A regimen to minimize pain during blue light photodynamic therapy of actinic keratoses: Bilaterally controlled, randomized trial of simultaneous versus conventional illumination.

BACKGROUND: Blue light photodynamic therapy (PDT) is effective for actinic keratosis, but many patients experience stinging pain during illumination. OBJECTIVE: To compare a conventional regimen (1 hour of 5-aminolevulinic acid [ALA] preincubation, followed by blue light) versus a new modified regimen in which blue light is started immediately after ALA application. METHODS: A clinical trial with a bilaterally controlled, intrapatient study design was conducted with 23 patients. Topical 20% ALA was applied to the entire face and/or scalp. On 1 side of the body, blue light was started immediately and continued for either 30, 45, or 60 minutes (simultaneous PDT). On the contralateral side, the blue light began 1 hour after ALA application and lasted 1000 seconds (conventional PDT). Pain was evaluated on a scale from 0 to 10. Actinic keratosis lesion counts were determined by clinical examination and photography. RESULTS: All patients experienced significantly less pain during simultaneous illumination than during the conventional regimen. At 3 months after treatment, lesion clearance was nearly identical on the 2 sides, as determined by statistical testing of noninferiority ± 15% margin. LIMITATIONS: Although bilaterally controlled, the study was relatively small. Additional studies are recommended. CONCLUSION: The modified PDT regimen is essentially painless, yet it provides treatment efficacy similar to a conventional regimen.

Residual Squamous Cell Carcinoma After Shave Biopsy in Solid Organ Transplant Recipients.

BACKGROUND: After histopathological confirmation of a biopsy sample, cutaneous squamous cell carcinoma (cSCC) is often treated surgically; yet, residual tumor within the excision sample is not always found. The prevalence of residual cSCC after shave biopsy in solid organ transplant recipients (SOTRs) is unknown. OBJECTIVE: Determine the prevalence of residual cSCC after shave biopsy in SOTRs. METHODS: A retrospective case-controlled review was performed from a single center. Data were collected for 117 SOTRs and 117 age-matched nonimmunosuppressed controls diagnosed with shave biopsy-proven cSCC who underwent subsequent wide local excision from January 2004 to December 2016. Multivariable conditional logistic regression was used to determine variables associated with residual tumor in the combined population. Univariate logistic regression was used to investigate if transplant-related variables were associated with residual tumor in the SOTR group. RESULTS: Of the 117 SOTRs, 57 (48.7%) had residual tumor within the excisional specimen. Of the 117 controls, 31 (26.5%) had residual tumor within the excisional specimen. Solid organ transplant recipients have 2.59 times greater odds of having residual cSCC after shave biopsy (95% confidence interval: 1.29-5.22, p = .0076). CONCLUSION: Solid organ transplant recipients have a higher prevalence of residual cSCC after shave biopsy when compared with nonimmunosuppressed controls and should be prioritized for margin-controlled surgery.

The role of the ugly duckling sign in patient education.

BACKGROUND: The ABCDE (with A standing for asymmetry, B for border irregularity, C for color variegation, D for diameter larger than 6 mm, and E for evolution) rule for melanoma (MM) recognition is widely taught in the general population. The ugly duckling (UD) sign is an alternate MM recognition strategy that is not generally taught. OBJECTIVE: To compare the sensitivity, specificity, and accuracy of MM recognition with UD sign and the ABCD rule in a general population. METHODS: Participants were randomized into either the ABCD or UD arm of the study. An educational tutorial on their respective teaching method followed. Participants were subsequently tested using images of 9 lesions (7 nevi and 2 MMs) and asked to categorize each image as MM or not MM. RESULTS: A total of 51 participants were randomized to the ABCD group and 50 to the UD group. The sensitivity for MM recognition of both groups was similar. The specificity and accuracy for MM recognition was significantly higher (P =.02, P = .02) in the UD group. LIMITATIONS: The E for evolution in the ABCDE rule was not tested. No follow-up knowledge retention test was conducted. CONCLUSION: The UD sign significantly improved accuracy and specificity of MM recognition. We recommend adding the UD sign to patient education in addition to the traditional ABCDE rule.

Skin Infections due to Bacteria in Solid Organ Transplant Recipients: A Review.

Though there is an abundance of information on cutaneous malignancies in transplant recipients, cutaneous infections in solid organ transplant recipients (SOTRs) are underrepresented in the dermatological literature. Our paper provides a comprehensive review of bacterial cutaneous infections within the solid organ transplant population. Cutaneous bacterial infections may lead to significant morbidity and even mortality in this immunosuppressed population. Thus, it is to the benefit of both dermatologists and other transplant care providers to better understand and recognize the features of cutaneous bacterial infections in SOTRs. This paper can aid providers in promptly identifying, diagnosing, and treating bacterial skin infections. This review discusses the diagnosis and treatment of the following bacterial species: Staphylococcus, Streptococcus, Pseudomonas aeruginosa, Escherichia coli, Nocardia, Mycobacteria, and Bartonella henselae.

OnabotulinumtoxinA versus PrabotulinumtoxinA-xvfs: A Randomized, Triple-blind, Split-face Study on the Time to Onset, Rhytid Appearance, and Patient Satisfaction in Forehead and Glabellar Lines.

Background: Both onabotulinumtoxinA and prabotulinumtoxinA-xvfs are FDA-approved formulations of botulinum toxin A for the treatment of glabella and forehead rhytids. Objective: We sought to compare the onset to action and patient satisfaction of onabotulinumtoxinA and prabotulinumtoxinA-xvfs in treating dynamic rhytids of the forehead and glabella. Methods: Fifteen patients, aged 28 to 74, were enrolled and completed the study. Patients were randomly assigned to receive equal amounts of onabotulinumtoxinA and prabotulinumtoxinA-xvfs injected to opposite sides of the face in the glabella and forehead at Day 0 by a blinded injector. Glabellar and frontalis muscle onset to action and rhytid appearance were blindly evaluated using photographs at Days 0, 2, 4, 6, 8, 10 post-injection. Patients rated their satisfaction of left and right sides using a standardized scale. Results: There was no statistically significant difference in onset to action, rhytid appearance, and patient satisfaction after injection with onabotulinumtoxinA versus prabotulinumtoxinA-xvfs in the corrugator and frontalis muscles. Although not statistically significant, a trend existed towards increased patient satisfaction with onabotulinumtoxinA. Conclusion: Both onabotulinumtoxinA and prabotulinumtoxinA-xvfs are equally efficacious formulations of botulinum toxin type A for the treatment of glabellar and forehead rhytids.

Online, game-based education for melanoma recognition: A pilot study.

OBJECTIVE: To evaluate the effectiveness of a game-based learning (GBL) intervention, Tapamole, in improving recognition of the features of melanoma (MM) compared to a written education intervention. METHODS: Tapamole, an online education intervention, was developed using GBL. Participants were voluntarily recruited from the Dermatology waiting room and randomized to three groups: game, pamphlet, and no intervention. Participants completed a pre-intervention survey, post-intervention survey, and test on MM recognition. Clustered binary data equations were used to calculate sensitivity, specificity, and accuracy for each group and GEE model with log link was used to compare measures between groups. RESULTS: Sixty participants were recruited. The sensitivity for MM recognition in the game group was 100% compared to 95% for the pamphlet group. The specificity (40.8% vs 53.3%) and accuracy (60.6% vs 67.2%) of the game and pamphlet groups were similar. Participants in the game group reported higher enjoyment than those in the pamphlet group. CONCLUSION: GBL was as effective as the written intervention in identifying features of MM. PRACTICE IMPLICATIONS: With increasing use of the Internet for health information, it is critical to have effective online education interventions. GBL education tools are effective, enjoyable, and should be used to improve MM patient education.

Prevalence of skin cancer in Native American kidney transplant recipients.

BACKGROUND: Skin cancer prevalence is well-characterized for white solid organ transplant recipients. Although the prevalence of skin cancer in non-white (Black, Asian, Hispanic) kidney transplant recipients (KTRs) has been assessed, no study has reported the prevalence of skin cancer in Native American (NA) KTRs. The aim of this study is to determine if the prevalence of skin cancer in NAKTRs is the same as in white KTRs. METHODS: We conducted a case-controlled retrospective review from a single transplant center. One hundred thirteen NAKTRs who received a transplant between 2001 and 2011 were age- and transplant-year matched with 113 white controls. RESULTS: The 226 KTRs consisted of 141 (62.4%) men and 85 (37.6%) women, with a mean age of 50.2 ± 10.8 years. There was no skin cancer found in NAKTRs prior to or post transplantation, while seven (6.2%) white KTRs had eight skin cancers prior to transplantation, and 28 (24.8%) white KTRs developed 66 skin cancers post transplantation. Twenty-two (19.5%) NAKTRs did not follow-up with dermatology at this institution. The median follow-up in NAKTRs was 3.3 years compared to 3.0 years in white KTRs. CONCLUSION: NAKTRs have a decreased prevalence of skin cancer compared to their white counterparts.

Blue light versus red light for photodynamic therapy of basal cell carcinoma in patients with Gorlin syndrome: A bilaterally controlled comparison study.

BACKGROUND: Photodynamic therapy (PDT) is a non-scarring alternative for treating basal cell carcinoma (BCC) in patients with Basal Cell Nevus Syndrome (BCNS), also known as Gorlin syndrome. In Europe, red light (635 nm) is the predominant source for PDT, whereas in the United States blue light (400 nm) is more widely available. The objective of this study was to conduct a head-to-head comparison of blue light and red light PDT in the same BCNS patients. METHODS: In a pilot study of three patients with 141 BCC lesions, 5-aminolevulinate (20% solution) was applied to all tumors. After 4 h, half of the tumors were illuminated with blue light and the remainder with red light. To ensure safety while treating this many tumors simultaneously, light doses were escalated gradually. Six treatments were administered in three biweekly sessions over 4 months, with a final evaluation at 6 months. Tumor status was documented with high-resolution photographs. Persistent lesions were biopsied at 6 months. RESULTS: Clearance rates after blue light (98%) were slightly better than after red light (93%), with blue light shown to be statistically non-inferior to red light. Eight suspicious lesions were biopsied, 5 after red light (5/5 were BCC) and 3 after blue light (1 was BCC). Blue light PDT was reportedly less painful. CONCLUSION: Blue light and red light PDT appear to be equally safe and perhaps equally effective for treating BCC tumors in BCNS patients. Further studies to evaluate long-term clearance after blue light PDT are needed.

Transplant center assessment of the inequity in the kidney transplant process and outcomes for the Indigenous American patients.

BACKGROUND: The goal is to determine the delays and reduced rates of kidney transplant (KTx) for the Indigenous Americans and variables predictive of these outcomes at a large single transplant center. METHODS: 300 Indigenous Americans and 300 non-Hispanic white American patients presenting for KTx evaluation from 2012-2016 were studied. RESULTS: Compared to whites, the Indigenous Americans had the following: more diabetes, dialysis, physical limitation and worse socioeconomic characteristics(p<0.01); median difference of 20 day delay from referral to KTx evaluation, 17 day delay from approval to UNOS listing and 126.5 longer delay on the waitlist compared to whites(p<0.001). Of the Indigenous Americans listed, more died, were removed, or were still waiting than transplanted compared to whites (p<0.001). Variables predictive of delay from referral to transplant evaluation included: Indigenous race, distance from transplant center, coronary artery disease, and time on dialysis (p<0.05). Cumulative incidence of waitlisting and KTx was lower for Indigenous Americans (p<0.0001). Independent predictors of decreased likelihood of waitlisting included age, peripheral vascular disease, no caregiver, physical limitation, and illegal drug use history (p<0.05). Variables predictive of lower likelihood of KTx included Indigenous race, percentage of time inactive on the waitlist, no caregiver, and O blood type. CONCLUSIONS: Among patients referred and evaluated for KTx, the Indigenous American race was independently associated with significant delays in the KTx process after accounting for co-morbid and socioeconomic factors. Cardiovascular morbidity and physical limitation were identified as important determinants of delay and decreased likelihood of waitlisting. Further quantitative and qualitative work is needed to identify and intervene on modifiable barriers to improve access to KTx for the Indigenous Americans.

Cutaneous fungal infections in solid organ transplant recipients.

Although there is an abundance of information on cutaneous malignancies in transplant recipients, information on cutaneous infections in solid organ transplant recipients is underrepresented in dermatologic and transplant literature. Our paper provides a comprehensive review of fungal cutaneous infections within the solid organ transplant population. We compiled literature specific to the solid organ transplant population, reviewing cutaneous manifestations owing to fungal infections. Furthermore, we discuss the diagnosis and treatment of such infections. The following is a list of some of the fungi that we will discuss.

Laser in the management of burn scars.

BACKGROUND AND OBJECTIVE: Burn scars are associated with significant morbidity ranging from contractures, pruritus, and disfigurement to psychosocial impairment. Traditional therapies include silicone gel, compression garments, corticosteroid injections, massage therapy, and surgical procedures, however, newer and advanced therapies for the treatment of burn scars have been developed. Lasers, specifically ablative fractional lasers, show potential for the treatment of burn scars. METHODS: Both MeSH and keyword searches of the PubMed, Medline and Embase databases were performed and relevant articles were read in full for the compilation of this review. RESULTS: Fifty-one relevant observational studies, clinical trials, and systematic reviews published in English from 2006 to 2016 were reviewed and summarized. CONCLUSION: Laser therapy is effective for the treatment of burn scar appearance, including measures such as pigmentation, vascularity, pliability, and thickness. Ablative fractional laser therapy, in particular, shows significant potential for the release of contractures allowing for improved range of motion of affected joints. Patients may benefit from the use of lasers in the treatment of burn scars, and the safety profile of lasers allows the benefits of treatment to outweigh the risks. Laser therapy should be included in burn scar treatment protocols as an adjuvant therapy to traditional interventions.

Skin-Limited Graft-versus-Host Disease after Pancreatic Transplantation.

INTRODUCTION: The phenomenon of graft-versus-host disease, a solid organ transplant recipient, is a rare development with a very poor prognosis. CASE PRESENTATION: A 40-year-old woman with type 1 diabetes developed cutaneous graft-versus-host disease following second pancreas transplantation. CONCLUSION: The development of a nonspecific rash in the early posttransplant period following a pancreas transplant warrants suspicion for graft-versus-host disease.