Chemical Peels as Field Therapy for Actinic Keratoses: A Systematic Review.

BACKGROUND: Actinic keratoses (AKs) are a common premalignant cutaneous neoplasm and can progress to squamous cell carcinoma. A variety of treatment options are available for field therapy of diffuse AKs. OBJECTIVE: This review systematically analyzes the use of chemical peels for treatment of AKs. MATERIALS AND METHODS: A systematic review of PubMed was performed searching from 1946 to March 2020 to identify the literature on chemical peels for AKs. RESULTS: Of the 151 articles identified, 5 met inclusion criteria for review. Four of the reviewed articles demonstrated the efficacy of chemical peels in reducing AK count and minimal adverse effects. In some studies, chemical peels exhibited potential to prevent additional AK formation and development of keratinocyte carcinomas. CONCLUSION: Chemical peels are an efficacious and affordable treatment option for field treatment of AKs. With improved patient tolerance and adherence, chemical peels are an attractive option for field therapy of AKs for both dermatologists and patients.

Effect of Topical Instillation of Pegaptanib Sodium Upon Inflammatory Corneal Neovascularization in Rabbits.

Purpose: To evaluate the effect of topical instillation of pegaptanib sodium upon inflammatory angiogenesis induced in the rabbit cornea by alkaline cauterization. Methods: Inflammatory angiogenesis was induced by alkaline (sodium hydroxide) cauterization in the corneas of 29 male New Zealand rabbits. The animals were divided into 4 groups: a control group treated with 0.5% carboxymethylcellulose sodium eye drops, a group treated with 1.0% prednisolone acetate eye drops, a group treated with 0.5% pegaptanib sodium diluted in 15 mL 0.5% carboxymethylcellulose sodium, and a group treated with 1.0% pegaptanib sodium diluted in 15 mL 0.5% carboxymethylcellulose sodium. After cauterization, eye drops were administered every 12 hours for 21 days. The animals were evaluated every 3 days after cauterization, and the newly formed vessels were quantified from photographs. The treatment effectiveness was analyzed with 3 parameters of antiangiogenic response: neovascularization area (NA), total vascular length (TVL), and number of blood vessels (BVN). Results: Average NA, TVL, and BVN values were significantly higher in both pegaptanib groups than in the prednisolone group. A nonstatistically significant reduction in parameters on days 18 and 21 was the minimum achieved in both pegaptanib groups. The efficacy of the treatments in relation to the control was significantly greater in the prednisolone group than in the 0.5% pegaptanib group or the 1.0% pegaptanib group (P < 0.001). Conclusion: Topical instillation of 0.5% and 1.0% pegaptanib sodium diluted in 15 mL 0.5% carboxymethylcellulose sodium had no inhibitory effect on corneal neovascularization in this rabbit model.

Use of Silver Nitrate Application as Mini-Invasive Treatment of Pilonidal Sinus Disease.

OBJECTIVES: To investigate the cure rate and adverse effects of silver nitrate application for treatment of pilonidal sinus disease (PSD). Methods: Number of sinus pit orifices, and complications with silver nitrate application and debridement for sacrococcygeal PSD between January 2015 and July 2018 were analyzed in this retrospective study. Data were obtained from surgical, discharge, and outpatient follow-up records. Among 56 patients who were treated with silver nitrate stick, 11 patients with incomplete hospital records were excluded from the study. Demographic data including age, gender, length of follow-up, number of silver nitrate applications, number of involved sinuses and recurrence and complication rates were recorded. Results were expressed as frequencies, means, and range of values. The Mann Whitney U and chi square tests were used to evaluate significance. Results: Mean age was 24.3 +- 5.18 (range, 14 - 36) years, and recurrence occurred in 4 (8.9%) patients. Complications developed in 10 (22.2%) patients and included abscess, erythema, and necrosis in 5 (11.1%), 2 (4.4%), and 3 (6.6%) patients, respectively. The recurrence rate was significantly higher in patients who developed abscesses during the follow-up period (p = 0.001) than those who did not. There was no statistically significant correlation between the recurrence rate and number of sinuses or the number of silver nitrate applications. CONCLUSION: Low morbidity and high healing rates achieved with silver nitrate provide support for this application as a feasible and effective conservative outpatient treatment for PSD in certain patients.

Comparison of Three Different Therapies for Cutaneous Leishmaniasis and Identification of the Etiologic Isolates in Isfahan, Iran.

BACKGROUND: In Iran, zoonotic and anthroponotic cutaneous leishmaniasis (CL) are caused by Leishmania major and L. tropica respectively. Despite extensive studies, no effective therapies have ever been reported for CL. The main objective of this research was to determine and compare the three different protocols for treatment of CL patients referring to Skin Diseases and Leishmaniasis Research Center (SDLRC), affiliated to Isfahan University of Medical Sciences, Isfahan, Iran from September 2017 to October 2018. METHODS: In a randomized controlled parallel groups clinical trial, 150 selected CL patients who met our inclusion criteria were randomly assigned to one of the three therapy groups: A, intra-lesional glucantime plus 50% trichloroacetic acid (TCA), B, intralesional glucantime and C, systemic glucantime. All patients in the three groups received the complete course of treatment and were followed for 6 months. To identify the etiologic agents, smears from their lesions were prepared and PCR-RFLP was used after parasite culture. Also, clinical characteristics, history of previous involvement, endemic emigration and demographic data were collected. RESULTS: The results showed that the mean value of healing period was 53.12 ± 25.88 (median: 45, IQR: Q1 = 30-Q3 = 77) days in group A, 57.22 ± 44.02 (median: 42.5, IQR: Q1 = 30-Q3 = 60) days in group B, and 73.56 ± 41.08 (median: 71, IQR: Q1 = 45-Q3 = 90) days in group C; the observed differences were statistically significant (P=0.024). There was a significant difference between group A and group C (P = 0.049), and between group B and group C (P = 0.047) in terms of mean healing period. Finally, complete recovery rates of 80%, 62% and 42% were shown in the three medicinal groups of A, B and C, respectively (P = 0.022). CONCLUSION: In this study, the average duration of lesion healing among the three groups was the shortest in patients with IL glucantime plus 50% TCA treatment regimen. Also, the use of 50% TCA in patients suffering from CL was associated with a significant improvement in the depth of scars, the time and the percentage of recovery, and the low cost of this agent in the treatment of CL.

Corrosive ingestion managements in children.

Corrosive (caustic) material ingestion remains a major health issue, particularly in developing countries. The management strategy after corrosive ingestion should be planned according to the signs and symptoms. The management of corrosive ingestion based on endoscopic grading, nothing by mouth, and barium studies should be abandoned. With the new management protocol, esophageal stricture can be predicted with high accuracy using the simple new prognostic DROOL score (≤ 4) rather than endoscopic grading, reduced by immediate oral feeding as soon as the patient can swallow saliva instead of nothing by mouth, diagnosed earlier (10-14 days) by fluoro-endoscopic balloon-assisted esophageal examination for patients with persistent dysphagia instead of relying on a barium study (≥ 21 days), and adequately treated by initiating balloon dilation earlier during the same anesthesia procedure. Fluoroscopically guided balloon dilatation with large balloons (18-20 mm) seems to be safe, with a low frequency of complications and a high success rate. If dilatation fails after a few months, esophagectomy and replacement surgery using the stomach should be considered. The increased risk of developing esophageal carcinoma after ingestion of corrosive substances should be kept in mind.

Chemical Peels: Role of Chemical Peels in Facial Rejuvenation Today.

The practice of chemical peeling remains an important aspect of the nonsurgical techniques available to the aesthetic surgeon when approaching skin rejuvenation. Despite past predictions of their disappearance in favor of lasers, the overall use of chemical peels by plastic surgeons continues to grow. In the past two decades, the techniques available to the clinician have evolved in safety and efficacy based on the dermatologic investigations of various individuals, including Obagi, Hetter, and Stone. The versatility, clinical endpoint-directed predictability, and favorable risk profile of chemical peels proffered by these latest advancements affirm that this modality is essential to the practice of the plastic surgeon treating patients with rhytides and dyschromias. This review presents the current role of chemical peels in skin rejuvenation, emphasizing the significant clinical advancements and their modern day applications and practice.

Trichloroacetic acid 10% injection for treatment of conjunctival inclusion cysts.

Purpose: To evaluate the effect of intra-lesional injection of Trichloroacetic acid (TCA) 10% in patients with conjunctival inclusion cysts.Methods: This prospective case series study included all patients with conjunctival inclusion cyst who were referred to our referral center from August 2016 to August 2018. All patients received TCA 10% injection into the conjunctival cyst, and outcomes of the intervention were evaluated at least 6 months later.Results: Ten patients with mean age of 24 ± 17.6 (range 6-65) years including three children received TCA 10% injection into the conjunctival cyst. We included 6 anophthalmic and 4 ophthalmic cases. All patients were treated successfully and no recurrence of the lesion was observed in any case. Mean follow up duration was 18.1 ± 8.3 (range 6-28) months.Conclusion: Intra-lesional injection of TCA 10% is a safe, simple, and effective treatment in patients with conjunctival inclusion cysts including ophthalmic cases and anophthalmic cases, both in adults and in children. This concentration may avoid ocular surface complications.

Effects of different therapeutic modalities for postacne scars on circulating collagen III.

BACKGROUND: Therapies for postacne scarring act through modulation of elastin and collagen, and collagen III might therefore represent a biomarker of treatment effectiveness. PATIENTS AND METHODS: Patients (n = 70) with postacne scars and individuals without scars (n = 56) were included in this case-control study. Patients were treated with Dermaroller microneedling, trichloroacetic acid chemical reconstruction, punch excision, or scar subcision. Scar severity was graded immediately before and after treatment with a photographic quartile scale and the ECCA scale. Serum levels of collagen III were measured in control individuals and in patients, before treatment, 1 month after the first treatment session, and 4 months after the final session. RESULTS: Circulating levels of collagen III were significantly higher in patients with postacne scarring (24.1 ± 12.5) before treatment than in control individuals (2.6 ± 0.8). Circulating levels of collagen in patients were significantly lower 4 months posttreatment (14.3 ± 8.1) than at baseline. The mean percentage change in serum collagen III was positively correlated with both the mean percentage improvement by photographic evaluation (r = .530, P < .000) and the mean percentage change in the ECCA scale (r = .632, P < .000). CONCLUSION: Circulating collagen III is a biomarker for improvement of postacne scarring following different therapies.

Combination of continuous wave CO2 laser and topical application of trichloroacetic acid 50% vs CO2 laser alone the treatment of cutaneous leishmaniasis (A case series of 6 patients).

BACKGROUND: Cutaneous leishmaniasis (CL) is an endemic disease of Iran and despite self-healing nature of this disease and many suggested treatments, scar is usually inevitable results of the affection with this cutaneous infection. CO2 laser in CL has a specific thermolysis effect on infected tissues and application of trichloroacetic acid (TCA) 50% solution for treatment of leishmaniasis scars showed promising results. AIM: To evaluate CO2 laser plus TCA 50% versus CO2 laser alone for treatment of CL. PATIENTS/METHODS: In the current report, we present 6 cases of noduloulcerative CL that were treated successfully by the combination of the continuous wave CO2 laser plus topical application of TCA 50%. RESULTS: Five patients improved after 3 weeks of starting treatment, and 1 patient needed to repeat treatment. The scars were flat and good. CONCLUSIONS: The CO2 laser plus topical TCA 50% may be more effective in treatment of the cutaneous leishmaniasis and results in shorter healing time.

Comparative study of 15% trichloroacetic acid peel combined with 70% glycolic acid and 35% trichloroacetic acid peel for the treatment of photodamaged facial skin in aging women.

BACKGROUND: Photoaging (extrinsic aging) is caused by environmental exposure to ultraviolet radiation. Superficial and medium-depth chemical peels with trichloroacetic acid (TCA) are performed to reduce wrinkles, hyperpigmentation, dryness, and erythema caused by photoaging process. AIM: The aim of this study was to compare the efficacy and tolerability of 15% TCA peel against the combined 70% glycolic acid and 35% TCA for the treatment of photodamaged facial skin. PATIENTS/METHODS: Forty female patients with types II and III of Glogau photoaging scale were divided into two groups of twenty subjects (GA/TCA and 35% TCA). The GA/TCA group was treated with combination peeling of 70% GA and 15% TCA, whereas the 35% TCA group was treated with monopeeling of 35% trichloroacetic acid. Each patient was submitted to five sessions of these peels, with an interval of 14 days between each session. The following skin aging parameters were examined before treatments, before each session, and 3 months after the last application: hydration, elasticity, melanin index, and erythema index (MPA-5; Courage-Khazaka, Germany); and depth and volume of wrinkles (PRIMOS; GFMesstechnik GmbH, Germany). RESULTS: Both peel methods achieved significant improvement in all skin parameters: elasticity, hydration, melanin index, and erythema index. Significant differences between the GA/TCA and 35% TCA groups were found only for hydration and melanin index. GA/TCA was characterized by significantly higher values of the hydration parameter and lower values of melanin index compared with 35% TCA. Combination peel GA/TCA did not cause dryness, edema, or intensive lysis of the epidermis, and the frequency of peel-induced erythema did not increase with the addition of glycolic acid, but with higher concentration of the TCA solution. However, subject-perceived improvements of the 35% TCA peel did not differ significantly from subject-perceived improvements of combination peel treatment. Adverse events requiring intervention or discontinuing treatment were not observed in either group. CONCLUSION: The addition of glycolic acid before 15% TCA chemical peel application significantly enhanced TCA-induced improvement in photoaging parameters (increase in skin elasticity and hydration; reduction in melanin index and erythema index), and subject-perceived improvements. However, 35% TCA peel is more effective in reducing wrinkles, despite a lower tolerability. Both medium-depth chemical peels including 15% TCA in combination with 70% GA and 35% TCA alone proved to be useful for the removal of epidermal or superficial lesions and to improve the texture of photodamaged facial skin (grade II-III Glogau photoaged skin).

Efficacy and tolerability of using platelet-rich plasma versus chemical peeling in periorbital hyperpigmentation.

BACKGROUND: Various therapeutic modalities for periorbital hyperpigmentation (POH) have been proposed. OBJECTIVE: This study was designed to compare the efficacy and tolerability of autologous platelet-rich plasma (PRP) and chemical peeling in POH. SUBJECTS AND METHODS: Forty-two patients were enrolled in this study and randomly subdivided into two groups. Group A patients were assigned to receive four sessions of chemical peeling using trichloroacetic acid and lactic acid, while group B was assigned to patients who received four sessions of PRP injection with 2 weeks of intervals. Patients were assessed by digital photographs. The degree of improvement included four degrees from poor to excellent, and side effects were reported. RESULTS: Females constituted 38 out of 42 patients (mean age, 28.14 ± 3.47 years). There was a significant improvement in favor of chemical peeling over PRP. Good improvement occurred in 47.6% in the group A versus 4.8% in group B (P < 0.001). None of the PRP group had excellent improvement, while 38% of chemical peeling group did. Most of group A patients reported very pleased (47.6%) to excellent (38%) degree, in contrast to group B where 52.5% were just pleased (P < 0.001). Some of group A patients experienced itching (14.3%) and redness (14.3%), while in group B, they experienced pain (23.8%) and edema (14.3%) with nonsignificant difference between both groups (P = 0.07). CONCLUSIONS: Both PRP and chemical peeling are effective for treatment of POH; however, chemical peeling is much more effective, tolerable, and satisfying procedure than PRP.

Cryotherapy vs trichloroacetic acid 90% in treatment of common warts.

INTRODUCTION: Common warts are hyperkeratotic, benign cutaneous growths caused by types 1, 2, and 7 Human papilloma viruses. Different modalities are available to treat warts. Cryotherapy is one of the most common and effective treatments for common warts. Trichloroacetic acid (TCA), in high concentrations, can be used as a therapeutic modality. OBJECTIVES: The aim of this study is to compare the efficacy and safety of cryotherapy using liquid nitrogen (spray method) versus trichloroacetic acid 90% in treatment of common warts. PATIENTS AND METHODS: Thirty-five patients with 414 common warts, from the Dermatology outpatient clinic, Assiut University Hospital, were enrolled in this study. We used two techniques for the treatment of common warts. The lesions in each patient were divided into two groups (A and B), group A treated by cryotherapy while group B treated by trichloroacetic acid (TCA) 90%. RESULTS: There was significant decrease in the size of the warts in both groups. There were statistically significant better results among group A than group B regarding the mean percentage of improvement (90.11 ± 27.92 vs 26.19 ± 42.93, respectively; P < 0.001) and grade of improvement, where good response was obtained in 89.2% in group A compared with 26.2% in group B (P < 0.001). Complete cure was significantly higher in group A (83.1%) than group B (21.3%; P < 0.001). However, side effects were significantly higher among group A than group B. CONCLUSION: Cryotherapy is more effective than TCA 90% in treatment of common wart. TCA 90% has lesser complications than cryotherapy.

"Chemical" surgery in treating basal cell carcinoma in elderly.

The incidence of basal cell carcinoma (BCC) has been increasing in the last decades due to population aging and precise diagnosis. The difficulty that physicians face frequently is related to the treatment decision for BCC; when treating BCC, correct and personalized choices must be taken into consideration by selecting from a large variety of therapeutic options such as: surgical excision ("the golden standard therapy"), electrodessication, cryosurgery, radiation therapy, laser, photodynamic therapy, curettage, topical treatment (imiquimod, 5-fluorouracil, vismodegib), or combining different treatments. The present authors present series of cases of patients diagnosed with BCC, highlighting that "chemical surgery" using 70% trichloroacetic acid could be a valuable option in the treatment of nonaggressive BCC of the face.

Brief Report: Effectiveness of Trichloroacetic Acid vs. Electrocautery Ablation for the Treatment of Anal High-Grade Squamous Intraepithelial Lesion in HIV-Infected Patients.

BACKGROUND: Trichloroacetic acid (TCA) and electrocautery ablation (ECA) are 2 of the main treatment options for anal high-grade squamous intraepithelial lesion (HSIL). Our aim was to compare the efficacy and tolerance of TCA vs. ECA for HSIL. METHODS: Retrospective uncontrolled study of HIV-infected men who have sex with men who had an anal HSIL treated with TCA or ECA. On-treatment effectiveness was evaluated at 6-8 weeks after treatment. A complete response was defined as resolution of HSIL, a partial response as regression to low-grade lesion, and recurrence as biopsy-proven HSIL during follow-up. A propensity-score analysis was used to adjust efficacy to potential confounding. RESULTS: From May 2009 to March 2018, 182 and 56 cases of anal HSIL were treated with ECA and TCA, respectively. Comparing ECA with TCA, a complete response was observed in 33.5% (95% confidence interval: 25.8 to 41.6) vs. 60.7% (50.0 to 74.8) and a partial response in 28.0% (20.3 to 36.0) vs. 23.2% (12.5 to 37.3), respectively (P < 0.001). These differences were maintained in the propensity-score analyses. Side effects were common in both treatment, but tolerance was reported as good in 80.6% (74.2 to 89.2) and 82.6% (73.9 to 93.9) of cases treated with ECA and TCA, respectively, and no serious events were described. Recurrence cumulative incidence for the first 12 months was 14.6% (9.1 to 23.1) for ECA episodes and 27.6% (11.5 to 57.7) for TCA (P = 0.183). CONCLUSIONS: Our study showed a higher efficacy of TCA than ECA with similar rates of side effects. In our opinion, considering the benefits of TCA, it should be considered as a first-line therapy for most anal HSIL management.