A Practice Approach to Acne Fulminans in Adolescents.

Acne fulminans (AF) is a severe form of inflammatory acne commonly associated with adolescents. It is characterized by an abrupt onset of painful nodules and plaques and can progress to suppurative, ulcerative, and hemorrhagic lesions. AF can be associated with systemic symptoms such as fever, arthralgia, and bone pain. The etiology of AF is unknown but it has been linked to the use of certain medications and has been rarely found in autoinflammatory syndromes. In previous years, there have been reports of <200 cases in the literature; however, AF may be more common in clinical practice than reported. The most common presentation of AF is seen in adolescents starting isotretinoin therapy. Diagnosis of AF is determined based on its clinical findings. The main purpose of this article is to provide clinicians with a practical approach to treating AF. Current evidence for its treatment is limited to case reports and case series. The mainstay treatment of AF is a combination of prednisone and isotretinoin. It is important to taper or discontinue any exacerbating or precipitating medications such as isotretinoin, antibiotics, or androgens when AF is identified. Along with treatment of AF, it is important to treat associated scarring. Early identification and treatment of AF in adolescents is crucial to minimize both acute symptoms and long-term scarring, and further research is needed to determine optimal management.

Cutaneous interaction with visible light: What do we know?

Visible light has been used therapeutically in dermatology for years for a variety of cosmetic and medical indications, including skin rejuvenation and the treatment of inflammatory and neoplastic conditions, among others. Until recently, visible light was thought to be relatively inert compared to its spectral neighbors, ultraviolet and infrared radiation. However, recent literature has described the ability of visible light to cause erythema in light skin and pigmentary changes in individuals with darker skin types. Concern surrounding its potentially damaging cutaneous effects has been raised in both the medical community and social media outlets. In this article, we provide an evidenced-based review describing what is currently known about visible light, focusing on its role in dermatologic diseases including disorders of hyperpigmentation such as melasma and postinflammatory hyperpigmentation.

Emerging topical therapies to treat pigmentary disorders: an evidence-based approach.

BACKGROUND: Hyperpigmentation disorders are commonly encountered in dermatology clinics. The use of prescription-grade and over-the-counter topical lightening agents has increased in popularity, leading to a substantial growth of research over the past decade. OBJECTIVE: We seek to review clinical studies evaluating the use of different Rx-grade and OTC ingredients in treating hyperpigmentation. METHODS AND MATERIALS: A comprehensive search on PubMed was conducted to identify patient-based evidence on the most common ingredients used as topical lightening agents: arbutin, ascorbic acid, cysteamine, hydroquinone, kojic acid, niacinamide, retinoids, and triple-combination therapy. The topicals were classified as either prescription-grade or over-the-counter. RESULTS: Varying levels of evidence support the use of topicals in treating hyperpigmentation. There were more clinical trials examining Rx-grade products than OTC products. Mild but tolerated side effects are noted in many of these agents. CONCLUSION: Careful monitoring and adjustment of doses will be needed to maximize skin lightening benefits and minimize side effects.

Indoor tanning: Evidence surrounding advertised health claims.

Indoor tanning continues to remain common, despite evidence of an increased risk of skin cancer from artificial ultraviolet (UV) radiation. In the hopes of gaining customers, the tanning bed industry has marketed health benefits of indoor tanning such as increased vitamin D production, development of a base tan, enhanced mood, and treatment of certain dermatologic conditions. To better educate their patients, providers need a comprehensive reference reviewing the evidence that support or oppose these claims. In this work, we conducted an evidence-based review of the literature to identify and grade studies that investigate health claims related to UV exposure. Results indicate that there is little evidence to support each of these proposed health benefits. Tanning beds emit primarily UVA radiation, which is relatively ineffective at activating vitamin D or mood enhancing pathways, and the effects are minimal in regard to tanning beds generating a protective base tan or treating dermatologic conditions compared with the increased risk of skin cancer. Health care providers must continue to warn and educate patients about the misleading information propagated by the tanning bed industry as well as about the dangers of artificial UV radiation.

Commonly Used Over the Counter Therapies for Hair Growth in Skin of Color: An Evidenced-Based Review.

BACKGROUND: Given the immense psychosocial effects of hair loss as well as patient preference for treatment type, it is common for patients to turn to alternative medicine to improve their conditions. However, the commonly used alternative treatments can vary greatly between patients and particularly among skin of color populations. OBJECTIVE: In this work, we performed a scoping review of the evidence behind alternative topical treatments for hair loss used by skin of color patients. Methods & Materials: We conducted a comprehensive search using PubMed to identify relevant studies. RESULTS: Results show a diverse variety of hair growth products used; however, only a few are supported by randomized controlled trials, case reports, pilot studies, and animal studies with some important limitations. CONCLUSION: This information will be exceedingly useful for physicians so they may relay accurate evidence on these haircare practices to their skin of color patients. J Drugs Dermatol. 2021;20(7):726-731. doi:10.36849/JDD.5689.

The Use of Botanical Extracts in East Asia for Treatment of Hyperpigmentation: An Evidenced-Based Review.

Recent years have seen a growth in the Asian cosmeceutical industry and an expanding worldwide marketplace with increasing consumer use of plant-based skin care products. The rising prevalence of Asian cosmeceuticals has led to research studies assessing the safety and efficacy of these products. We seek to review current evidence on safety and efficacy of key ingredients used in Asian cosmeceuticals to treat disorders of hyperpigmentation. A comprehensive search on PubMed was conducted to identify hyperpigmentation-related research studies on eight popular ingredients used in Asian cosmeceuticals: green tea, soy, orchid, licorice, rice water, ginseng, bamboo, and aloe. Both in vitro studies and clinical trials involving human subjects were included. Of the ingredients reviewed, soy and licorice had the most clinical evidence supporting their efficacy, while all other ingredients were supported by in vitro studies. More research is needed to further evaluate the safety and efficacy of Asian cosmeceutical ingredients in treatment of hyperpigmentation. J Drugs Dermatol. 2020;19(7): doi:10.36849/JDD.2020.4776.

Career satisfaction of leaders in academic dermatology: Results from a national survey.

BACKGROUND: A positive correlation between leadership roles and job satisfaction has been noted in some areas of business. Since senior leaders in academic dermatology appear to be more satisfied than their junior colleagues, a similar relationship may be important in dermatology. OBJECTIVE: To determine if there is an association between leadership roles and career satisfaction of academic dermatologists. METHODS: A cross-sectional, anonymous survey was mailed to 1263 academic dermatologists across the US. Participants were questioned on demographics and career satisfaction. Academic rank and position was compared with career satisfaction. RESULTS: The leadership cohort was comprised of 140 (77%) men and 41 (23%) women (p < 0.01). Leaders were significantly more satisfied in their careers than non-leaders (65% versus 36%, p < 0.01), and were also less likely to leave academia. Factors related to career satisfaction included satisfaction with the promotion process (p < 0.01), presence of career development programs (p < 0.02), physician health (p < 0.01), and the ability to achieve balance in one's personal and professional lives (p = 0.01). Our analysis also demonstrated a gender gap within the leadership sector, with female leaders reporting less satisfaction overall with their career (44% versus 71%, p < 0.01), with the tenure/promotion process at their institutions (89% vs. 68%, respectively, p < 0.01), as well as their personal and professional balance (49% vs. 80%, p < 0.01) compared to their male leaders counterparts respectively. However, there was no difference in the likelihood of leaving academia between male and female leaders. CONCLUSION: Academic leaders overall had higher career satisfaction than non-leaders, and were more likely to stay within academia. Despite this, patterns of gender disparities in the academic dermatology leadership persist with males outnumbering females in the leadership pool, and male leaders reporting higher levels of satisfaction compared to their female counterparts, as well as perceiving fewer challenges in finding balance between their personal and professional lives.

Increased Tattoo Fading in a Single Laser Tattoo Removal Session Enabled by a Rapid Acoustic Pulse Device: A Prospective Clinical Trial.

BACKGROUND AND OBJECTIVES: The ability to provide improved tattoo fading using multiple laser passes in a single office laser tattoo removal session is limited. In part, this is due to the loss of laser effectiveness caused by epidermal and dermal vacuole "whitening" generated during the initial laser pass at the tattoo site. The Rapid Acoustic Pulse (RAP) device generates acoustic shock wave pulses that clear epidermal and dermal vacuoles to enable multiple laser passes in a single office laser tattoo removal session. The objectives of this study were to determine if the RAP device, when used as an accessory to the 1064 nm Nd:YAG Q-switched (QS) laser can enable delivery of multiple laser passes in a single office laser tattoo removal session, and therefore result in increased tattoo fading compared to the clinical standard single-pass QS laser tattoo removal session. STUDY DESIGN/MATERIALS AND METHODS: The RAP device was evaluated in a single-center (SkinCare Physicians), prospective, IRB approved study. A total of 32 black ink tattoos, from 21 participants, were divided into three zones and treated with either multiple QS laser passes, each followed by 1 minute of RAP device application (Laser + RAP) in zone one and single-pass QS laser treatment (Laser-Only) in zone two, separated by an untreated control zone. The treatment sites were assessed for the number of laser passes and adverse events immediately, 6 weeks, and 12 weeks following the treatment session. Photographs of the treatment sites were assessed for percent fading at 12 weeks post-treatment by three blinded reviewers. RESULTS: When the RAP device was applied as an accessory to the QS laser in a multi-pass laser tattoo removal treatment, an average of 4.2 laser passes were delivered in a single session, with no unexpected or serious RAP device-related adverse events. At the 12-week follow-up, tattoos treated with Laser + RAP showed a statistically significant increase in average fading (44.2%) compared with tattoos treated with Laser-Only (24.8%) (P < 0.01). Additionally, a significantly higher overall proportion of tattoos treated with Laser + RAP (37.5%) had a response of >50% fading compared with tattoos treated with QS Laser-Only (9.4%) (P < 0.01) as well as a response of >75% fading from Laser + RAP treatment (21.9%) compared with Laser-Only treatment (3.1%) (P < 0.05). CONCLUSIONS: The RAP device, applied as an accessory to the 1064 nm Nd:YAG QS laser, safely enables multiple QS laser treatments in a single office laser tattoo removal session by clearing the whitening caused by the previous QS laser pass. Enabling multiple QS laser passes results in a statistically significant increase in tattoo fading in a single office laser tattoo removal session compared to the clinical standard single-pass QS laser tattoo removal session. © 2019 The Authors. Lasers in Surgery and Medicine Published by Wiley Periodicals, Inc.

Delayed-Onset Nodules to Differentially Crosslinked Hyaluronic Acids: Comparative Incidence and Risk Assessment.

BACKGROUND: Robust and long-term data on true incidence of delayed-onset nodules and immune tolerance of hyaluronic acid (HA) fillers are lacking. OBJECTIVE: To characterize the incidence of delayed nodules in Vycross (VYC) HA fillers compared with previously reported FDA and non-FDA data of all HA fillers. METHODS AND MATERIALS: The incidence of delayed nodules in all patients who had received VYC fillers in a 12-month period was assessed through a retrospective chart review. Nodule incidence for currently approved nonanimal-stabilized hyaluronic acid (NASHA) fillers was assessed using the FDA Summary of Safety and Effectiveness Data. RESULTS: Overall, 1,029 patients received 1,250 VYC filler treatments. Five patients developed delayed nodules to VOB, with an incidence of 1.0% per patient and 0.8% per syringe. No nodules were observed in patients who received VLR or VOL. All nodules were treated successfully using a combination of intralesional triamcinolone and hyaluronidase. Compared with other currently approved NASHA fillers, VOB is associated with a higher incidence of nodule formation. CONCLUSION: The introduction of VYC HAs has introduced a new variable that may be changing the immune tolerance of these substances, resulting in a higher incidence of delayed nodules than previously expected.

Setting appropriate pain expectations: Lessons learned from a clinical trial.

OBJECTIVE: This retrospective study compares subject-reported pain levels and expectations set forth by industry and treating physicians during a clinical trial of an energy based device. The physiologic and emotional aspects of pain expectations are discussed and recommendations are made for strategic patient counseling. MATERIALS AND METHODS: Average and mode pain scores were collected from the records of a previously conducted clinical trial investigating a radiofrequency microneedling device at three different settings. The trial protocol and device manual were reviewed to ascertain language regarding procedural pain. Treating physicians were asked how they learned about procedural pain and how they described it to subjects. Subject-reported pain scores and verbal pain descriptors from the device manual and trial protocol were translated onto validated pain scales, the Numerical Rating Scale (NRS), and the Verbal Rating Scale (VRS), for comparison. RESULTS: A total of 90 procedural pain scores were collected from 30 subject charts. The average procedural pain scores for three different device settings were 5.3, 6.7, and 4.6 out of 10 and the mode pain score was 6 out of 10. This translated to a 5-6 and 7-8 on the NRS, respectively and classification as "painful but bearable" and "considerable pain" on the VRS. Industry sourced pain levels translated to a 2-4 on the NRS and classification as "little pain" on the VRS. CONCLUSION: Subject-reported pain scores were higher than those set forth by industry materials and personnel. Physicians should be wary of manufacturer materials or anecdotal evidence that might mislead patients and cause undue physiological or emotional stress. Lasers Surg. Med. 9999:XX-XX, 2018. © 2018 Wiley Periodicals, Inc.

Nonscarring alopecia associated with vitamin D deficiency.

Vitamin D is well known for its role in bone health and immune regulation, playing a role in cell differentiation, proliferation, and apoptosis. Vitamin D deficiency also has been associated with various forms of nonscarring hair loss. We describe a notable case of nonscarring alopecia associated with only vitamin D deficiency in which vitamin D replacement therapy helped promote hair regrowth. We also discuss diagnosis, prevention, and treatment of vitamin D deficiency.

Patient Positioning and Skin Sequelae: Ischemic Epidermal Necrosis from Tight Padding During Cardiac Surgery.

Careful positioning and padding of pressure points during surgery are recommended to prevent pressure ulcers, vascular injury, and nerve damage in an immobilized patient. However, overpadding may have unintended consequences. We report a case of ischemia-induced full-thickness epidermal necrosis secondary to tight foam padding during a cardiac surgery.

Midodrine-induced acute generalized exanthematous pustulosis.

Acute generalized exanthematous pustulosis (AGEP) is an acute sterile pustular eruption most commonly induced by medications. We present a case of AGEP with erythroderma following use of midodrine in a 58-year-old man. Although antibiotics are most commonly implicated in AGEP, we emphasize that nonantibiotic agents also may cause AGEP, which often manifests after a longer time interval compared to antibiotic-associated AGEP.

Role of sex in academic dermatology: results from a national survey.

OBJECTIVE: To determine whether there is an association between sex and academic rank and track, leadership, productivity, income, and career satisfaction. DESIGN: National cross-sectional survey. SETTING: Academic dermatologists across the United States. PARTICIPANTS: A total of 1263 full-time academic dermatologists. MAIN OUTCOME MEASURES: The association of sex with the following predictive variables: rank, promotion, academic productivity, leadership, salary, and career satisfaction. RESULTS: Of the 343 respondents (27.2% response rate), 259 were full-time academic dermatologists, of whom 159 (61.4%) were men. Men held more senior positions (P < .001) even after adjustment for age (P < .02) and number of years since completion of residency (P < .05). Men were also more likely to occupy investigative career tracks (26.5% vs 11.1%), whereas women predominantly occupied clinical educator tracks (81.5% vs 50.0%) (P = .03). There was no significant difference in the hours worked between men and women (P = .052), and after controlling for academic rank, there was no difference in number of publications (P = .06) or grants received (P = .19). Difference in yearly salary became insignificant when adjusted for rank and other variables ($20 000 decrement for women; P = .12). Although most men (90.3%) and women (82.8%) were satisfied with their career, women were 24.6% more likely than men to consider leaving academia (P < .001). CONCLUSIONS: Sex-based differences in academic dermatology, including career track, academic rank distribution, leadership, and career satisfaction, persist. Measures that enhance the subjective rewards (eg, influence, collegiality, and mentorship) of academics and increased family-friendly measures for early-career academicians are important to close these gaps.

Dilated lymphatic vessels in tufted angioma: a potential source of diagnostic confusion.

Tufted angioma (TA), an uncommon benign vascular tumor, has a variable clinical presentation, and histopathologic findings are a key component of diagnosis. The presence of lymphatic vessels suggestive of lymphangioma can occasionally be the predominant finding and cause diagnostic confusion. Nine biopsies from 7 cases of TA were studied to assess the frequency and distribution of lymphangioma-like areas. Specimens were also stained with D2-40, VEGF-A, GLUT-1, and HHV-8. In one biopsy, lymphangioma-like vessels were the main finding. In all other cases of TA, lymphatics were present in the stroma but were often overshadowed by tufts of capillaries. D2-40 highlighted the stromal lymphatics and partially stained the capillaries within tufts. VEGF-A showed diffuse nonspecific staining of epidermis and endothelial cells in all specimens. GLUT1 and HHV-8 staining were uniformly negative in all 9 specimens. Accurate diagnosis of TA has important clinical implications given its occasional association with Kasabach-Merritt phenomenon, and the presence of lymphangioma-like vessels in biopsies of vascular lesions is entirely compatible with TA.

A close call: the role of screening mammography in the fight against breast cancer: health and medicine for women: a multidisciplinary, evidence-based review of mid-life health concerns.

A multidisciplinary panel debated the role of screening mammography in fighting breast cancer during the Health and Medicine for Women continuing medical education (CME) conference at Yale Medical School in September 2010. Different guidelines from professional societies have presented conflicting recommendations for patients regarding both the benefits of mammography and the appropriate age and frequency of screening. In addition, a recent longitudinal study argues that screening mammography may only offer a modest benefit in terms of reducing cancer mortality. In light of these considerations, the panel debated whether mammography should be an informed decision that must be discussed and individualized for each patient based on the context of risk factors such as family history, age, and genetic dispositions.

The 2008 anatomy ceremony: voices, letter, poems.

Yale University medical and PA students express their gratitude in a compilation of reflections on learning human anatomy.