Nuevas gotas pueden ser utiles en la caida de parpados como complicacion luego de Toxina botulinica para arrugas.

Dermatologic Surgery

Effect of Low-Concentration, Nonmydriatic Selective Alpha-Adrenergic Agonist Eyedrops on Upper Eyelid Position

Dermatol Surg 2016 Dec 02;[EPub Ahead of Print], TB Mendonça, AP Lummertz, FJ Bocaccio, F Procianoy 

• Ptosis is a potential complication after botulinum toxin treatment, and apraclonidine is traditionally recommended for management. Because apraclonidine is not commercially available in Brazil any longer, this study evaluated alternative options including brimonidine 0.2%, phenylephrine 0.12%, and naphazoline 0.05%. In this nonrandomized clinical trial, 20 healthy participants were divided into three groups and given drops in their left eyes. The upper margin reflex distance (MRD1) and pupil size were measured 30, 60, and 120 minutes after administration. The MRD1 increased significantly after treatment with naphazoline (0.56 mm after 30 minutes). No statistically significant difference in mean MRD1 was noted in participants given brimonidine and phenylephrine.

• Naphazoline may be useful for the management of upper eyelid ptosis.

  – Sarah Churton, MD

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

4000-1054

2208-8206

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Factores de riesgo para hemangioma infantil.

Dermatology

Written by

 

 

Sarah L Chamlin MD

Gestational Diabetes: A Newly Identified Association With Infantile Hemangiomas 

These investigators systematically evaluated the maternal prenatal risk factors associated with infantile hemangiomas in a large case–control study. Their study confirmed what others have previously reported, including the association of infantile hemangiomas with early gestational age, multiple gestations, maternal progesterone use, gestational hypertension, and preeclampsia. Of note, they reported a new potential association with gestational diabetes mellitus.  

This study strengthens the argument for the theory that infantile hemangiomas are stimulated by exposure to a hypoxic in utero environment. Such an environment is present when preeclampsia, gestational hypertension, or gestational diabetes occur, and this milieu promotes growth factors that stimulate hemangioma growth, including vascular endothelial growth factor A (VEGF-A). Further support for the hypoxia theory is suggested by the increase in glucose transporter 1 (GLUT-1) expression in both infantile hemangiomas and in the placentas of mothers with diabetes. More investigation into this new association is warranted and may shed further light on the cause of this very common birthmark.   

This final infantile hemangioma article reviewed for 2016 further highlights the "2016 Top Stories in Dermatology: Infantile Hemangioma: We Have Come a Long Way."

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

4000-1054

2208-8206

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Listerine en gonorrea.

Listerine Mouthwash Inhibits Oral Gonorrhea Bacteria

Listerine (Johnson & Johnson Consumer Inc) mouthwash inhibits the growth of oral gonorrhea bacteria in the mouth, a new study has found.

In a randomized trial, 52% (95% confidence interval [CI], 34% - 69%), of the pharyngeal surfaces of men who rinsed and gargled with the mouthwash for a minute tested positive for Neisseria gonorrhoeae compared with 84% (95% CI, 64% - 95%) of the pharyngeal surfaces of men who rinsed and gargled with a saline solution.

"With daily use it may increase gonococcal clearance and have important implications for prevention strategies," Eric P. F. Chow, PhD, from Melbourne Sexual Health Centre in Australia, and colleagues write in an article published online December 20 in Sexually Transmitted Infections.

Gonorrhea infections among men are increasing in many countries as condom use declines, mostly among men who have sex with men (MSM), the researchers explain.

In Australia, new diagnoses doubled from 6892 to 11,508 in the last 5 years, with 70% of these infections in MSM, the researchers write.

As the incidence of the infections rises, so do concerns about the risk for antibiotic resistance, highlighting the need for new preventive measures, they say.

As early as 1879, well before the advent of antibiotics, the manufacturer of Listerine claimed it could be used to cure gonorrhea. Until now, however, no published research has tested this claim.

To fill that gap, Dr Chow and colleagues assessed whether the mouthwash could curb the growth of N gonorrhoeae in laboratory tests and in a clinical trial of MSM.

In the laboratory tests, the researchers applied various dilutions up to 1:32 of Listerine Cool Mint and Total Care to cultures of N gonorrhoeae to see which, if any, of them might curb growth of the bacteria. Both formulations contain 21.6% alcohol. The authors also applied a saline solution to an identical set of cultures.

Listerine at dilutions up to 1 in 4, applied for 1 minute, significantly reduced the number of N gonorrhoeae on the culture plates. The saline solution had no effect.

Encouraged, the researchers undertook a clinical trial, starting with 196 MSM who had tested positive for gonorrhea in their mouths or throats and were returning for treatment at Melbourne Sexual Health Centre between May 2015 and February 2016.

At this return visit, 58 of the men once again tested positive for the bacteria on their pharynxes. The median age of these men was 27 years. They had had a median of six sexual partners in the previous 3 months.

The researchers assigned 33 men to rinse and gargle for 1 minute with the mouthwash, and 25 to rinse and gargle with a saline solution for 1 minute.

The researchers then retested the men and found that those in the mouthwash group were 80% less likely to test positive for gonorrhea on their pharyngeal surface compared with the other men (odds ratio, 0.20; 95% CI, 0.07 - 0.72).

Similarly, of the men who gargled and rinsed with the mouthwash, 57% (95% CI, 34% - 77%) tested positive for gonorrhea at the tonsillar fossae compared with 90% (95% CI, 68% - 99%) of those in the saline group (P = .016).

Men in the mouthwash group were 86% less likely to test positive on this surface than men in the saline group (odds ratio, 0.14; 95% CI, 0.03 - 0.77).

Of the men in the mouthwash group, 57% (95% CI, 34% - 77%) were infected on their posterior oropharynx compared with 70% (95% CI, 46% - 88%) of those in the saline group.

Although the difference between groups in pharyngeal surface infections was statistically significant (P = 0.013), as was the difference in tonsillar fossae infections (P = .016), the difference in posterior oropharynx infections was not (P = .277).

The researchers acknowledge that the follow-up time in the study was short, so it is possible that the effects of the mouthwash might be short-lived. However, the laboratory test results suggest a longer-term effect, they reason.

Whether or not an oral mouthwash can reduce gonorrhea infections of the anus and urethra remains to be seen. Some studies have suggested that pharyngeal gonorrhea spreads to the anus and urethra, the researchers note.

As people are less likely to have symptoms from oral gonorrhea infections, they are less likely to receive treatment rapidly than with urethral infections, the researchers point out.

A larger trial is currently underway to confirm the results of this study and see whether the use of mouthwash could curb the spread of gonorrhea, according to a news release from the journal.

The study was funded by the Australian National Health and Medical Research Council. The researchers have disclosed no relevant financial relationships.

Sex Transm Infect. Published online December 20, 2016. Full text

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

4000-1054

2208-8206

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Pruebas de parche determinan agravantes en Enfermedad Intestinal Inflamatoria.

Skin patch testing pinpoints dietary triggers of IBS

SAN DIEGO – About 90% of patients reported improvement in symptoms of irritable bowel syndrome after avoiding type 4 food allergens identified by skin patch testing, according to an uncontrolled study.

Furthermore, 69% of patients reported at least moderate improvement after eliminating foods to which they reacted, said Dr. Michael Stierstorfer, a dermatologist at East Penn Dermatology in North Wales, Pa., who partnered with gastroenterologists at Temple University to conduct the study. "This raises questions about a possible overlap between IBS and allergic contact enteritis," the researchers stated in a poster presented at the annual Digestive Disease Week.

Irritable bowel syndrome is often treatment refractory and tends to elude conventional diagnostics. That was the case for Dr. Stierstorfer, who several years ago developed symptoms of IBS with constipation (IBS-C) that eventually affected him about half the time, he said in an interview. A hydrogen breath test, upper endoscopy, colonoscopy, abdominal/pelvic CT, and tests for gluten-sensitive enteropathy and parasites revealed no abnormalities except decreased small intestinal motility, he said.

But after "flaring badly" twice when he ate Indian food, he began to suspect a cause. "I stopped eating garlic and within a day, I was absolutely fine," Dr. Stierstorfer said. "The symptoms recurred only if I accidentally ate garlic again."

Studies had refuted links between IBS and type 1 hypersensitivity but had not explored the role of type 4 (delayed) hypersensitivity in the disorder, Dr. Stierstorfer discovered. "Dermatologists do patch testing all the time for patients with refractory eczema to search for type 4 allergic contact factors that might be causing their rash," he said. "I performed a patch test of garlic on myself to look for a type 4 allergy, and it was strongly positive. I thought I probably wasn't the only person walking around with symptoms that mimicked IBS but were really from a type 4 food allergy."

He tested that idea by skin patch testing 50 patients with IBS symptoms whom he recruited through his dermatology practice. In all, 30 (60%) patients reacted to at least one food allergen, of whom 14 (46%) reported symptomatic improvement after eliminating the suspected triggers from their diets. The findings appeared in the March 2013 Journal of the American Academy of Dermatology (68:377-84). 

Next, Dr. Stierstorfer partnered with Dr. Grace Shin, a 3rd-year gastroenterology fellow at Temple University, Philadelphia, and her colleagues. Together, they tested 57 patients with physician-diagnosed IBS with diarrhea (about 43% of patients), IBS with constipation (16%), mixed IBS (30%), or unsubtyped IBS (11%). Patients averaged 41 years of age (standard deviation, 15 years) and 77% were female. Each patient had between 118 and 122 individual allergen patches placed on his or her back. Two days later, the patches were removed and the skin evaluated for macular erythema consistent with a type 4 hypersensitivity reaction. The patients were checked again a day or 2 later to catch any highly delayed reactions. 

In all, 56 patients (98%) showed evidence of at least one hypersensitivity, and most reacted to between two and three allergens, Dr. Stierstorfer said. The most commonly identified triggers were cinnamon bark (35 patients; 61%) and sodium bisulfite (26 patients; 46%). At baseline, patients rated their abdominal pain or discomfort at an average of 6.7 on a 10-point severity scale (SD, 2.3 points). After 2-4 weeks of avoiding allergens to which they developed macular edema, they reported a mean 4.4-point improvement in their abdominal symptoms (SD, 2.7 points; P less than .001).

The patients also reported an average 5.8-point improvement on a 10-point scale of global IBS symptom severity (SD, 3.2 points; P less than .001). Overall, 91% of patients reported at least partial relief of abdominal symptoms, while 89% of patients reported at least partial relief of global symptoms, the investigators reported.

Based on these results, "food-related type 4 hypersensitivity reactions may contribute to the pathogenesis of IBS and IBS-like symptoms," Dr. Shin said in an interview. "The idea of allergic contact enteritis intrigued me, because it made me think that some patients diagnosed with IBS, especially IBS with diarrhea, might benefit from allergy testing when the standard approaches don't work." 

Another dietary intervention for IBS, the low-FODMAP diet, can help relieve symptoms, "but it's a hard diet to follow," Dr. Shin added. "Being able to focus on eliminating one or two things would be easier than eliminating multiple classes of foods that are so common to an American diet."

Next, the team is planning a controlled trial of the skin patch test. "There is still more validation work to do," said Dr. Stierstorfer. "But I think this shows that looking at something from a unique perspective – in this case, a dermatologic perspective for a GI problem – can result in a new approach, and potentially an advance in medicine."

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

4000-1054

2208-8206

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Importancia de los exámenes serológicos en los pacientes con Herpes Simple I y II.

A Recommendation Against Serologic Screening for Genital Herpes Infection—What Now?

Genital herpes, one of the most prevalent sexually transmitted infections (STIs) in the United States, is caused either by herpes simplex virus (HSV) type 2 (HSV-2), a virus that almost exclusively causes genital infections, or increasingly by HSV type 1 (HSV-1), a closely related virus that causes both oro-labial herpes ("cold sores") and genital herpes.^,2 Genital herpes should be prioritized as a public health problem. HSV-2 is estimated to infect more than 45 million individuals (15.3%) living in the United States aged 14 to 49 years, and more than 10% to 20% of new genital herpes infections are now caused by HSV-1. Further, genital herpes is an example of the striking health disparities that characterize STIs in the United States; HSV-2 seroprevalence among non-Hispanic blacks (about 39%) is far higher than the seroprevalence among whites (about 12%).^,3 Congenital herpes, which is not a reportable condition, is estimated to be more than twice as common as congenital syphilis (31/100 000 vs 12.4/100 000 live births) and can be devastating for children born to infected mothers. In addition, there is a strong association between genital herpes infection and increased risk for acquisition of human immunodeficiency virus type 1.^,5

There is no cure for genital herpes or a vaccine to prevent infection. Despite high rates and the considerable morbidity associated with genital herpes, at present there is no coordinated national effort to control genital herpes. Efforts to reduce genital herpes morbidity are challenging, because most infected persons are unaware of their infections yet remain at risk for transmission of infection to others.^,3,6

A first step in confronting a widespread, largely underrecognized public health problem is to identify infected individuals to prevent further transmission. In this issue of JAMA, the US Preventive Services Task Force (USPSTF) presents an update of its 2005 recommendation and once again has recommended "against routine serologic screening for genital HSV infection in asymptomatic adolescents and adults, including those who are pregnant (D recommendation)." The task force noted problems of poor test performance, potential harms that might result from screening, and limited evidence of benefit from medical treatment to reduce transmission to uninfected sex partners or children born to infected mothers.

These recommendations are based on a comprehensive review of the literature, also published in this issue of JAMA, by Feltner and colleagues, who reviewed the accuracy, benefits, and harms of serologic screening for HSV-2 in asymptomatic persons, including pregnant women. The literature review also assessed the effectiveness of administration of preventive medication and counseling for reducing future symptomatic recurrences or transmission to uninfected persons. After consideration of the natural history of genital herpes, the epidemiology of infection, and available evidence on serologic screening for herpes, the USPSTF again concluded that the potential harms of serologic screening are greater than the benefits of serologic screening of otherwise asymptomatic adolescents and adults, including pregnant women.

A major problem identified by the review and leading to the recommendation against screening is unsatisfactory test performance. Feltner et al reviewed 11 evaluable studies, all conducted in populations with more than double the estimated US population prevalence of infection, and concluded that current tests are not suitable for use in the general, asymptomatic sexually active population. In these studies, using the manufacturer's cutpoint for interpretation of results, the sensitivity of the test most widely used for detection of serologic evidence of HSV-2 infection was high (99%), but the specificity was so low (83% [95% CI, 72%-90%]) that screening a population with an HSV-2 seroprevalence about the same as for US residents aged 14 to 49 years (16%) would yield nearly as many false-positive results as true infections. Using higher cutpoints for determining test positivity did not improve the performance sufficiently to provide confidence in the test results when used for general screening. These are not new findings. Despite well more than a decade of appreciation of suboptimal test performance as a tool for general population screening, commercially available tests have not evolved.

Clearly there is room for improvement of available tests as well as for development of new tests. In addition to development of better tests, a research agenda should evaluate the utility of routine implementation of a 2-step testing process in which specimens yielding an initial positive result are then tested using a second test targeting different HSV antigens for purposes of confirmation. Use of currently available tests in this way has been demonstrated to improve the specificity and predictive value somewhat, although not enough to allow this recommendation to be used in screening for the general population.^,9 This approach, modeled after the "screen-confirm" model used for infections such as syphilis, should be further evaluated as a means of improving the performance of new and currently available tests in appropriate populations.

The recommendation against serologic screening for genital HSV is warranted but should concern clinicians and patients and serve as a call to action for the National Institutes of Health, other federal agencies, and industry partners to address this ongoing epidemic, prioritizing development of improved tests and test strategies for diagnosis of HSV.

In addition, these conclusions should foster vigorous campaigns that seek to reduce the pervasive stigma that affects individuals diagnosed with HSV and hinders management and control efforts. Throughout the 20th century, popular perceptions and much of public health STI prevention education has tended to foster stigmatization of persons who have acquired STIs. The potential harm described by Feltner et al is real and demonstrates the harm that can result from misinformation and misperception. Widespread misperceptions regarding the severity, lack of effective treatment, and physical morbidity of genital herpes contribute to disproportionate concerns about genital herpes infection and stigmatization of those infected. These misperceptions should serve as impetus for work to reduce the stigma associated with STIs, including herpes.

Public perception about the consequences and morbidity of genital herpes is not consistent with current knowledge of the natural history of infection and the experience of clinicians who regularly care for persons with infection. That more than 8 of 10 people who have genital herpes are unaware of their infection^,6 serves to emphasize that this disorder is not always obvious to those infected or those who care for such persons and suggests that infected persons can live normal lives despite their infection. Randomized clinical trials have demonstrated that currently available therapy reduces the discomfort and duration of outbreaks and that chronic suppressive therapy reduces both recurrences and transmission to others. In addition, the randomized crossover clinical trial by Wald and colleaguesalso described in this issue of JAMA is an example of continuing progress in development of new antiviral agents for HSV management. In this study of 91 adults with frequently recurring genital HSV-2, daily oral pritelivir compared with oral valacyclovir reduced the percentage of genital swabs with detected HSV (an indicator of genital shedding) (2.4% vs 5.3%) and the percentage of days with genital lesions present (1.9% vs 3.9%). Although further research is needed to assess longer-term efficacy and safety, this study contributes to the research base that should inform current efforts to emphasize scientific evidence and sexual health over disease-related morbidity and should help address misperceptions about this common infection.

The recommendation from the USPSTF and the results of the accompanying evidence review should not be misinterpreted to assume that currently available tests, despite their limitations, do not have a role in some elements of current HSV management. Nor should these reports be interpreted to suggest that progress is not being made in expanding management options for treatment of genital herpes. Currently available tests, even with their suboptimal performance characteristics, remain useful for diagnostic testing and for evaluation of persons with histories of recurring anogenital lesions and provide information that may influence treatment decisions based on which virus type (HSV-1 or HSV-2) is present in persons with genital HSV. Current tests also provide important information for sex partners of persons diagnosed with HSV who are uncertain of their own status and for other suggestive but not definitive symptoms or signs.

While it is disappointing that so little progress in test performance has occurred in the more than a decade since the 2005 USPTF recommendation against general population screening for this important and widespread STI, the current USPSTF recommendation should serve to renew efforts to develop better tests for HSV, to improve management strategy, and to address the pervasive and harmful stigma associated with genital herpes.

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Article Information

Corresponding Author: Edward W. Hook III, MD, Department of Microbiology, The University of Alabama at Birmingham, 703 19th St S, Zeigler Research Bldg 242, Birmingham, AL 35294-0006 (ehook@uab.edu).

Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported receiving grants from Hologic and Roche Molecular, a grant and personal fees from Becton Dickinson, and research supplies from Cepheid.

References

1.

Centers for Disease Control and Prevention. Sexually Transmitted Disease Surveillance 2015. Atlanta, GA: US Dept of Health and Human Services; 2016.

2.

Satterwhite  CL, Torrone  E, Meites  E,  et al.  Sexually transmitted infections among US women and men: prevalence and incidence estimates, 2008. Sex Transm Dis. 2013;40(3):187-193.
PubMedArticle

3.

Centers for Disease Control and Prevention (CDC).  Seroprevalence of herpes simplex virus type 2 among persons aged 14-49 years—United States, 2005-2008. MMWR Morb Mortal Wkly Rep. 2010;59(15):456-459.
PubMed

4.

Thompson  C, Whitley  R.  Neonatal herpes simplex virus infections: where are we now? Adv Exp Med Biol. 2011;697:221-230.
PubMed

5.

Wald  A, Link  K.  Risk of human immunodeficiency virus infection in herpes simplex virus type 2-seropositive persons: a meta-analysis. J Infect Dis. 2002;185(1):45-52.
PubMedArticle

6.

Fanfair  RN, Zaidi  A, Taylor  LD, Xu  F, Gottlieb  S, Markowitz  L.  Trends in seroprevalence of herpes simplex virus type 2 among non-Hispanic blacks and non-Hispanic whites aged 14 to 49 years—United States, 1988 to 2010. Sex Transm Dis. 2013;40(11):860-864.
PubMedArticle

7.

US Preventive Services Task Force.  Serologic screening for genital herpes infection: US Preventive Services Task Force recommendation statement. JAMA. doi:10.1001/jama.2016.16776

8.

Feltner  C, Grodensky  C, Ebel  C,  et al.  Serologic screening for genital herpes: an updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. doi:10.1001/jama.2016.17138

9.

Morrow  RA, Friedrich  D, Meier  A, Corey  L.  Use of "biokit HSV-2 Rapid Assay" to improve the positive predictive value of Focus HerpeSelect HSV-2 ELISA. BMC Infect Dis. 2005;5:84.
PubMedArticle

10.

Brandt  AM. No Magic Bullet: A Social History of Venereal Disease in the United States Since 1880. New York, NY: Oxford University Press; 1985.

11.

Wald  A, Timmler  B, Magaret  A,  et al.  Effect of pritelivir compared with valacyclovir on genital HSV-2 shedding in patients with frequent recurrences: a randomized clinical trial. JAMA. doi:10.1001/jama.2016.18189

12.

Satcher  D, Hook  EW  III, Coleman  E.  Sexual health in America: improving patient care and public health. JAMA. 2015;314(8):765-766.
PubMedArticle

13.

Workowski  KA, Bolan  GA; Centers for Disease Control and Prevention.  Sexually transmitted treatment guidelines, 2015 [published correction appears in MMWR Recomm Rep. 2015;64:33]. MMWR Morb Mortal Wkly Rep. 2015;64(RR-03):1-137.

Productos para el cabello, favoreciendo la epidemia actual de acné...

Debemos preguntar, analizar, concientizar y eliminar productos sospechosos del cuidado diario del cabello en pacientes con acnes caracteristicos de "en Pomade"!

Smooth hair – an acne-causing epidemic

Do you ask your acne patients about which hair products they use? This common question has recently brought our attention to popular hair products that are causing an acne epidemic. Have we forgotten about "Pomade acne"? Well, it's making a comeback. Originally described in ethnic women, new frizz-fighting hair products have resurged and so has pomade acne in all skin types and in both men and women.

Smoothing serums, heat styling sprays, leave-in products popularly known as "It's-a-10," "Biosilk," "anti-frizz serums," "heat-protectants," "thermal setting sprays," and "shine sprays," contain silicone-derived ingredients and oils to control frizz, add shine, and detangle the hair. They work by smoothing the hair cuticle, and for women with difficult-to-manage hair, they have become an essential part of the daily beauty regimen.

Men are not in the clear either. Hair waxes and pomades used to style men's hair contain greasy wax-based ingredients that also clog pores, trap bacteria, and cause inflammatory breakouts.

As a general rule in skin and body care, most products work well for what they are made to do, but when misused, they can cause mishaps. You wouldn't moisturize your face with your hair serum would you? It seems obvious that this could cause some skin issues; however, most people will not think to correlate their acne breakouts with their hair products until we mention it. These products rub off on the face or on the pillow at night. In addition, the less we wash our hair, the more we are going to bed and getting the daytime products all over our pillowcases. Our faces are rolling around in oily, waxy, hair products all night.

Makeup is known to cause acne, and some of the makeups that are well known culprits contain the same ingredients as in hair products. Foundations, primers, and popular "BB" creams often contain cyclopentasiloxane and dimethicone. They serve a similar purpose: smoothing the skin and smoothing the hair. Both should be avoided in acne-prone patients.

Common culprits in hair products include PVP/DMAPA acrylates, cyclopentasiloxane, panthenol, dimethicone, silicone, Quaternium-70, oils, and petrolatum.

The only way to eliminate acne caused by hair products is to completely eliminate the hair product from the daily routine. However, if your patients can't live without their hair products, here are some tips to share with them to reduce breakouts:

• Choose a hairstyle that keeps the hair away from the face, or wear hair up to avoid prolonged contact with the face, particularly while sleeping.

• Change pillowcase often (every day if possible), especially for side sleepers. Regardless of the fabric, pillowcases trap oil, dirt, and bacteria.

• Shower at night and sleep with clean hair and clean skin.

• Style hair before applying makeup. Wash hands thoroughly to remove all hair products before touching the skin.

• Cover the face prior to applying any hair sprays.

• Cover the hair at bedtime; however, tight head coverings can stimulate sweat and cause scalp breakouts.

As a general rule, any patient with difficult-to-control acne, recalcitrant acne, or acne in areas on the cheeks or hairline should eliminate these hair products in their daily routine or avoid skin contact with these products.

References

1. J Clin Aesthet Dermatol. 2010 Apr;3(4):24-38.

2. Arch Dermatol. 1972;106 (6):843-50.

3. J Am Acad Dermatol. 2003; 48:S127-33.

4. Arch Dermatol. 1970;101(5):580-584.

5. "Cosmetics in Dermatology," Second Edition, by Zoe Diana Draelos (New York: Churchill Livingstone, 1995).

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month's column is by Dr. Talakoub.

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

4000-1054

2208-8206

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Componente vascular en Melasma

The hidden vascular component to melasma

So lets revisit this topic. We hate melasma. It is recalcitrant, resistant, and often recurs. But how many of us dermatologists look at melasma with a dermatoscope? A minority? And probably even fewer of us biopsy melasma. Are we missing the many, many cases of vascular or erythematotelangiectatic melasma and just treating melasma as a pigment problem instead of treating it as a vascular problem?

We know that melasma develops because of increased melanin production, not an increased number of melanocytes, but the underlying cause of increased melanogenesis is not fully understood. Several recent studies suggest that the increased vascularity in melasma skin is the underlying etiology. Understanding the way endogeneous and exogeneous stimuli such as sex hormones, oral contraceptives, ultraviolet irradiation, and visible light stimulate inflammation in the dermis, leading to the release of various mediators that stimulate angiogenesis and the activation of melanocytes, will help us improve the treatment of this relentless disease.

It's clear that UV exposure and visible light are the predominant triggers in the development of melasma. Recent studies looking at biopsies of lesional skin in melasma patients show similarity to solar-damaged skin. Solar elastosis has been shown to be secondary to the synthesis of alpha-melanocyte stimulating hormone (alpha-MSH) and adrenocorticotropic hormone (ACTH) derived from pro-opiomelanocortin (POMC) in keratinocytes. These peptides lead to proliferation of melanocytes, as well as increase in melanin synthesis via stimulation of tyrosinase activity and tyrosinase-related protein 1 (TRP-1).
Similarly, elevated estrogen and progesterone in pregnancy or with oral contraceptive use is known to stimulate melasma. Melanocytes express estrogen receptors and estradiol increases the level of TRP-2, which stimulates melanocytes to produce melanin. Recent literature has shown that the number of blood vessels, vessel size, and vessel density also are greater in lesional melasma skin than in perilesional skin. In addition, immunohistochemical staining has shown an increased level of factor VIIIa-related antigen in blood vessels in melasma skin, compared with perilesional normal skin.

Elevated vascular endothelial growth factor (VEGF) in keratinocytes also has been hypothesized to play a role in the elevated vascularization of melasma. Biopsies from affected skin also reveal increases in mast cells that release mediators – including histamine, VEGF, tumor necrosis factor-alpha, and interleukin-8 – which promote vascular proliferation. The evidence now points to these stimuli triggering angiogenesis, leading to release of mediators that cause melanocyte activation and melanin production.

Unfortunately, the treatment of vascular melasma is very difficult. Lasers such as the pulsed dye laser that help skin vascularity can trigger worsening melanogenesis through dermal inflammation. The melanin cap overlying the melanocyte nucleus also can mask the underlying vascularity and make laser treatments more difficult. The isolated treatment of epidermal pigment also may be ineffective and transient.

By targeting the vessels in addition to the pigment, we will get improved clinical results and fewer relapses. We suggest that melasma be treated conservatively, not aggressively. It should be treated as an inflammatory process. Patients with melasma also have a slightly abnormal skin barrier, so we should be hesitant in using deep lasers, radio frequency, and aggressive chemical peels. Topical preparations – particularly triple-combination bleaching agents, retinoids, and nonhydroquinone skin lighteners – should be used sparingly and always in combination with treatments targeting skin vascularity.
 

References

J Dermatol Sci. 2007 May;46(2):111-6.

Exp Dermatol. 2005 Aug;14(8):625-33.

Clin Exp Dermatol. 2008;33(3):305-8.

J Eur Acad Dermatol Venereol. 2009 Nov;23(11):1254-62.

Ann Dermatol. 2010 Nov;22(4):373-8.

J Eur Acad Dermatol Venereol. 2013 Jan;27 Suppl 1:5-6.

Am J Clin Dermatol. 2013 Oct;14(5):359-76.

J Am Acad Dermatol. 2014 Feb;70(2):369-73.

Dr. Talakoub and Dr. Wesley and are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month's column is by Dr. Talakoub. Write to them at dermnews@frontlinemedcom.com.

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

4000-1054

2208-8206

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Combinan calcipotriol con 5 fu para mejorar tolerancia y efectividad

Addition of calcipotriene to 5-FU increases efficacy, tolerability as AK treatment

FROM THE JOURNAL OF CLINICAL INVESTIGATION

A combined formulation of calcipotriol and 5-fluorouracil (5-FU) outperformed 5-FU alone in reducing the number of actinic keratoses (AKs), with a shorter treatment course and less inflammation than typically seen with 5-FU alone, researchers reported in a study published online in November.

5-FU is effective, but it produces crusting and significant irritation, and is temporarily disfiguring, creating discomfort and inconvenience that often leads to poor patient compliance with treatment.

In light of recent developments surrounding tumor immunotherapy, the researchers decided to combine 5-FU with calcipotriol (calcipotriene, which is approved for psoriasis), which induces thymic stromal lymphopoietin (TSLP), "an epithelium-derived cytokine and a master regulator of allergic inflammation in the skin," according to the authors. TSLP in turn recruits anti-tumor T cells.
After demonstrating that the combined treatment reduces AKs in mice, they conducted the study of 131 patients with AKs, randomized to treatment with a cream containing 5% 5-FU and 0.005% calcipotriol, or Vaseline plus 5% 5-FU alone. Participants applied the treatments twice per day for 4 days.

Eight weeks after treatment, the combination group had a mean 87.8% reduction in the number of AKs on the face, compared with 26.3% of the 5-FU controls. The treatment group also had better responses on the scalp (a mean 76.4% reduction in AKs versus 5.7%), right upper extremity (68.8% versus 9.6%), and left upper extremity (79% versus 16.3%). All differences were statistically significant (P less than .0001 for all comparisons).

"The greater efficacy of calcipotriol plus 5-FU versus Vaseline plus 5-FU treatment in eliminating actinic keratoses remained highly significant after controlling for the baseline actinic keratosis count, age, and sex of the participants," they wrote (J Clin Invest. 2016 Nov 21. pii: 89820. doi: 10.1172/JCI89820).

Significantly more of those in the combination group has skin redness during treatment, and 39% experienced a burning sensation on treated skin, compared with 13% of the 5-FU treated group. The rate of scaling and itching of treated skin during treatment was similar, and no patients had crusting or wounding of the treated skin.

"It was incredibly well tolerated. There wasn't as much discomfort or crusting to where people had to stop. And patients who had used 5-FU in the past preferred this shorter treatment course as well as the type and amount of inflammation they had," compared with their previous experience, Lynn Cornelius, MD, professor and chief of dermatology, Washington University, Saint Louis, said in an interview. "And it was more efficacious," added Dr. Cornelius, who was one of the study authors.

Both drugs are readily available, but more studies need to be done to optimize and maximize stability if the drugs are to be stored for any amount of time. Dr. Cornelius and senior author Shadmehr Demehri, MD, of the Center for Cancer Immunology and Cutaneous Biology Research Center, Massachusetts General Hospital, Boston, have approached pharmaceutical companies regarding commercialization, but have not yet had any agreements.

The trial was investigator initiated. Two authors received grants from the American Skin Association, the Dermatology Foundation, the Burroughs Wellcome Fund, the American Philosophical Society, the La Roche-Posay Research Foundation, and the National Institutes of Health; three investigators were supported by an NIH grant. Dr. Cornelius reported having no financial disclosures.

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

4000-1054

2208-8206

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A consulta devrevision de piel con la pareja!

Couples Who Receive Skin Examination Training May Find More Mole Irregularities, Research Suggests.

HealthDay (12/14, Preidt) reports that research indicated "couples who received...skin examination training found far more mole irregularities – potential skin cancer lesions – than those in" a "control group, and they also became more confident in their ability to find irregular moles." The findings were published in JAMA Dermatology.

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

4000-1054

2208-8206

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Nuevo topico para DA

New Eczema Treatment Approved

By the Editors

The FDA has approved crisaborole ointment (marketed as Eucrisa) to treat mild-to-moderate atopic dermatitis in patients aged 2 years and older.

The phosphodiesterase 4 (PDE-4) inhibitor is applied to the affected area twice daily. The FDA says its mechanism of action in treating atopic dermatitis is unknown.

Approval was based on two placebo-controlled trials comprising over 1500 patients aged 2 to 79 years. Those who used crisaborole had a greater treatment response after 4 weeks of treatment.

The most common side effect was local pain, such as stinging. Hypersensitivity reactions also may occur.

FDA news release (Free)

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

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Riesgo de anestesia repetitiva en menores de 3 años y embarazadas.

FDA Issues Warning on Use of Sedation Drugs in Young Children, Pregnant Women

By Amy Orciari Herman

Edited by Susan Sadoughi, MD, and Richard Saitz, MD, MPH, FACP, DFASAM

Repeated use of general anesthetic and sedation drugs — or use for longer than 3 hours — in children under age 3 years and in pregnant women in their third trimester could adversely affect child brain development, the FDA warned on Wednesday.

The agency cited animal data showing that early, lengthy exposure to these drugs caused neuronal and oligodendrocyte cell loss in the brain, which was associated with long-term effects on learning and memory. Meanwhile, some studies in humans have shown associations between early anesthesia exposure and later cognitive and behavior problems, while others have not.

The FDA notes that "a single, relatively short exposure to general anesthetic and sedation drugs ... is unlikely to have negative effects on behavior or learning."

The agency advises clinicians to weigh the benefits and potential risks of anesthesia in young children and pregnant women, "especially for procedures that may last longer than 3 hours or if multiple procedures are required in children under 3 years."

The drugs' labels will be updated to note these potential risks. A list of the affected drugs is available in the FDA safety communication linked below.

FDA MedWatch safety alert (Free)

FDA drug safety communication (Free)

Background: NEJM Journal Watch Pediatrics and Adolescent Medicine coverage of anesthesia before age 4 and later cognition (Your NEJM Journal Watch subscription required)

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

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2208-8206

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Dermatitis de contacto mas frecuente en atópicos que en NO atópicos... algo conocido pero ahora mejor demostrado.

Original Article

Contact sensitization in Dutch children and adolescents with and without atopic dermatitis – a retrospective analysis

Authors

• First published: 11 November 2016Full publication history
• DOI: 10.1111/cod.12711View/save citation
• Cited by: 0 articles
• 

• Conflicts of interest: The authors have no conflicts of interest to declare.
• Funding: This study has no funding source.

Summary

Background

Allergic contact dermatitis is known to occur in children with and without atopic dermatitis, but more data are needed on contact sensitization profiles in these two groups.

Objectives

To identify frequent allergens in children with and without atopic dermatitis suspected of having allergic contact dermatitis.

Methods

A retrospective analysis of children aged 0–17 years patch tested between 1996 and 2013 was performed.

Results

Of all 1012 children tested because of suspected contact dermatitis, 46% developed one or more positive reactions, the proportions for children with (n = 526) and without (n = 395) atopic dermatitis being 48% and 47%, respectively. Children with atopic dermatitis reacted more often to lanolin alcohols (30% pet., p = 0.030), Amerchol L-101 (p = 0.030), and fragrances [fragrance mix I (p = 0.048) and Myroxylon pereirae (p = 0.005)]. Allergens outside the European baseline series that frequently gave positive reactions in these groups included cocamidopropyl betaine and Amerchol L-101. Reactivity to these allergens was significantly more frequently found in atopic dermatitis children.

Conclusion

Sensitization prevalences in children with and without atopic dermatitis were similar, but children with atopic dermatitis reacted significantly more often to lanolin alcohols and fragrances. Testing with additional series besides the European baseline series may be necessary, as reactions to, for example, cocamidopropyl betaine and Amerchol L-101 may otherwise be missed.