Hipotiroidismo y Carcinoma epidermoide?

Hypothyroidism May Be Associated with SCC

Dermatol Surg; ePub 2017 Aug 8; Ahadiat, et al

August 30, 2017

Patients with squamous cell carcinoma (SCC) are more likely to have a history of hypothyroidism than the general population, a recent study found. Therefore, researchers conclude that hypothyroidism may be linked to the development of cutaneous SCC. A retrospective review was performed for patients seen at the University of Southern California with cutaneous SCC. Chart review was conducted for the presence of hypothyroidism and thyroid replacement therapy before the diagnosis of SCC for each patient. Multiple prevalence studies were gathered from the literature for comparison, reporting the prevalence of overt and subclinical hypothyroidism in the general US population and/or elderly US population. They found:

• Of the 265 patients diagnosed with SCC of the skin, 61 (23%) were found to have a preceding diagnosis of hypothyroidism.
• The prevalence of hypothyroidism among the population of SCC patients was significantly greater than the prevalence of hypothyroidism (overt and subclinical) in any general and/or elderly US population reported.

Citation:

Ahadiat O, Higgins S, Trodello C, Talmor G, Kokot N, Wysong A. Hypothyroidism potentially linked to cutaneous squamous cell carcinoma: Retrospective study at a single tertiary academic medical center. [Published online ahead of print August 8, 2017]. Dermatol Surg. doi:10.1097/DSS.0000000000001241.

Benjamin Hidalgo-Matlock

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Dr. Warren Heymann on Psoriatic Alopecia and Sebaceous Glands: An Unfinished Symphony | PracticeUpdate

Published in Dermatology

Expert Opinion / Commentary · August 29, 2017

Dr. Warren Heymann on Psoriatic Alopecia and Sebaceous Glands: An Unfinished Symphony

Written by

 

 Warren R Heymann MD

Every so often, patients with psoriasis would ask me about their hair loss, and I assumed that it was mechanical in nature, probably due to breakage of hair getting tangled in scales, and traumatized by pruritus. George et al., in their review of psoriatic alopecia, state, "Alopecia and other hair abnormalities occurring in patients with psoriasis were first recognized over four decades ago, yet psoriatic alopecia is not a well-known concept among clinicians."1 I am embarrassed to admit that I am one of those clinicians. It's time to appreciate the presentations of psoriatic alopecia – although much remains to be learned of its pathogenesis.

In a retrospective review of 33 scalp biopsies on 31 patients having histopathologic diagnosis of psoriasis, alopecia was a presenting feature in 48% of cases. The most common follicular-related changes were infundibular dilatation (87%) followed by perifollicular fibrosis (77%), perifollicular lymphocytic inflammation (68%), thinning of the follicular infundibulum (55%), and fibrous tracts (28%). Of interest, sebaceous glands were absent in 60% and atrophic in 25% of cases.2

Alopecia may occur within the plaque itself; it is usually non-scarring and improves with therapy. Scarring may occur in the context of secondary infection. Psoriatic alopecia may also appear as a generalized telogen effluvium, be associated with alopecia areata, or be due to medication, notably methotrexate or retinoids. Increasingly, there have been reports of psoriatic alopecia secondary to TNF-alpha inhibitors.1

TNF-alpha inhibitors may yield psoriatic alopecia in the context of their paradoxical reaction of causing (or exacerbating) psoriasis, regardless of whether prescribed for psoriasis, rheumatoid arthritis or Crohn's disease. In most cases, alopecia in psoriatic patients improves with standard therapy (such as topical steroids) or upon discontinuation of the inducing medication.

One of the major intrigues is trying to decipher what role the sebaceous gland has in this process. Liakou et al., performing histological and stereological analyses of involved and healthy skin of 14 psoriatic patients, were able to demonstrate a significant reduction of the number of sebaceous glands and the volume of the individual glands themselves. The authors speculated that the sebocytes may not differentiate properly in psoriasis, and may play a role in the pathogenesis of psoriasis and psoriatic alopecia.3 In a transcriptome study of lesional psoriatic skin vs normal skin, Rittié et al. found that a co-expressed gene module (N5) enriched 11.5-fold for lipid biosynthetic genes. They also observed fewer visible hairs in psoriatic skin, compared with uninvolved nonlesional psoriatic skin or normal skin (P < .0001). Sebaceous glands were markedly atrophic in psoriatic versus non-lesional psoriatic skin with a 91% average reduction in volume. These results suggested that loss of visible hair in psoriasis may result from abnormal sebaceous gland function.4

As stated earlier, there have been an increasing number of reports of TNF-associated psoriatic alopecia. Afanasiev et al. reported 3 cases in middle-aged women, with histories of either Crohn's disease or inflammatory arthritis, but without a prior history of psoriasis. Two patients received adalimumab and one infliximab. All 3 developed psoriatic plaques in the scalp with alopecia, after a variable length of time of being on TNF-inhibitors, ranging from 4 months to 3 years. Each patient improved after discontinuing the TNF inhibitor. Histologically, marked atrophy of the sebaceous glands was observed. A re-biopsy of the scalp in one of the patients showed regrowth of the sebaceous lobules upon stopping the TNF inhibitor therapy. The authors concluded that atrophy of sebaceous lobules is a potentially reversible, characteristic, and conspicuous feature of tumor necrosis factor inhibitor-associated psoriatic alopecia; this may be distinguished from idiopathic psoriatic alopecia by the clinical history of drug exposure and sometimes by the histologic presence of a mixed inflammatory response including plasma cells and eosinophils.5

The role of the sebaceous gland in psoriatic alopecia is speculative. Perhaps there is a mechanical component, in that drier hair may be more brittle and subject to trauma. The sebaceous gland is located just superior to the bulge area that harbors hair follicle stem cells; could it be that diminution of the sebaceous gland has some bearing on the regenerative capability of the hair follicle? Much remains to be learned about the relationship of the sebaceous gland with psoriatic alopecia. Until such time, patients may be reassured that their alopecia will likely improve with topical treatments, and/or removal of the offending agent.

Disclaimer: First published on Dr. Warren Heymann's Dermatology Insights and Inquiries website on June 25, 2017. Republished with permission.

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Dieta baja en Carbohidratos

High Carbohydrate Consumption May Be Harmful, Research Suggests.

Reuters (8/29, Seaman) reports that research suggests "global dietary guidelines should possibly be changed to allow people to consume somewhat more fats, to cut back on carbohydrates and in some cases to slightly scale back on fruits and vegetables."

        STAT (8/29, Skerrett) reports that the findings come "from data released...by the international Prospective Urban Rural Epidemiology (PURE) study."

        TIME (8/29, Park) reports that investigators found that "people eating high quantities of carbohydrates...had a nearly 30% higher risk of dying during the study than people eating a low-carb diet." Meanwhile, individuals "eating high-fat diets had a 23% lower chance of dying during the study's seven years of follow-up compared to people who ate less fat."

        MedPage Today (8/29, Husten) reports that the study "also found that the benefits of fruits, vegetables, and legumes top out at just three to four total servings per day."

        Medscape (8/29, Hughes) reports that the research was presented at the European Society of Cardiology 2017 Congress and was "published as two separate papers in The Lancet – one on the fat and carbohydrate outcome data and one on fruit/vegetables/legumes outcome data." An additional "paper in Lancet Diabetes and Endocrinology focuses on effects of the different dietary patterns on lipid levels and blood pressure."

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Interesante: hasta en Melanoma... mejor atipico conocido que nuevo por conocer

Most Melanomas Occur As New Lesions, Not In Existing Moles, Meta-Analysis Finds.

HealthDay (8/29, Reinberg) reports a meta-analysispublished online in the Journal of the American Academy of Dermatology found that existing moles are not the most likely place for melanoma to develop. A review of 38 previously published medical studies involving over 20,000 melanomas revealed that just 29 percent of the skin cancers began in moles patients already had, while 71 percent came from new lesions on the skin. Medscape (8/29, Harrison) also covers the study.

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http://www.medscape.com/viewarticle/884431?nlid=117412_1585&src=WNL_mdplsfeat_170822_mscpedit_derm&uac=32331EX&spon=33&impID=1416222&faf=1

Common Chemicals in Cosmetics, Soaps Tied to Poor Semen Quality

(Reuters Health) - Men who have been exposed to common chemicals known as parabens have lower testosterone levels and more sperm that are abnormally shaped and slow moving, according to a study that suggests these ingredients may contribute to infertility.

Researchers examined lab tests done on 315 male patients of a fertility clinic in Poland to pinpoint issues they were having with reproduction. All of the men provided samples of urine, saliva, blood and semen for analysis.

Compared to men who had low concentrations of parabens in their urine, men with high concentrations of the chemicals also had a larger proportion of sperm with the abnormal morphology that's associated with infertility, the study found.

Higher levels of parabens in the urine were also associated with DNA damage in the sperm and with decreased sperm motility, which may contribute to infertility.

"We have observed an impact of parabens on semen quality," said lead study author Joanna Jurewicz of the Nofer Institute of Occupational Medicine in Lodz.

"To avoid parabens is very difficult because they are widespread, but we can try to minimize the exposure by only using personal care products with label information saying that there are no parabens in the particular product," Jurewicz said by email.

Parabens are widely used preservatives in cosmetic products, including soaps, creams and makeup. The most common parabens in cosmetics are methylparaben, propylparaben and butylparaben. Typically, several parabens are used in combination to increase their effectiveness.

Some parabens are banned from cosmetics in the European Union, but the U.S. Food and Drug Administration has not limited use of the ingredients.

Past research in animals has suggested that parabens can mimic the hormone estrogen and lower testosterone levels, the authors note in the Journal of Occupational and Environmental Medicine, online July 7.

Parabens and other so-called hormone disruptors may have developmental, reproductive, neurological and immune-system side effects, and they may be found in pharmaceuticals, cosmetics, pesticides, plastics, detergents, food, toys, and flame retardants, according to the U.S. National Institutes of Health.

The current study found one chemical in particular, butyl paraben, associated with an increase in the percentage of sperm with an abnormal size and shape as well as a decrease in sperm motility.

Another chemical, ethyl paraben, was associated only with sperm of atypical size and shape.

Beyond its small size, other limitations of the study include the lack of data on other environmental or medical factors that might influence sperm quality or infertility. Because the men all joined the study after visiting a fertility clinic, it's also possible the results might not apply to other men.

Scientists don't know exactly what amount of parabens might be harmful or exactly how they work in the human body to damage fertility.

"No one really knows the mechanism of action of these compounds," said Marisa Bartolomei, co-director of the epigenetics program at the University of Pennsylvania Perelman School of Medicine in Philadelphia.

Parabens are also so ubiquitous that they're hard to avoid.

"Parabens are in many products: sunscreens, body lotions, facial lotions and cleansers, mascara, assorted lipsticks, hand soaps, shampoos, conditioners, sprays, gels, and some food products," Bartolomei, who wasn't involved in the study, said by email.

Products labeled "paraben-free" may not necessarily be safe, either.

"Many of us wonder what substitutes for these chemicals there are and if the substitutes are better or if they have even been tested," Bartolomei said.

SOURCE: http://bit.ly/2vGWge0

J Occup Environ Med 2017.

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Alopecia epidemica

Women Of Color Have More Toxic Chemicals In Their Bodies From Beauty Products Than White Women, Study Says.

The New York Daily News (8/17, Gibbs) reports a new study published in the American Journal of Obstetrics and Gynecology found that products marketed toward women of color "that pressure them to conform to European beauty standards" are more likely to have "toxic chemicals like hormone disrupters and heavy metals, researchers from George Washington University and Occidental College found." Researchers found that chemicals found in skin bleachers and hair straighteners include formaldehyde, phthalates, parabens, lead and mercury. Even in trace amounts, "these chemicals can affect the endocrine system, cause cancer, or even affect unborn children." The study says, "Compared with white women, women of color have higher levels of beauty product-related environmental chemicals in their bodies, independent of socioeconomic status."

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Clinical Presentation of Terbinafine-Induced Severe Liver Injury and the Value of Laboratory Monitoring | PracticeUpdate

Published in Dermatology

Journal Scan / Review · August 15, 2017

Clinical Presentation of Terbinafine-Induced Severe Liver Injury and the Value of Laboratory Monitoring

The British Journal of Dermatology

CONTEXT

Many physicians monitor liver function tests during terbinafine therapy.

OBJECTIVE

Evaluate the symptoms of published cases of terbinafine associated severe DILI (Drug Induced Liver Injury) to assess the utility of laboratory monitoring.

DATA SOURCES

We based our search on the Liver Tox database of the National Institute of Health, but searched PUBMED as well as EMBASE. In addition, we hand-searched the references of the papers we found.

STUDY SELECTION

All reports of patients with DILI on terbinafine and reported clinical symptoms, or absence thereof, were evaluated.

DATA EXTRACTION

Two independent reviewers (J.A. and O.K.) assessed articles for eligibility of inclusion, and collected and evaluated the data.

DATA SYNTHESIS

38 papers fulfilled the inclusion criteria with reports of 69 symptomatic patients. Mean duration of terbinafine treatment until onset of symptoms was 30.20 days (range 5 - 84). Symptoms in order of frequency were jaundice, flu-like symptoms, dark urine, and pruritus. Patients experienced symptoms for a mean and median of 14.78 and 16 days, respectively, (range of 0 - 42) until seeking medical attention.

CONCLUSIONS

Patients who had DILI were symptomatic, usually with jaundice, abdominal pain, general malaise, but also with severe pruritus. No asymptomatic patient was identified through laboratory screening. The timeline of DILI onset varies significantly, but most cases occur between 4 and 6 weeks. There was no timepoint at which monitoring is meaningful, and we do not recommend monitoring of LFTS on terbinafine, however, patients should be advised to discontinue treatment and search medical care when symptoms of DILI occur.

Comment:

Severe, usually idiosyncratic, drug-induced liver injury (DILI) due to terbinafine is universally symptomatic and can lead to liver transplantation and death.1 A large-scale cohort of 69,830 patients treated with oral antifungal agents estimates incidence rates of DILI to be 134.1, 10.4, and 2.5 per 100,000 person-months for ketoconazole, itraconazole, and terbinafine, respectively.2

This article was chosen to be our Story of the Week because it emphasizes the importance of listening to the patient, counseling the patient, and ordering lab tests based on the best available data. A cursory review of this article could lead the reader to surmise that more lab monitoring is needed since terbinafine can cause significant injuries and even death. Of course, we agree with the authors that the data tell a different story. The good news is that ordering liver function tests is not hopelessly expensive; but, as the authors state in their own comments, laboratory monitoring is not completely safe. They note that it conveys the belief to the patient that the testing has clinical utility and is somehow protective of symptomatic drug-induced liver injury.

A key take-home point is that all cases of terbinafine-induced hepatotoxicity were clinically symptomatic. Most of these patients had jaundice, flulike symptoms, abdominal discomfort, and pruritus. The authors could not find any specific point in time when laboratory monitoring would be ideal, especially for patients who were asymptomatic. In fact, they didn't find a single report of terbinafine-induced liver injury in an asymptomatic patient identified through laboratory screening.

I believe most dermatologists order labs for patients treated with terbinafine because they lump this medication with other onychomycosis medications that are associated with more significant hepatotoxicity (ketoconazole and itraconazole) Ketoconazole has even earned a black box warning from the FDA. Terbinafine-induced hepatotoxicity is a very rare idiosyncratic event, and there are other potential idiosyncratic events that can happen as well (eg, idiopathic thrombocytopenia). As the word idiopathic, or idiosyncratic, implies, we have no idea why this occurs.

In my practice, I like to minimize exposure to medication when possible. Although the FDA-approved method of treating onychomycosis is with continuous therapy for 3 months, there have been a number of articles that demonstrate the effectiveness of a variety of pulsed regimens. Ever since terbinafine became generic, I've prescribed 250 mg once daily for 1 week. Patients wait 3 weeks and repeat this treatment each month for a total of 4 weeks of treatment over 4 months. In the United States, this generally cost the patients $10 for their 28 tablets. As for blood monitoring, I ask them about hepatic symptoms to start, although I probably don't counsel them as much about idiosyncratic reactions as I should (but I'm going to start doing a better job on this, having been thinking about this article). Then I get a CBC and a comprehensive metabolic panel at baseline. The truth is that I am looking for an idiosyncratic reaction that might affect their white cell count or platelets, kidney, or liver. This is repeated at the end of the first week. Patients are instructed that there is no guarantee that they will not have a problem with the subsequent pulses, but it is comforting to know that they did not have a hypersensitivity (idiosyncratic) reaction on the first pulse. The cost of a CBC and a comprehensive metabolic panel is affordable for most patients even if they do have high deductibles or no insurance.

I recognize that the cure rate of pulsed dosing does not match that of continuous therapy, but recurrences are quite common even with continuous dosing; so, I favor a "minimalist" approach to onychomycosis. I do use continuous therapy for tinea capitis and more severe tinea corporis, monitoring bloodwork at baseline and then at 1 to 3 weeks. This may detect idiopathic reactions in these patients as well. Most importantly, all patients are instructed to call the office if they develop jaundice, abdominal pain, flulike symptoms, or pruritus. I have become convinced that monthly lab studies in all patients treated with antifungal drugs wastes healthcare dollars, gives patients a false sense of security, and is not warranted on scientific grounds. I am unsure if rank and file dermatologists will feel they can defend themselves in a court of law if a lawsuit occurs as a result of an idiosyncratic reaction.

References

1. US Food and Drug Administration. Guidance for Industry, Drug-Induced Liver Injury: Premarketing Clinical Evaluation. http://www.fda.gov/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/default.htmPublished July 2009. Accessed August 15, 2017.
2. Garcia Rodriguez LA, Duque A, Castellsague J, et al. A cohort study on the risk of acute liver injury among users of ketoconazole and other antifungal drugs. Br J Clin Pharmacol 1999; 48(6): 847-852. http://onlinelibrary.wiley.com/doi/10.1046/j.1365-2125.1999.00095.x/abstract

TAKE-HOME MESSAGE

• This review article uses data from the LiverTox database of NIH as well as sources found in a review of the literature to evaluate the value of laboratory monitoring to detect terbinafine-induced severe liver injury. A total of 173 cases of terbinafine-induced hepatic dysfunction were identified, although presenting symptoms were available for only 69, which the researchers analyzed. The mean duration of terbinafine treatment prior to the onset of symptoms was 30 days, with a range of 5 to 84 days. All patients were taking a dose of 250 mg/day. Cases presented clinically with a wide range of symptoms, including jaundice, itch, nausea, weight loss, and malaise. Fulminant liver failure requiring liver transplant developed in 3 patients. The authors argue that laboratory monitoring is not useful because all cases were symptomatic, and no cases were found through monitoring alone.

• This review article examines terbinafine-induced severe liver injury and does not recommend routine laboratory monitoring during terbinafine therapy.

  – Anna Wile, MD

  
  

  The British Journal of Dermatology

  Clinical Presentation of Terbinafine-Induced Severe Liver Injury and the Value of Laboratory Monitoring: A Critically Appraised Topic

  Br J Dermatol 2017 Aug 01;[EPub Ahead of Print], ON Kramer, J Albrecht 
  

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Medicamentos topicos durante el embarazo.

Journal Scan / Review · August 14, 2017

Topical Antiviral and Antifungal Medications Should Be Administered Cautiously in Pregnancy

Journal of the European Academy of Dermatology and Venereology: JEADV

Abstract

Medications should be employed with caution in women of childbearing age who are pregnant or considering pregnancy. Compared to oral or parenteral agents, topical medications have limited systemic absorption and are deemed safer. However, their safety profile must be assessed cautiously due to the limited available data. In this article, we aggregate human and animal studies to provide recommendations on utilizing topical antiviral and antifungal medications in pregnancy. For antiviral medications, acyclovir and trichloroacetic acid are safe to use in pregnancy. Docosanol, imiquimod and penciclovir are likely safe, but should be utilized as second-line agents. Podofilox and podophyllin resin should be avoided. For antifungal medications, clotrimazole, miconazole and nystatin are considered first-line agents. Butenafine, ciclopirox, naftifine, oxiconazole and terbinafine may be utilized after the above agents. Econazole should be avoided during the first trimester and used sparingly during 2nd and 3rd trimester. Ketoconazole and selenium sulphide are likely safe, but should be employed in limited areas for brief periods.

Journal of the European Academy of Dermatology and Venereology: JEADV

Topical Antiviral and Antifungal Medications in Pregnancy: A Review of Safety Profiles

J Eur Acad Dermatol Venereol 2017 Aug 04;[EPub Ahead of Print], VM Patel, RA Schwartz, WC Lambert 

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The Most Harmful Cosmetics On The Market - Newsletter: DocCheck News - DocCheck-News - DocCheck News

The Most Harmful Cosmetics On The Market

Compared to medications, specifications about cosmetic substances in hair and skin care products are vague. Complaints about disturbing side effects are rapidly increasing, US dermatologists indicate. Despite known risks, these products often remain on the market.

Strong hair, a pore-deep cleansed skin or fewer wrinkles: many cosmetic products draw consumers with full-bodied promises. It's true that US scientists have not tackled the subject of credibility of advertisements. They do however report that more and more adverse events are occurring due to their harmful components.

Number of complaints doubled

Dr. Steve Xu © Northwestern University

Dr. Steve Xu, dermatologist at the Northwestern University Feinberg School of Medicine, has evaluated complaints from consumers about cosmetics. His analysis covered the US market. Many of the criticised products are also available in Europe.

Although the Food and Drug Administration (FDA) recorded more than 5,000 cases between 2004 and 2016, this is probably only the tip of the iceberg, says Xu. As he found out, the number doubled from 2015 (706) to 2016 (1,591). In view of global turnover of 430 billion US dollars per year and millions of different products the expert is left unconvinced by FDA statistics.

The most frequent complaints in the database related to hair care products, skin care products and tattoos. Aromatic amines turned up in many colouration mixes. In addition, inks from which tattoos are created contained harmful dyes.

Increased number of known problems with cosmetics. Estimated do not exist. © JAMA

Despite the known risks, products often remain on the market, which is mainly due to legal quibbles. "The FDA has far fewer opportunities to withdraw cosmetics from the market than to recall medicines or medical devices, Xu crtiticises. "It is difficult to get harmful cosmetics off the supermarket shelves (…) If we were dealing with a medication, the story would be different".

Alopecia by hair conditioner

Here is a controversial case. In 2014 FDA toxicologists sent letters to the cosmetics producer Chaz Dean, Inc, and to the direct marketing company Guthy-Renker, in response to 127 consumer reports. The matter at hand was the product "WEN by Chaz Dean Cleansing Conditioner". It was only through their searches that representatives of the authorities learned that both companies had already received 21,000 consumer complaints. Those affected usually complained about scalp irritation and alopecia. Nevertheless the product series remained available. "Three or four people may be wrong. But it's hard to ignore 21,000 cases", the scientist says.

US laws give the FDA no authority to obligate cosmetics manufacturers to provide safety data. On the contrary, representatives of the authorities must prove that a particular product is harmful to health if used as intended. Further investigations are carried out at the FDA as well as before the court.

According to US media more than 200 women from 40 states have initiated a class action in order to assert liability claims against the manufacturer. Which of the ingredients may potentially be causing hair loss is from a scientific viewpoint unclear. The prosecution refers to "a corrosive substance" which destroys hair and follicles.

Critical cosmeceuticals

Dangers do arise however from many product groups. Xu warns specifically about so-called cosmeceuticals. These are cosmetic products with biologically active ingredients (pharmaceuticals). They act not only in upper layers, but pass the skin barrier.

All active substances must be well characterised in terms of their action and their toxicological properties. The delimitation from medicinal products is not always clear, despite numerous paragraphs. For instance regarding dexpanthenol: is the foremost matter here wound healing, or the skin care in itself?

This is also shown by other molecules in cosmeceuticals. Some examples from an unmanageably extensive variety:

• Antimicrobial substances such as azelaic acid, salicylic acid, clotrimazole
• Antioxidants such as vitamin C and vitamin E esters, or coenzyme Q₁₀
• Anti-inflammatory molecules, such as gamma and alpha-linolenic acids, panthenol or extracts of aloe vera
• Itch-relieving substances such as urea or allantoin
• Molecules that activate growth factors: retinoids, vitamins, echinacea extracts
• Peelings based on fruit acids or salicylic acid
• Phytohormones such as isoflavonoids
• Molecules to activate collagen formation, such as vitamin C derivatives
• Molecules with firming properties such as extracts of butcher's broom, horse chestnut and horsetail

Dr. Steve Xu's conclusion: "Although it is not explicitly examined in the published article, this cosmetic product class is becoming a growing problem in the USA".

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Tratamiento con retinoides orales, inclusive Isotretinoina, debemos controlar fucion tiroidea!

Effects of isotretinoin on the thyroid gland and thyroid function tests in acne patients: A preliminary study.

Abstract

BACKGROUND: Isotretinoin is widely used in the treatment of acne.

AIMS: We investigated the effects of isotretinoin on thyroid function tests and thyroid volume in acne patients.

METHODS: In this prospective study, a total of 104 acne patients were included. Sixty-six patients were treated with isotretinoin for at least 4 months. Thirty eight patients were included in the control group. The levels of thyroid stimulating hormone, free triiodothyronine, free thyroxine, antithyroglobulin and antithyroid peroxidase antibodies were measured and a thyroid ultrasound was performed in all the subjects before treatment and 4 months after treatment. A "p" value of < 0.05 was considered significant.

RESULTS: In the isotretinoin-treated group, thyroid stimulating hormone levels increased significantly during isotretinoin treatment (P = 0.018). Free triiodothyronine, free thyroxine, anti-thyroid peroxidase levels and thyroid volume decreased significantly during treatment (P = 0.016, P= 0.012, P= 0.006, P = 0.020 respectively).

LIMITATIONS: The major limitation of this study is the lack of follow-up data after the cessation of isotretinoin therapy in acne patients.

CONCLUSION: Patients treated with isotretinoin should be monitored with thyroid function tests.

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Interesante reportaje sobre charla de filtros solares... No bloqueadores!

Sunscreens With SPF >50 Are Effective and Key to Reducing Melanoma Risk

July 30, 2017—New York—Sunscreen with SPF >50 is effective and important in reducing melanoma risk. The best formulation of sunscreen is the one that the patient will apply regularly as recommended.

These conclusions, based on a talk entitled, What's New in Sunscreen: What Your Patients Are Asking and Need to Know," were presented by Darrell S. Rigel, MD, MS, of New York University Medical Center.

He gave the talk at the 2017 American Academy of Dermatology Summer Meeting, which took place from July 27 – 30.

Epidemiology of Melanoma

More skin cancers occur than all other cancer combined in the US. Lifetime risk of invasive melanoma has risen from one in 1500 in 1930 to one in 50 in 2017. This risk is projected to rise to one in 40 by 2020. Though more than one American dies of melanoma every hour, deaths from melanoma dropped from 10,130 in 2017 to 9730 in 2017.

The lifetime risk of invasive melanoma among US males is one in 28, for females, one in 44. In 2017, 63,410 cases of in situ melanoma have been reported, and 87,100 cases of invasive disease. In 2017, 6% (n=52,170) of new cancers in males were melanoma, and 4% (n=34,940) of those in females.

Melanoma is one of the few cancers of which we know the cause—ultraviolet radiation exposure, and for which a simple behavioral change—minimization of ultraviolet light exposure—lowers risk.

The incidence of melanoma rises with proximity to the Equator, such that Hawaii is the most affected state in the US. Between 89% and 95% of annual cutaneous melanoma cases are caused by solar ultraviolet light exposure. Not all melanomas are caused by ultraviolet light exposure, but the vast majority are. 

News on Sunscreen That Patients May Mention

In the third week of May, Consumer Reports and the Environmental Working Group issue updates on sunscreens. These updates are circulated in social media, peeking awareness and provoking questions to physicians. 

In 2016, Consumer Reports rated 67 sunscreens categorized as chemical and mineral, chemical, and mineral. They stated that half the products were an SPF below that printed on the label.

In 2017, the Environmental Working Group reported that sunscreen spray sales exceeded lotions for the first time. They listed aerosol spray sunscreens with SPF >50 that contained the harmful additives oxybenzone and retinyl palmitate. The Environmental Working Group rated two products made by the Honest Company among the best beach and sport sunscreens, yet a lawsuit accused this startup of selling deceptively labeled products.

Websites of both Consumer Reports and the Environmental Working Group carry a link to Amazon.com to purchase the products. The Environmental Working Group states that it may receive a commission for purchases made via the Amazon.com link.

The Weight of Evidence in Favor of Regular Sunscreen Use

In a small study by Green et al. in 2011, regular sunscreen use was associated with reduced melanoma risk. A total of 1621 randomly selected residents of Queensland, Australia, age 25 – 75 years, were randomized to daily or discretionary sunscreen application to the head and arms. They were treated for 5 yeas and followed for 10 years. Only 11 new cases of malignant melanoma occurred in the daily group vs 22 in the discretionary group (P = .051). Of the 11 new melanomas, two were invasive. Dr. Green concluded that regular sunscreen use may reduce melanoma risk.

A 2015 study by Olsen et al. found that regular sunscreen use prevented skin cancers in Australia. Dr. Olsen estimated the proportion of skin cancers that would have occurred but were likely prevented by regular sunscreen use. Regular sunscreen use was estimated to have prevented approximately 14,190 persons from developing squamous cell carcinoma (prevented fraction 9.3%) and 1730 from melanoma (prevented fraction 14%). Dr. Olsen concluded that prevailing levels of sunscreen use probably reduced skin cancer incidence by 10%-15%, and that sunscreen should be a component of a comprehensive sun protection strategy.

A 2016 Norwegian study found that in women with blonde or red hair who freckled in the sun, using a sunscreen with SPF >15 was associated with significant improvement.

Waiting 15 – 20 minutes after sunscreen application, though mandatory on product labels, is not necessary. Ultraviolet protection is instantaneous. Reapplication after 2 h, also mandatory on labels, is not necessary but is advisable to assure a proper application level and to hit "missed spots."

Jung et al., in 2012, found that extended exposures to high temperatures can degrade sunscreen but a 2010 study by Rego et al found that sunscreen protection does not degrade at outdoor summer temperatures during a typical vacation period.

Are SPFs Higher Than 50 Worth the Extra Cost?

Sunscreens with SPF ≥50 are available in developed countries such as New Zealand, the US, and in Europe. Australia, among others, caps SPF at 50+.

Arguments in favor of capping SPF include containing the higher cost of the increased SPF formulations and the little marginal improvement in ultraviolet B protection that these products confer. The increase in ultraviolet B protection is only 1% from SFP 50 to SPF 100. 

The argument against capping the products at SPF 50+ is that sunscreens with higher SPFs confer better protection at "real world" application concentrations. In addition, a 1979 study by Sayre et al found that SPF 15 sunscreens prevent 93.3% of ultraviolet B absorption, SPF 20 products prevent 96.7%, SPF 45 products prevent 97.8%, and SPF 50 products prevent 98%. These rates assume that sunscreen is applied at the tested concentration of 2 mg per square centimeter. Typically, only 25% to 50% of the rated amount is applied.

A 1997 study by Stokes et al. found that sunscreen is underused. Sunscreen application varies widely, with many individuals using less than the recommended 2 mg per square centimeter. Users were found to receive a mean SPF of 20%-50% of the expected amount due to inadequate application. Underprotection due to inadequate application may explain why sunscreen use has been reported in some studies to be a risk factor for melanoma.

Sunscreen SPF is tested using a thickness of 2 mg per square centimeter. Investigations show that sunscreen, under natural conditions, is applied insufficiently, at amounts approximately 0.39 to 1.0 mg per square centimeter. Other pitfalls that reduce the protective effect of sunscreens are missing areas and ultraviolet radiation exposure before sunscreen application.

Numerous studies have shown that consumers typically underapply sunscreen by ¼ to ½ of the recommended amount. They seldom reapply after the initial application, and not all body areas receive comprehensive application and coverage.

Whether high SPF compensates for underapplication of sunscreen was determined by Ou-Yang et al. in 2012. They measured the SPF values of various sunscreens from SPF 30 – 100 applied in the reduced amounts typically used by consumers. They found a linear relationship between application density and SPF delivered. Sunscreens labeled >50 SPF provided significant protection, even when applied at "real world" typical application densities.

Whether sunscreens with SPF >50 provide additional benefit was determined by Williams et al in an in vivo comparison of SPF 100 vs SPF 50 in "real world" conditions. They found that high-SPF sunscreen did provide significant clinical benefit in real world conditions, that sunscreen with SPF 100+ was more effective than that with SPF 50+.

In addition, Russak et al. found in 2010 that high-SPF formulations were more effective during intensive ultraviolet exposures. They tested a formulation containing SPF 85 vs one containing SPF 50 sunscreen. Fifty-six subjects applied sunscreen to the face while skiing in 2008. 

They applied sunscreen only once at the start of the day and were exposed an average of 5.0 h. Seven of 28 sunburned with SPF 50 sunscreen vs one of 28 who applied SPF 85 sunscreen (P = .02). Dr. Russak concluded that the SPF 85 formulation was more effective than the SPF 50 formulation in protecting from sunburn after a single application in a high-ultraviolet test environment.

A study not yet published by Williams et al. took into consideration the facts that in real-world settings, consumers apply sunscreen at densities lower than those used to determine SPF clinically, and that the linear dependence of SPF to application density is well established. It hypothesized that a sunscreen with higher SPF would provide greater in-use efficacy than one labeled at the proposed maximum of SPF 50+. The objective was to evaluate the difference in sunburn protection provided by different SPF sunscreens during a day of skiing.

The split-face study compared SPF 100+ or SPF 50+ sunscreen lotion. Usage, application density, and reapplication frequency were comparable. After 6 h of sun exposure while skiing, SPF 100+ sunscreen was found to be significantly more effective at protecting against sunburn than SPF 50+ sunscreen. Erythema was significantly lower on the SPF 100+ protected side of the face, and erythema progression was observed to be more than twice as severe on the SPF 50+ protected side. The number of sunscreen reapplications was not observed to diminish the enhanced protection benefit of the SPF 100+ product.

Dr. Williams concluded that the SPF 100+ sunscreen was significantly more effective in protecting against sunburn than the SPF 50+ sunscreen, and that sunscreens labeled as SPF higher than 50+ are needed to provide consumers with better choices of sunburn protection.

A 2016 randomized, evaluator-blinded, controlled study by Ou-Yang et al. set out to measure sunburn protection offered by shade from a beach umbrella vs SPF 100 sunscreen for 3.5 h at a lakeside beach near Dallas, Texas. Subjects were reminded to reapply the sunscreen after 2 h.

The shaded group used a standard beach umbrella with an ultraviolet protection factor rating of 1000+. They wore no sunscreen and were reminded to reposition the umbrella as the solar angle changed.

The group wearing sunscreen experienced a significantly higher increase in sunburn to the face only (P < .05). The shaded group experienced a significant increase in sunburn to all body sites (P < .001). Seventy-eight percent of subjects in the shaded group had an increased sunburn score. Twenty-five percent of subjects in the sunscreen group had an increased sunburn score.

Dr. Ou-Yang concluded that the shaded group scored significantly higher in sunburn (P < .001), and that seeking shade alone may not provide sufficient protection during extended ultraviolet sun exposure. Neither shade nor high SPF sunscreen alone prevented sunburn completely. Dr. Ou-Yang suggested that multiple sun-protective measures be recommended rather than a single approach.

Retinyl Palmitate: An Ingredient Whose Safety Has Been Questioned

The safety of retinyl palmitate, a vitamin A analog cosmetic ingredient and antioxidant used in sunscreen, has been questioned. In 2010, Wang et al. proposed that no published evidence suggests that topical retinoids increased the risk of photocarcinogenesis. Retinyl palmitate has been used in topical agents for over 40 years. Retinoids are used for chemoprevention of skin cancer in persons at high risk, such as transplant population and patients with xeroderma pigmentosum, with no evidence of increased skin cancer risk.

Protection Against Photodamage Other Than Melanoma

To determine whether sunscreen protects against other photodamage, in 2014, Cole et al. evaluated whether high-SPF sunscreen can protect skin at the cellular level under ultraviolet exposure doses, similarly to the SPF value. Sunburn cells, Langerhans cells, thymic dimers, protein 53, and matrix metalloproteinase 1 and 9 endpoints were evaluated in biopsies from 12 subjects. They were either unprotected, and exposed to 0, 1, and 3 minimal erythema dose or had applied SPF 55 sunscreen and were exposed to 55 minimal erythema dose of ultraviolet radiation. 

After 55 minimal erythema doses, sunscreen-protected sites showed either significantly less damage or no difference than the one minimal erythema dose – exposed unprotected sites. Dr. Cole concluded that high-SPF sunscreen with high ultraviolet A preventive factor can provide proportionately high protection against multiple cellular damage markers.

Hughes et al., in 2013, set out to evaluate sunscreen to prevent skin aging in a randomized trial. They were randomized to daily use of a broad spectrum sunscreen and 30 mg of beta-carotene, daily use of sunscreen and placebo, discretionary use of sunscreen and 30 mg of beta-carotene, or discretionary use of sunscreen and placebo. 

Skin aging from baseline to conclusion was significantly less in the daily sunscreen group than in the discretionary group (odds ratio 0.76). Dr. Hughes concluded that regular sunscreen use retards skin aging in healthy, middle-age men and women. Beta-carotene was not shown to affect skin aging.

Nanoparticles vs Microsized Particles

In 2014, Singh et al. compared the sun protection of metal oxide nanoparticles vs conventional particles in an in vitro study. Nanoparticle formulations conferred better spreadability and better SPF values by a 2 x margin. Dr. Singh concluded that nanoparticles in sunscreen proved advantageous, conferring benefits of good texture, better spreadability, and enhanced in vitro SPF.

Borase et al., in 2014, found that gold nanoparticles are a potent alternative to traditionally used titanium oxide and zinc oxide nanoparticles in commercial sunscreens.  

In 2011, Smijs et al. evaluated the safety and efficacy of titanium dioxide and zinc oxide nanoparticles vs microsized titanium dioxide and zinc oxide. The conclusion was that caution should be exercised when new sunscreens are developed because sunscreen nanoparticles induce (photo) cyto- and genotoxicity, which have been sporadically observed in viable skin layers.

Polypodium leucotomos

In 2013, Jansen et al. published an article on Polypodium leucotomos, a natural fern leaf extract with anti-inflammatory and antioxidant properties that is taken orally. Administration of oral P. leucotomos to a group of high-risk patients with malignant melanoma or dysplastic nevus syndrome led to a significant reduction in sensitivity to ultraviolet radiation in all patients. Other studies have found that oral administration of 480 – 1200 mg daily of this extract can prevent polymorphous light eruption lesions in patients with polymorphous light eruption.

P. leucotomos has been shown to reduce the known effects of ultraviolet radiation, including minimal erythema dose, minimal phototoxic dose, ultraviolet-induced epidermal proliferation, development of DNA damage, and reactive oxygen species. Studies published in 2004, 2013, and 2015 confirmed that the extract is effective for long-term use.

Changing Behavior

A 2014 study by Idorn et al. found that even patients diagnosed with cutaneous malignant melanoma failed to maintain long-term cautious sun behavior.

A 2013 evaluation of trends in physicians' sunscreen recommendations over a 21-year period, by Akamine et al., found that physicians mentioned sunscreen in one in 60 visits, and 86% of these mentions were by dermatologists. Even they mentioned sunscreen in only 1.6% of visits.

In 2013, Dennis et al. examined artificial ultraviolet use prior to vacation to protect against vacation-related sunburn. Tanning using an artificial ultraviolet source during the 10 weeks prior to vacation was not associated with reduced risk of sunburn during the vacation, but rather with an increase in this risk. Dr. Dennis concluded that maintaining a tan may not protect against sunburn, and that public health messages need to address this misconception. 

Photoprotection in Car Windows

Wachler, in 2016, assessed levels of ultraviolet A protection in automobile windshields and side windows. The average percentage of front-windshield ultraviolet A blockage was 96% (range 95% - 98%) and side window blockage was 71% (range 445 – 96%). Dr. Wachler concluded that the results may in part explain the reported increased rates of cataract in left eyes and left-sided facial skin cancer. 

Photoprotection and DEET Insect Repellant

Yiin et al., in 2014, assessed dermal absorption of DEET-containing insect repellant and oxybenzone-containing sunscreen, amid concerns about oxybenzones increasing the dermal absorption of DEET. The goal was to determine the best way to use these two products concurrently without extra absorption of either. Dr. Yiin confirmed enhanced DEET absorption when oxybenzone is applied after DEET. Applying the oxybenzone-containing sunscreen first, and then the insect repellant, with a 15-minute interval between the two applications, was recommended.

Conclusions

Dr. Rigel concluded that physicians need to learn what their patients are hearing about sun protection and have answers ready. When patients ask about photoprotection, clinicians need to assert that it is important and lowers melanoma risk. Sunscreens with SPF >50 are effective. Though many questions remain unanswered, new formulations are evolving with new agents and ingredients. The best sunscreen is the one that a patient will use regularly.

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Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

4000-1054

2208-8206

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Antinvejecimiento!

Retinyl Propionate, Climbazole Improves Photodamaged Skin

FRIDAY, July 28, 2017 (HealthDay News) -- Retinyl propionate and climbazole (RPC) is associated with clinical improvement in moderately photodamaged skin for women aged 40 to 70 years, according to a study published online July 22 in the International Journal of Cosmetic Science.

Stacy Hawkins, Ph.D., and colleagues from Unilever Research and Development in Trumbull, Conn., and colleagues recruited 45 healthy Caucasian women, ages 40 to 70 years, with moderately photodamaged skin for a 16-week randomized facial study. Using split-face product application, the authors compared the efficacy of RPC treatment with 0.1 percent retinol, in the same product base formulation, twice daily.

The researchers found that, compared to 0.1 percent retinol treatment, RPC treatment correlated with significant improvement in aging attributes (P < 0.05), with minimal irritation. After five weeks of product application, more than 50 percent of subjects showed improvement of deep wrinkles in the crow's feet area; continued improvement was seen throughout the study. The appearance of lines and wrinkles in the nasolabial fold also improved, as did mottled hyperpigmentation. Subjective self-assessment results confirmed in vivo clinical assessments. Significantly less irritation was seen for the RPC product versus the 0.1 retinol product in a separate patch study.

"RPC delivered significant skin antiaging benefits comparable or greater than 0.1 percent retinol, with minimal irritation," the authors write.

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

4000-1054

2208-8206

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Interesante, sobre suturas en cara...

Published in Dermatology

Journal Scan / Research · July 31, 2017

Aesthetic Outcomes and Complications of Simple Interrupted vs Running Subcuticular Sutures in Facial Surgery

Journal of the American Academy of Dermatology

TAKE-HOME MESSAGE

• This randomized controlled multicenter trial compared outcomes 12 months after treatment and complications in 142 adults who underwent facial surgery and were randomized to receive simple interrupted sutures (SIS) or running subcuticular sutures (RSS). Both techniques yielded similar cosmetic results at 1 year after surgery based on scores from a single observer. Although the techniques demonstrated comparable postoperative risk, hyper- or hypoesthesia at 12 months was more common in the individuals assigned to RSS compared with those assigned to SIS in both intention-to-treat and per-protocol analysis.

• Although SIS and RSS showed similar aesthetic outcomes and complications, SIS may be preferred in facial surgery when appropriate as it yielded less dysesthesia.

  – InYoung Kim, MD, PhD

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

4000-1054

2208-8206

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Otra razon para visitar al dentista!

Older Women With Gum Infections May Have Higher Risk For Certain Cancers, Research Suggests.

Reuters (8/1, Rapaport) reports that researchpublished in Cancer Epidemiology, Biomarkers and Prevention suggests "older women with gum infections are more likely to get many common cancers than their peers who have perfect oral health."

        The New York Daily News (8/1, Dziemianowicz) reports that investigators looked at "data on 65,000 postmenopausal subjects between the ages of 54 and 86 enrolled in the ongoing Women's Health Initiative."

        Medscape (8/1, Jenkins) reports that the researchers found that "postmenopausal women with a history of periodontal disease, including those who have never smoked, are at significantly increased overall risk for cancer as well as site-specific cancers, including lung, breast, esophageal, gallbladder, and melanoma skin cancers."

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

4000-1054

2208-8206

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Muchos tratamientos en heridas requieren mayor rigurosidad cientifica

Many People Suffer From Chronic Wounds Without Science-Backed Treatments.

In a 2,000-word article, Kaiser Health News (8/1, Taylor) reports that 6.5 million patients in the US suffer from chronic wounds, and Medicare is estimated to spend over $25 billion per year on treatment, but there is little scientific evidence that shows the treatments used are effective. For example, the Department of Health and Human Services conducted a "review of 10,000 studies examining treatment of leg wounds known as venous ulcers" and "found that only 60 of them met basic scientific standards." The article reports that businesses "have stepped in with products that the FDA permits to come to market without the same rigorous clinical evidence as pharmaceuticals."

Benjamin Hidalgo-Matlock

Skin Care Physicians of Costa Rica

4000-1054

2208-8206

Please excuse the shortness of this message, as it has been sent from a mobile device.