The bicycle wheel analogy for linear closures of small suborbital cheek defects.

Primary closure of suborbital skin defects can cause tension along the closure resulting in ectropion. The bicycle wheel analogy is a simple yet effective guide to aid in reducing tension vectors resulting in ectropion.

Economic Costs Avoided by Diagnosing Melanoma Six Months Earlier Justify >100 Benign Biopsies.

New melanoma drugs bring enormous benefits but do so at significant costs. Because melanoma grows deeper and deadlier over time, deeper lesions are costlier due to increased sentinel lymph node biopsy, chemotherapy, and disease-associated income loss. Prior studies have justified pigmented lesion biopsies on a "value per life" basis; by contrast we sought to assess how many biopsies are justified per melanoma found on a purely economic basis. We modeled how melanomas in the United States would behave if diagnosis were delayed by 6 months, eg, not biopsied, only observed until the next surveillance visit. Economic loss from delayed biopsy is the obverse of economic benefit of performing biopsy earlier. Growth rates were based on Liu et al. The results of this study can be applied to all patients presenting to dermatologists with pigmented skin lesions suspicious for melanoma. In-situ melanomas were excluded because no studies to date have modeled growth rates analogous to those for invasive melanoma. We assume conservatively that all melanomas not biopsied initially will be biopsied and treated 6 months later. Major modeled costs are (1) increased sentinel lymph node biopsy, (2) increased chemotherapy for metastatic lesions using increased 5-yr death as metastasis marker, and (3) income loss per melanoma death at $413,370 as previously published. Costs avoided by diagnosing melanoma earlier justify 170 biopsies per melanoma found. Efforts to penalize "unnecessary" biopsies may be economically counterproductive.

J Drugs Dermatol. 2016;15(5):527-532.

Safe and efficacious use of intralesional steroids for the treatment of focally resistant mycosis fungoides.

Cutaneous T-cell lymphoma is a cancer of skin-homing T cells, of which mycosis fungoides (MF) is the most common variant. MF treatments range from topical steroids to systemic chemotherapy. Resistant cutaneous MF nodules can present a special challenge in that typical topical therapies may not penetrate thick lesions, and increasing systemic therapy brings added risk of side effects. We report successful use of intralesional steroids (ILS) for treatment-resistant MF, including tumor-stage plaques and nodules in 4 consecutive patients with focally resistant MF. ILS have been widely used to treat a broad range of cutaneous conditions such as alopecia areata and keloids. Side effects of ILS include hypopigmentation, atrophy, telangiectasias, lilac discoloration, acne, and striae. Rarely, and in circumstances involving unusually large doses, ILS may cause Cushing's syndrome, hypothalamus-pituitary-adrenal axis suppression, and reduced bone mineral density. The MF patients tolerated treatment well without any of the above side effects other than local hypopigmention in a single patient. These results point toward further exploration into ILS as a treatment for focally resistant MF.

Psoriasis: can statins play a dual role?

Recently, a strong association between "psoriasis" and "atherosclerosis" has emerged. Psoriasis patients have an increased prevalence of atherosclerotic disease including coronary artery, cerebrovascular, and peripheral vascular diseases. The exact connection between psoriasis and atherosclerosis remains unclear, but it is thought that inflammation, which plays an important role in both diseases, may be the causative link. Nevertheless, psoriasis patients suffer from an increased burden of atherosclerotic disease and most commonly die from "coronary artery disease" (CAD). Psoriatic patients have an increased prevalence of CAD risk factors and an increased risk of myocardial infarction (MI). One CAD risk factor in psoriasis patients that can easily be managed is "hyperlipidemia." "Statins" are safe, cost-effective, and have been proven to be highly effective in preventing CAD, including MI, in patients with hyperlipidemia. Furthermore, in addition to their lipid lowering properties, statins have anti-inflammatory immunomodulator activities that may be beneficial in several autoimmune diseases including psoriasis. Considering the safety and cost-effectiveness of statins, we feel that it is worth investigating if statins can play a dual role in psoriasis by treating the increased atherosclerotic disease burden in these patients through their lipid lowering effects and by decreasing psoriatic disease activity through their anti-inflammatory immunomodulatory properties.

Review of home phototherapy.

BACKGROUND: Outpatient phototherapy is a safe, effective, and low-cost treatment modality for moderate to severe psoriasis. Barriers to outpatient phototherapy including patient inconvenience, patient co-pays, decreased physician compensation, and insurance disincentive structures have led to decreased use and underutilization of phototherapy. Home phototherapy can potentially overcome many of the barriers associated with outpatient treatment but is not widely used because of concerns over safety and efficacy, lack of resident and physician education, and lack of insurance coverage. PURPOSE: The purpose of this study is to review the use of phototherapy with emphasis on the safety, efficacy, and practical use of home phototherapy. METHODS: A comprehensive Pubmed literature search was done using the keywords NB-UVB, narrowband UVB, BB-UVB, broadband UVB, PUVA, psoralen and UVA, UVA, history of phototherapy, mechanism of phototherapy, phototherapy in dermatology, home phototherapy, and phototherapy for psoriasis. All relevant articles were reviewed. CONCLUSIONS: Home NB-UVB phototherapy can be as safe, effective, and cost-effective as outpatient phototherapy. Further, home UVB is more convenient for patients, has higher patient satisfaction, and a lower treatment burden compared to outpatient phototherapy. Home NB-UVB should be considered as a treatment option for patients eligible for phototherapy.