Novel application of high-dose rate brachytherapy for severe, recalcitrant palmoplantar pustulosis.

Palmoplantar pustulosis (PPP) is a chronic pustular dermatitis of the palms and soles, which is frequently associated with significant pruritus and pain, often limiting daily activities. We present the case of a 36-year-old man with severe PPP who had treatment failure with multiple medical therapies but showed marked improvement with high-dose rate brachytherapy. Brachytherapy has the advantage of providing a conformal dose distribution over complex curved surfaces, such as the foot and ankle. Our observations suggest that brachytherapy may be a well-tolerated treatment option for patients with severe, refractory PPP.

The effectiveness of 1,064-nm long-pulsed Nd:YAG laser in the treatment of severe onychomycosis.

INTRODUCTION: Severe onychomycosis in the elderly is a common condition and generally difficult to treat. Long-pulsed Nd:YAG (LPNY) laser has been found to be useful in the treatment of onychomycosis. We sought to evaluate the effectiveness of 1,064-nm LPNY laser in the treatment of severe onychomycosis. MATERIALS AND METHODS: Forty nails in 13 patients with severe onychomycosis were divided into two groups. Each group received eight treatment sessions at one-week intervals with 1,064-nm LPNY laser. Parameters for group A were 0.3 ms pulse duration, 5 mm spot size, 16 J/cm(2) fluence, and 10 Hz frequency, and those for group B were 0.6 ms, 2 mm, 225 J/cm(2), and 5 Hz. Clinical and mycological clearance were evaluated at 12 and 24 weeks after initial treatment. RESULTS: Clinical improvements at 12 and 24 weeks presented 47.6 and 57.1% in group A, and 26.3 and 36.8% in group B. In the treated nails with clinical improvement, mycological positive rates at 24 weeks were approximately 40% in both groups. DISCUSSION: The treatment of onychomycosis using 1,064-nm LPNY laser were incomplete in clinical and mycological improvement, and it could imply a lot of potential recurrence. We suggest that 1,064-nm LPNY laser for severe onychomycosis should need additional or combined therapy with other therapeutic options.

Treatment of onychomycosis with a 1,064-nm long-pulsed Nd:YAG laser.

BACKGROUND: There are various treatment modalities of onychomycosis. Of these, however, oral antifungal therapies are complicated by potential drug interactions and systemic effects, and the surgical treatment can result in prolonged pain. Therefore, a new, safe and effective therapy is needed that can improve the aesthetic appearance of the nails. OBJECTIVE: The purpose of this study was to evaluate the effect of treatment of onychomycosis with a 1,064-nm long-pulsed Nd:YAG laser. METHODS: 13 patients (31 toenails, 12 fingernails) received five treatment sessions at 4-week intervals with a 1,064-nm long-pulsed Nd:YAG laser. Parameters for each treatment were 6 mm spot size, 5 J/cm(2) fluence, 0.3 ms pulse duration and 5 Hz pulse rate. RESULTS: Of the 13 patients, 8 (61.5%) were women and 5 were men. The mean age of the patients was 62. Of the 43 nails, 4 (9.3%) achieved a complete cure (9.3%), 8 had excellent treatment outcomes (18.6%) and 31 had good treatment outcomes (72%). None of the 13 patients experienced any discomfort except for a mild burning sensation and there were no adverse effects. CONCLUSIONS: Our results demonstrate that the 1,064-nm long-pulsed Nd:YAG laser could be a safe and effective treatment modality in the management of patients with onychomycosis.

[Mycosis fungoides palmaris et plantaris]. / Mycosis fungoides palmaris et plantaris.

Mycosis fungoides (MF) is a low-grade cutaneous T-cell lymphoma characterized by skin-homing CD4- positive helper T cells. Mycosis fungoides palmaris et plantaris is an uncommon variant primarily involving the palms and soles. An 80-year old man presented with hyperkeratotic erythematous palmoplantar changes. Clinical and histopathologic criteria led to the diagnosis mycosis fungoides palmaris et plantaris. Tumor staging using sonography of the abdomen and lymph nodes, chest x-ray and blood examination is recommended, because extracutaneous manifestations may be present.

Paring and intense pulsed light versus paring alone for recalcitrant hand and foot warts: a randomized clinical trial with blinded outcome evaluation.

BACKGROUND AND OBJECTIVES: Treatment of recalcitrant viral warts remains a therapeutic challenge. Intense pulsed light (IPL) has been suggested effective to clear wart tissue. The objective was in a randomized controlled trial to assess the efficacy of paring followed by IPL versus paring alone for recalcitrant hand and foot warts. MATERIALS AND METHODS: Eighty-nine patients with recalcitrant hand and foot warts were included and randomized (1:1) to three treatments at 3-week intervals with either paring of warts followed by IPL or paring of warts alone. IPL was given with the Ellipse Flex IPL system (Danish Dermatologic Development A/S, Hørsholm, Denmark, 400-950 nm, 5.5 millisecond pulse duration in double pulses with a 2 millisecond interval, 26.0-32.5 J/cm(2) repetitive passes). The primary outcome was complete and partial clearance of warts evaluated by blinded photo assessment at 6 weeks after final treatment. Secondary outcomes were treatment related pain and adverse reactions. RESULTS: We found no significant difference in clearance of warts between the two intervention groups (OR 1.64, 95% confidence interval 0.62-4.38). Paring followed by IPL resulted in complete or partial clearance of wart tissue in nine (22%) and five patients (12.2%) versus five (13.5%) and four patients (10.8%) from paring alone. Mostly plantar warts were treated (92.1%). The pain intensity after paring and IPL was moderate and significantly higher than the pain intensity after paring alone (P<0.0005). No adverse reactions were observed from the two interventions. CONCLUSION: Paring followed by IPL did not differ significantly from paring alone in clearance of recalcitrant hand and foot warts but caused significantly more pain.

Combined long-pulsed Nd-Yag laser and itraconazole versus itraconazole alone in the treatment of onychomycosis nails.

Background: Oral antifungal therapies are effective for onychomycosis but it was complicated by systemic effects. Effective and safe therapy is needed to improve esthetic appearance of nails.Objective: The present study is an attempt to evaluate and compare the efficacy of of combined treatment of onychomycosis with 1,064-nm long-pulsed Nd-Yag laser and pulse itraconazole therapy versus pulse itraconazole alone.Methods: Thirty onychomycosis patients were divided into two groups: Groups I and II. Patients of Group I are treated by itraconazole pulse therapy. Patients of Group II received six laser sessions with long-pulsed Nd:Yag laser and itraconazole pulse therapy. The investigators rated clearance using "Onychomycosis Severity Index (OSI)", photographs, and mycology at 6 and 9 months after treatment.Results: Group I's clinical improvement response was excellent in two cases, good in six cases, moderate in five cases, and mild in two cases. Mycological improvement response was excellent in two cases, good in two cases, moderate in six cases, and mild in five cases (OSI before treatment was 13.4 ± 3.02 and after was 6.67 ± 3.6). Group II's clinical improvement response was excellent in 10, good in 3, moderate in 1, and mild in 1. Mycological improvement's response was excellent in two cases, good in two cases, moderate in six cases, and mild in five cases (OSI before treatment was 13.33 ± 3.11 and after was 5.07 ± 4.15). There were no adverse effects. The clinical response showed best results with Group II, but the mycological cure was equal in both groups.Conclusions: The use of combined long-pulsed Nd-Yag laser and itraconazole pulse therapy gives the best clinical results and patient's satisfaction.

An infant with acrodermatitis continua of Hallopeau: successful treatment with thalidomide and UVB therapy.

Acrodermatitis Continua of Hallopeau is a rare, chronic, recurrent disorder classified as a form of pustular psoriasis, and most cases affect one or two digits. It tends to be resistant to both topical and systemic treatments for psoriasis. We present an infant with Acrodermatitis Continua of Hallopeau affecting nineteen nails, with an excellent response to the combination of thalidomide and ultraviolet B phototherapy.

Efficacy of topical PUVA soaks for palmoplantar dermatoses: an audit.

BACKGROUND: With a lack of evidence base for individual topical PUVA protocols, treatment is presently based on the consensus of current practice. This audit was designed to investigate the effectiveness of topical PUVA for palmoplantar dermatoses. METHODS: Phototherapy notes were reviewed on all patients who received hand and/or foot PUVA 2002-2007 in the Northern Health and Social Care Trust (NHSCT), Northern Ireland. RESULTS: Thirty patients met the inclusion criteria for the study. The mean number of treatments, maximum single UVA dose, and cumulative dose, were 18.4, 4.2 J/cm2, and 48.3 J/cm2, respectively. A positive response to treatment occurred in 51.3% of patients, which fell short of the 70% standard set. In a multivariate logistic regression analysis, number of treatments (P=0.04) and maximum single UVA dose (P=0.03) were the only variables associated with positive treatment outcome. The response was not influenced significantly by skin type, concurrent topical treatments, or cumulative UVA dose. Limitations to the study: Small patient numbers may have prevented the statistical significance of individual variables. CONCLUSIONS: UV dose increments should be clearly defined to avoid excess caution at the expense of an adequate patient response, and a minimum of 20 treatments administered to all patients, if tolerated.

[Ultraviolet therapy in patients with chronic hand eczema]. / Ultravioletttherapie des chronischen Handekzems.

Treatment of hand eczema is dominated by the administration of topical glucocorticosteriods. If topical treatment fails, the best second-line option is ultraviolet (UV) therapy alone or as combination therapy. UVB and PUVA (psoralen plus UVA) therapy is effective and has relatively few side effects. Due to the localized nature of the disease, topical PUVA therapy is preferable to systemic PUVA treatment. Among the topical methods, cream PUVA therapy is simple, safe and highly effective. Recent clinical studies have demonstrated the therapeutic efficacy of a new retinoid called alitretinoin, a 9-cis-retinoic acid. However, even this form of treatment does not lead to a complete cure in all patients. Under the primacy of multimodal treatment, UV therapy should be administered as combination therapy if oral retinoids are not sufficiently effective.

[595 nm pulse dye laser therapy for viral warts: a single-blind randomized comparative study versus placebo]. / Traitement des verrues palmo-plantaires par le laser à colorant pulsé à 595 nm: étude randomisée en simple insu contre placebo.

INTRODUCTION: Pulse dye laser (PDL) appears an attractive method to treat warts. However, data concerning the efficacy of this approach are based chiefly upon open clinical studies or case reports and results vary widely from one study to another. The purpose of this study was to compare the efficacy and safety of PDL with a placebo in the treatment of a homogeneous group of patients presenting palmoplantar warts. METHODS: This was a randomized, prospective, placebo-controlled, single-blind study conducted between December 2004 and July 2005 in patients consulting for palmoplantar warts at the Dermatology Department of the University Teaching Hospital of Nice. The treatment settings used for the 595-nm PDL were as follows: spot diameter 5 mm, pulse duration 0.45 ms, fluence 9 J/cm2 with 5 passes at a frequency of 1 Hz. Cryogen spray cooling (system incorporated in the machine) was given at a rate of 50 spurts of 40 ms prior to each laser pulse. In patients in the placebo group, cooling pulses alone were given. For the plantar warts (in both groups), hyperkeratosis was removed manually with a scalpel before each session. A maximum of three sessions was administered at 3-week intervals. The type and number of warts was counted and recorded in a treatment schedule before the start of therapy, at each session and 5 weeks after the final session. The global safety of the treatment was evaluated using a visual analog scale between 0 (intolerable) and 10 (completely safe). RESULTS: Nineteen patients were included in the laser group and 16 were included in the placebo group. Sixty-four per cent (48/75) of warts in the laser group resolved completely compared with 13% (4/30) in the placebo group (p<0.001). In the PDL group, 6 of 19 patients (31.5%) no longer had warts by the end of the study compared with 3 of 16 patients (18.75%) in the placebo group (p=0.46). The global safety score of the treatment as assessed by the patients themselves was 8.31 in the laser group and 9.81 in the placebo group. DISCUSSION: Pulse dye laser appears to be an effective treatment in palmoplantar warts but the efficacy of this method seems to be only equivalent to that of standard treatments (cryotherapy or salicylic acid preparations). Safety is excellent and constitutes one of the major advantages of this technique. The absence of any proven superiority over the standard treatments in terms of efficacy, coupled with the high costs involved, means that PDL should only be used second-line therapy in patients wishing to avoid constraints affecting their professional activity.

Radiation therapy for chronic vesicular hand dermatitis.

BACKGROUND: Chronic vesicular hand dermatitis is a chronic disease that can be debilitating for patients, and many treatment options do not provide lasting remission. OBJECTIVE: We attempted to determine the efficacy of megavoltage irradiation in the treatment of this disease. METHODS: Between July 2001 and March 2005, 9 patients with severe chronic vesicular hand dermatitis had megavoltage radiation therapy to their sites of disease. Eight pairs of hands and seven pairs of feet were irradiated (15 total sites). RESULTS: All patients had an improvement in their disease during the course of radiation therapy. Patients were followed after radiation therapy for a median follow-up time of 20.2 months (range, 1 to 45 months). The disease completely resolved in 7 of the 15 (47%) sites irradiated. There was a decrease in the severity or frequency of flare-ups at the other 8 sites (53%). CONCLUSION: Megavoltage radiation therapy may be effective in the treatment of chronic vesicular hand dermatitis and may provide durable remissions in some patients.

Broad-band UVB versus paint PUVA for palmoplantar psoriasis treatment.

BACKGROUND: Plaque-type palmoplantar psoriasis (PPTP) is a chronic recalcitrant dermatosis with treatment modalities ranging through topical, phototherapy or systemic. Phototherapy options include various forms of ultraviolet B (UVB) and ultraviolet A with prior psoralen sensitization (PUVA). Currently, few comparative studies have been reported. PURPOSE: To compare Broad-Band UVB (BB-UVB) versus paint PUVA (p-PUVA) in regard to efficacy and safety in the treatment of PPTP. METHODS: A retrospective non-randomized cohort study comprised of all the patients with PPTP treated in our phototherapy centre during 2010-2012, either with BB-UVB or p-PUVA. RESULTS: Among the 248 patients included in this study, 122 received BB-UVB and 126 followed p-PUVA treatment. About 36 (30%) and 53 (42%) had complete remission, 29 (24%) and 59 (47%) responded partially and 57 (47%) and 14 (11%) patients did not improve with BB-UVB and p-PUVA, respectively. The odds ratio for remission (p-PUVA: BB-UVB) was 7.9. Duration of remission was 21.9 ± 1.34 months for p-PUVA and 16.75 ± 1.83 months for BB-UVB. CONCLUSION: Both BB-UVB and p-PUVA are good therapeutic options for PPTP. P-PUVA emerges as the superior treatment modality, yielding a better and more extended response. BB-UVB represents a feasible alternative in patients with milder disease or possible contraindications for p-PUVA.

Use of 308 nm excimer laser for the treatment of chronic hand and foot eczema.

BACKGROUND: Chronic hand and foot eczema (CHFE), a prevalent debilitating disorder affecting approximately 15% of the population, presents a socioeconomic and psychosocial burden for patients and often follows a chronic course, refractory to conventional therapies. Thus, a large need exists for more effective therapeutics; the excimer laser (308 nm) is effective for some inflammatory skin diseases, but its efficacy has not been evaluated for CHFE. METHODS: The study is a retrospective chart review conducted on 30 patients with recalcitrant CHFE (19 with hand involvement, four with foot involvement, and seven with both) treated twice weekly with excimer laser (308 nm) single wavelength ultraviolet (UV)B radiation between January 2013 and December 2014. RESULTS: Improvements in clinical scores included a 69% reduction in average physician's global assessment (PGA) scores (from 2.77 at baseline to 0.87 after treatment, P < 0.0001) with a parallel reduction in average modified total lesion/symptom scores of 70% (from 10.2 to 3.1, P < 0.0001). Only mild sunburn-like reactions were observed. CONCLUSION: This report evaluates excimer laser for patients with refractory CHFE and shows excellent and sustained efficacy for this treatment. Compared to other UV therapies, excimer laser offers lower cumulative doses of UV radiation by targeting specific areas. This effective treatment should be considered alone or in combination with other established or newer therapies.

Rejuvenation of the aging hand.

This article reviews aging of the hand and the treatment options for cosmetic rejuvenation. Options available for cutaneous rejuvenation include microdermabrasion, chemical peeling, intense light sources, and laser therapy, including pigment lasers, ablative resurfacing, and noninvasive rejuvenation. Protuberant veins of the aging hand can be treated effectively with sclerotherapy. The soft tissue atrophy of the aging hand is best treated with fat augmentation. The article concludes with a mention of new fillers that are just beginning to be used for soft tissue atrophy of the hand.

Patient-reported outcomes after electron radiation treatment for early-stage palmar and plantar fibromatosis.

PURPOSE: Palmar and plantar fibromatosis (PPF) is a progressive connective tissue disorder of the hand/foot that often leads to debilitating functional impairment. In Europe, orthovoltage radiation therapy (RT) has been demonstrated to prevent local disease progression for up to 80% of patients with early-stage PPF. There are limited data reporting outcomes for populations outside of Europe or using electron RT. METHODS AND MATERIALS: Between 2008 and 2013, 44 early-stage PPF cases received RT. RT fields involved clinically defined targets encompassing involved areas (skin changes, cords, nodules) with at least 1.5-cm margins. En face electrons (6-12 MeV) and bolus (0.5-1 cm) were selected individually. Outcomes are reported for patients who participated in an institutional review board-approved standardized questionnaire and chart review. RESULTS: Thirty-three patients received 66 treatments (45 hands/15 feet and 6 reirradiations). Most frequent dose schemes were 21 Gy (3 Gy in 7 fractions) and 30 Gy (3 Gy in 10 fractions with 6- to 8-week breaks after 15 Gy). Median time to follow-up survey was 31 months. Disease progression at any location within or outside the RT treatment field occurred in 20 of 33 patients (61%). Fourteen of 60 sites (23%) developed in-field progression, but 4 sites were successfully reirradiated with final local control in 50 of 60 sites (83%). RT improved pretreatment symptoms of pain with strain at 30 of 37 sites (81%) and itch/burn sensations at 17 of 21 sites (81%). There were no reported grade ≥2 late toxicities even with reirradiation. Patient reported overall success with treatment was 31 of 33 patients (94%). CONCLUSION: PPF is a progressive disease. En face electron RT is an effective therapy that stabilizes or improves symptoms in the majority of patients. Reirradiation can be considered as a treatment option for in-field progression. Patients report minimal toxicity and a high rate of satisfaction with treatment.

[Angulation deformity of a finger after local radiotherapy]. / Déformation angulaire d'un doigt après radiothérapie locale.

The authors report a case of a third finger angulation deformity. This radial deviation deformity is owed to a local radiation for verrucae vulgaris at 16 years old. The treatment by corrective osteotomy of the phalange was performed with satisfactory correction and full restoration of function.

The effectiveness of grenz ray therapy for chronic dermatoses of the hands and feet.

BACKGROUND: Grenz ray therapy (GRT) has been used for inflammatory and neoplastic dermatologic diseases for over 100 years. Its use is declining, possibly because of the difficulties maintaining radiation certification and insurance coverage. OBJECTIVE: The aim of this study is to evaluate the safety and effectiveness of GRT in chronic inflammatory dermatoses of the hands and feet. METHODS: We performed a retrospective chart review of patients treated with GRT at the Oregon Health & Science University from 2006 to 2009. Candidates identified for the study were then mailed questionnaires to supplement data acquired from chart review. RESULTS: Most patients (73%; 95% confidence interval [CI], 65%-80%) experienced at least moderate improvement. This improvement persisted for at least 1 month in 66% of patients (95% CI, 57%-74%), with 18 patients (23%; 95% CI, 15%-33%) clear for over 1 year. Minimal adverse effects were reported, and most patients (63%; 95% CI, 52%-72%) stated that they would repeat GRT if available. CONCLUSIONS: Grenz ray therapy seems to be a safe and effective modality for chronic hand and foot dermatoses with some patients experiencing prolonged remissions. Grenz ray therapy, when available, should be considered before the use of systemic agents, which are often associated with higher costs and potential toxicities.