, "should reduce inherent infectious risk by controlling the inflammatory process and reducing disease severity, [but] these effects may be immunosuppressing and increase the risk of infection in other ways," according to Mr. Hsu and his associates. For their study, they analyzed data for 2002-2012 from the Nationwide Inpatient Sample, which covers 20% of hospitalizations in the United States. They extracted validated ICD-9 codes for psoriasis and serious infections, and calculated costs of care after adjusting for 2014 inflation, based on the United States Consumer Price Index.

Overall rates of serious infection and rates of pneumonia, MRSA, septicemia, diverticulitis, enterocolitis, encephalitis, and any viral or fungal infection rose significantly among inpatients with psoriasis between 2002 and 2012 (all P-values less than .05). Predictors of serious infections among inpatients with psoriasis included diabetes mellitus, obesity, and being of non-Caucasian race or ethnicity, female, older than 60 years, and on Medicare or Medicaid, the researchers reported at the annual meeting of the Society for Investigative Dermatology.

Furthermore, after controlling for age, sex, and race, psoriasis was a significant risk factor for many different types of serious infections. Among these were cellulitis, herpes simplex virus, infectious arthritis, osteomyelitis, meningitis, influenza, encephalitis, septicemia, enterocolitis, MRSA, methicillin-sensitive Staphylococcus aureusinfections, and Clostridium difficile. Further, inpatients with psoriasis were more prone to urinary tract infection, peritonitis or intestinal abscess, appendicitis, tuberculosis, and viral and fungal infections (all P-values less than .05). The average cost of hospital stay for inpatients with psoriasis was more than $2,200 greater when they were diagnosed with one or more serious infections than otherwise, and their average length of hospital stay was 2 days longer.

The study in the United Kingdom included nearly 200,000 patients with psoriasis and almost 1 million patients without psoriasis from The Health Improvement Network electronic medical record database. Between 2002 and 2013, patients without psoriasis developed an estimated 78.5 serious infections per 100,000 person-years, compared with 88.9, 85.7, and 145.7 serious infections per 100,000 person-years, respectively, for all psoriasis patients, patients with mild disease, and patients with severe disease requiring systemic or phototherapy, said Dr. Junko Takeshita and her colleagues at the University of Pennsylvania in Philadelphia. After controlling for many potential demographic and clinical confounders, psoriasis increased the risk of serious infection by about 21% (hazard ratio, 1.21; 95% confidence interval, 1.18-1.23). Patients with severe psoriasis had a 63% greater risk of infection than patients without psoriasis, compared with an 18% increase for patients with mild psoriasis. 

The findings show "serious infection, particularly respiratory and skin or soft tissue infections, to be an important and common cause of morbidity among patients with psoriasis, especially those with more severe disease," Dr. Takeshita and her associates said. Notably, the link between psoriasis and risk of serious infection persisted after excluding patients on immunosuppressive therapies, suggesting "that the greater infection risk is at least partially attributable to more severe psoriasis, itself," they added.

The analysis of Nationwide Inpatient Sample data was funded by the Agency for Healthcare Research and Quality and by the Dermatology Foundation. The analysis of Health Improvement Network data was funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, which is part of the National Institutes of Health, and by the Dermatology Foundation. None of the investigators reported conflicts of interest.

Key clinical point: Psoriasis is an independent risk factor for serious infections, and serious infections are increasing among inpatients with psoriasis.

Major finding: Overall rates of serious infection and rates of pneumonia, MRSA, septicemia, diverticulitis, enterocolitis, encephalitis, and any viral or fungal infection rose significantly among inpatients in the United States with psoriasis between 2002 and 2012 (all P-values less than .05). In the United Kingdom during the same time period, patients with severe psoriasis had a 63% greater risk of serious infection than patients without psoriasis.

Data source: Analyses of data from the Nationwide Inpatient Sample for 2002 through 2012, and from The Health Improvement Network for 2003 through 2012. 

Disclosures: The Nationwide Inpatient Sample analysis was funded by the Agency for Healthcare Research and Quality and the Dermatology Foundation. The analysis of The Health Improvement Network was funded by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, which is part of the National Institutes of Health, and by the Dermatology Foundation. None of the investigators reported conflicts of interest.

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

4000-1054

2208-8206

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Oxybuntina para hiperhidrosis en poblacion pediatrica...

Individualized Dosing of Oral Oxybutynin for the Treatment of Primary Focal Hyperhidrosis in Children and Teenagers

Pediatr Dermatol 2016 Apr 28;[EPub Ahead of Print], J Del Boz, JF Millán-Cayetano, N Blázquez-Sánchez, M de Troya 

Journal Scan / Research · May 11, 2016

Dose Individualization of Oral Oxybutynin for Primary Focal Hyperhidrosis in Children and Teenagers

Pediatric Dermatology

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TAKE-HOME MESSAGE

• This prospective study assessed the effectiveness of oxybutynin treatment for primary focal hyperhidrosis in children and teenagers. Patients received progressively increasing doses starting at 2.5 mg/day with a maximum of 12.5 mg/day until control was achieved. At the 3-month follow-up, 15/16 patients responded to treatment, 62.5% with an excellent response. The 11 patients who remained on the medication at 1 year continued responding. The most common adverse effect was oropharyngeal xerosis, with less common adverse effects including epistaxis, headaches, and drowsiness. 

• Individualized regimens of oxybutynin were found to be useful for the treatment of hyperhidrosis in children and adolescents.

  – Sarah Churton, MD

 Dermatology

Written by

 

 

Joy L Mosser MD

Pediatric hyperhidrosis commonly presents itself in the first 2 decades of life. There are limited therapies for this condition, ranging from antiperspirants to neurosurgery, with few choices in between. The FDA approval of botulinum toxin for this difficult condition has been the best new treatment option in years. This treatment can be painful and costly for any patient, let alone children. While antiperspirants are often the first line of therapy, they are frequently ineffective. Therefore, oral anticholinergics have been suggested to be a second-line treatment option in both children and adults with primary hyperhidrosis. 

In the US, glycopyrrolate is traditionally the oral anticholinergic of choice for hyperhidrosis. Several recent studies have shown oral oxybutynin (more commonly used for bladder instability) to be a safe and effective alternative. This article highlights that oral oxybutynin can be initiated at a lower dosage in pediatric patients then titrated up to an effective dose, whereas prior studies have used a fixed-dose regimen. Oxybutynin was started at a dose of 2.5 mg/day to a maximum of 12.5 mg/day. The most common side effect was dry mouth, which is similar to the finding in studies with oral glycopyrrolate. 

To date there have been no studies comparing oxybutynin and glycopyrrolate. With both medications readily available in the US, this could be valuable knowledge.

---

Abstract

BACKGROUND/OBJECTIVES

Oral anticholinergic drugs, such as oxybutynin, are often used in the treatment of hyperhidrosis, but few studies have focused on dosing strategies for children. The objective was to assess the effectiveness and safety of individualized dosing regimens of oral oxybutynin for treating primary focal hyperhidrosis (PFH) in children and teenagers.

METHODS

A prospective study was performed including patients who initiated treatment for hyperhidrosis between November 2011 and November 2014. Response to treatment and adverse effects were evaluated using the Hyperhidrosis Disease Severity Scale at baseline and at 3 and 12 months.

RESULTS

Of 16 patients included in the study, 15 (93.8%) had responded to treatment at the 3-month follow-up (62.5% with excellent response). At the 12-month follow-up, the 11 patients who continued the treatment were still responding (63.6% with excellent response). Adverse effects were reported for 68.8% of the patients at 3 months and 54.5% at 12 months, with a predominance of oropharyngeal xerosis. No serious adverse effects were observed.

CONCLUSION

Dose individualization of oral oxybutynin according to clinical response and tolerance observed in each patient is a useful management strategy in children and teenagers

Copyright © 2016 Elsevier Inc. All rights reserved.

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

4000-1054

2208-8206

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Uso especifico y con cautela de las fluoroquinolonas.

FDA Calls for More Restrictions on Fluoroquinolone Use

By Kristin J. Kelley

Edited by Susan Sadoughi, MD, and André Sofair, MD, MPH

The risks for "disabling and potentially permanent" side effects associated with systemic fluoroquinolone antibacterials (e.g., ciprofloxacin, moxifloxacin) generally outweigh the benefits in patients with sinusitis, bronchitis, and uncomplicated urinary tract infections, the FDA warned late last week. Fluoroquinolones should only be used for these indications when patients don't have other treatment options, the agency said.

Side effects can compromise the nerves, central nervous system, tendons, muscles, and joints. Symptoms may include confusion; hallucinations; joint, muscle, and tendon pain; or a tingling sensation (i.e., "pins and needles"). 

The action follows advisory panel recommendations made in late 2015 for stronger label warnings. The labels were previously updated in 2013 to warn of increased risk for peripheral neuropathy. Additionally, in 2008, a boxed warning was added to note risks for tendinitis and tendon rupture. 

See the linked FDA drug safety communication for a full list of fluoroquinolones currently approved for systemic use.

FDA MedWatch safety alert (Free)

FDA drug safety communication (Free)

FDA briefing document on benefits and risks of systemic fluoroquinolones (Free PDF)

Background: Physician's First Watch coverage of 2015 advisory panel vote (Free)

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

4000-1054

2208-8206

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Proteccion UVA de los vidrios en los carros es variable

Entre mas capas y el uso de laminas de protección, antirrobo o ruptura son las que filtran UVA y el entintado no es relevante.

Side Windows in Cars Let in Varying Amounts of UVA Light

By Kelly Young

Edited by André Sofair, MD, MPH, and William E. Chavey, MD, MS

Automobile side windows vary widely in their protection from cancer-causing ultraviolet-A light, suggests a small JAMA Ophthalmology study.

A researcher used a handheld meter to measure the UVA light penetrating the driver's side windows and windshields in 29 automobiles made from 1990–2014. On average, front windshields blocked 96% of UVA light, while side windows blocked 71%. Although windshields were fairly consistent in their protection, side window protection ranged from 55% in some 2013 BMW models to 96% in a 2011 Lexus. Tinting had no discernible effect.

To be shatterproof, front windshields contain two layers of glass with a UVA-blocking layer of plastic in between. Side windows, meanwhile, are made of a single layer of glass.

A commentator writes: "It is helpful for ophthalmologists to inform their patients that eye and skin protection may be indicated ... inside an automobile."

JAMA Ophthalmology article (Free)

JAMA Ophthalmology invited commentary (Subscription required)

Background: NEJM Journal Watch Dermatology coverage of UVA radiation and tanning beds (Free

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

4000-1054

2208-8206

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Imiquimod vs MAL-PDT vs Effudix para Carcinoma Basocelular Superficial

A randomized controlled trial including 601 patients previously showed that the effectiveness of imiquimod and fluorouracil cream were not-inferior to methylaminolevulinate photodynamic therapy (MAL-PDT) in patients with superficial basal cell carcinoma (sBCC) after one year follow-up. We now present the three years follow-up results. The probability of tumor-free survival at three years post-treatment was 58.0% for MAL-PDT (95% CI 47.8-66.9), 79.7% for imiquimod (95% CI 71.6-85.7), and 68.2% for fluorouracil (95% CI 58.1-76.3). The hazard ratio (HR) for treatment failure comparing imiquimod with MAL-PDT was 0.50 (95% CI 0.33-0.76, p=0.001). Comparison of fluorouracil with MAL-PDT and fluorouracil with imiquimod showed HRs of 0.73 (95% CI 0.51-1.05, p=0.092) and 0.68 (95% CI 0.44-1.06, p=0.091), respectively. Subgroup analysis showed a higher probability of treatment success for imiquimod versus MAL-PDT in all subgroups with an exception of elderly patients with sBCC on lower extremities. In this latter subgroup, the risk difference in tumor-free survival was 57.6% in favor of MAL-PDT. In conclusion, according to results at three years post-treatment imiquimod is superior and fluorouracil not inferior to MAL-PDT in treatment of sBCC.

TAKE-HOME MESSAGE

• The authors of this randomized controlled trial compared the effectiveness of imiquimod, fluorouracil cream, and methyl aminolevulinate photodynamic therapy (MAL-PDT) in 601 patients with superficial basal cell carcinoma (sBCC). At 3 years' follow-up, the tumor-free survival was 58.0% for MAL-PDT, 79.7% for imiquimod, and 68.2% for fluorouracil.

• Imiquimod was superior to MAL-PDT, and fluorouracil was not inferior to MAL-PDT, for treatment of sBCC at 3 years' follow-up.

Three Year Follow-Up Results of Photodynamic Therapy Versus Imiquimod Versus Fluorouracil for Treatment of Superficial Basal Cell Carcinoma: A Single Blind, Non-Inferiority, Randomized Controlled Trial

J Invest Dermatol 2016 Apr 22;[EPub Ahead of Print], MH Roozeboom, AH Arits, K Mosterd, A Sommer, BA Essers, MJ de Rooij, PJ Quaedvlieg, PM Steijlen, PJ Nelemans, NW Kelleners-Smeets 

Imiquimod vs MAL-PDT vs Effudix para Carcinoma Basocelular Superficial

A randomized controlled trial including 601 patients previously showed that the effectiveness of imiquimod and fluorouracil cream were not-inferior to methylaminolevulinate photodynamic therapy (MAL-PDT) in patients with superficial basal cell carcinoma (sBCC) after one year follow-up. We now present the three years follow-up results. The probability of tumor-free survival at three years post-treatment was 58.0% for MAL-PDT (95% CI 47.8-66.9), 79.7% for imiquimod (95% CI 71.6-85.7), and 68.2% for fluorouracil (95% CI 58.1-76.3). The hazard ratio (HR) for treatment failure comparing imiquimod with MAL-PDT was 0.50 (95% CI 0.33-0.76, p=0.001). Comparison of fluorouracil with MAL-PDT and fluorouracil with imiquimod showed HRs of 0.73 (95% CI 0.51-1.05, p=0.092) and 0.68 (95% CI 0.44-1.06, p=0.091), respectively. Subgroup analysis showed a higher probability of treatment success for imiquimod versus MAL-PDT in all subgroups with an exception of elderly patients with sBCC on lower extremities. In this latter subgroup, the risk difference in tumor-free survival was 57.6% in favor of MAL-PDT. In conclusion, according to results at three years post-treatment imiquimod is superior and fluorouracil not inferior to MAL-PDT in treatment of sBCC.

TAKE-HOME MESSAGE

• The authors of this randomized controlled trial compared the effectiveness of imiquimod, fluorouracil cream, and methyl aminolevulinate photodynamic therapy (MAL-PDT) in 601 patients with superficial basal cell carcinoma (sBCC). At 3 years' follow-up, the tumor-free survival was 58.0% for MAL-PDT, 79.7% for imiquimod, and 68.2% for fluorouracil.

• Imiquimod was superior to MAL-PDT, and fluorouracil was not inferior to MAL-PDT, for treatment of sBCC at 3 years' follow-up.

Three Year Follow-Up Results of Photodynamic Therapy Versus Imiquimod Versus Fluorouracil for Treatment of Superficial Basal Cell Carcinoma: A Single Blind, Non-Inferiority, Randomized Controlled Trial

J Invest Dermatol 2016 Apr 22;[EPub Ahead of Print], MH Roozeboom, AH Arits, K Mosterd, A Sommer, BA Essers, MJ de Rooij, PJ Quaedvlieg, PM Steijlen, PJ Nelemans, NW Kelleners-Smeets 

Cobalto: Alergeno de año 2016! ( Academia Americana de Dermatologia)

https://www.aad.org/dw/monthly/2016/may/cobalt-2016-allergen-of-the-year

By Abby Van Voorhees, MD, May 2, 2016

In this month's Acta Eruditorum column, Physician editor Abby S. Van Voorhees, MD, talks with Joseph F. Fowler Jr., MD, about his recent Dermatitis article, "Cobalt."   

Dr. Van Voorhees: Cobalt previously was more frequently seen in Europe than in the U.S. Why are we now seeing an increase in the U.S. frequency of the allergen? How frequently is cobalt thought to be the underlying culprit?

Fowler: Prior to about 20-30 years ago we in the U.S. didn't test routinely for cobalt allergy. European centers have looked for cobalt allergy for many years, so they had more information than we did. Most metals, including cobalt, have been showing gradual increases in prevalence over the last two to three decades. This may be due to more recognition and testing or may be due to greater exposure in the population. As is true with any potential allergen, not all positive patch tests to cobalt are relevant to the patient's presenting dermatitis, but cobalt is present in enough locations to make it something we need to explore with our patients any time we see a positive patch test. 

Dr. Van Voorhees: Are there people thought to be at an increased risk of allergy to cobalt? How often is this reaction found in men versus women?

Fowler: Women tend to be more allergic to most metals, probably because of a much higher exposure to jewelry and clothing ornamentation than men. Because of occupational patterns, men tend to have more cobalt allergy when a work-related cause is found. This includes construction workers with exposure to cobalt in drywall dust, concrete, bricks, etc., and "hard metal" workers handling tools and machinery.

Dr. Van Voorhees: Does allergy to cobalt always occur with nickel allergy? Is there a relationship between nickel and cobalt that allows for these two agents to travel together?

Fowler: Cobalt is often present in the earth in the same places as nickel, so cobalt and nickel tend to coexist in nature. Therefore human exposure to cobalt often parallels nickel — in costume jewelry or in industrial tools, for instance. Probably over half the patients allergic to cobalt are also allergic to nickel. There is also some overlap with allergy to cobalt and chromium, since both are found in cement and similar construction materials. Only about 20 percent of those allergic to cobalt are not allergic to other metals.

Dr. Van Voorhees: What are the sources of cobalt exposure that we need to think about? What is the most common exposure that causes acute contact dermatitis (ACD)? What about some of the less common sources?

Fowler: The newest information we have on cobalt allergy is that cobalt is commonly found in leather goods, including furniture, shoes, clothing, etc. Previously, we thought chromium was the major allergen in leather, but now we know cobalt is there as well. Some jewelry contains cobalt, especially jewelry that has more of a "dark metal" rather than a shiny silvery appearance. Metal objects used for cutting and grinding other metals, so-called "hard metal" tools, usually contain cobalt. Many orthopedic implants and other medical implants contain cobalt. As noted above, bricks, mortar, cement, drywall, plaster, and similar materials contain cobalt, as they are derived from cobalt-containing minerals in the earth.

There have also been several case reports over the years of allergy to cobalt in Vitamin B12 injections.

Dr. Van Voorhees: What are clues that cobalt might be found in jewelry? Is there a way to test jewelry for those with a history of cobalt allergy?

Fowler: A spot test for cobalt, similar to the one we have for nickel, has been developed by Jacob Thyssen, MD (a Danish dermatologist) and colleagues. It is based on a naphthol-disulfonate compound and when applied to a metal object, gives a yellow-orange color upon contact with cobalt.

Dr. Van Voorhees: What are some practical take-aways for dermatologists regarding cobalt?

Fowler: Think of cobalt allergy in patients who seem to have a contact dermatitis from jewelry, leather exposure, or in those who work in occupations with likely cobalt exposure. Also, be cautious in interpreting cobalt patch tests. Dr. Fran Storrs showed years ago that cobalt may give a unique irritant appearance at a patch test, consisting of "cayenne-pepper" like tiny red spots, with no induration or spread. This is due to toxicity to the acrosyringium and is not an indicator of allergy. 

​Dr. Fowler is clinical professor of dermatology at the University of Louisville in Kentucky. His article appeared in Dermatitis 2016 Jan/Feb 27(1):3-8. DOI: 10.1097/DER.0000000000000154.

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

4000-1054

2208-8206

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