2020 IDEOM Annual Meeting: Actinic Keratosis Stakeholders Survey Identifies Gaps in Research and Care.

This is a report of the survey results from the International Dermatology Outcome Measures (IDEOM) actinic keratosis (AK) workgroup. The purpose of the survey was to compile a list of gaps within AK care and management that require refinement. The results were discussed at the IDEOM annual meeting held virtually on October 23–24, 2020. This built a framework with which the AK workgroup, which consisted of physicians, patients, and pharmaceutical scientists, discussed at length in their breakout session at the meeting. The electronic survey was distributed to patients, pharmaceutical scientists, and leading physician experts in the field via email on September 22, 2020, with a deadline of October 2, 2020. The survey consisted of three open-ended prompts concerning key gaps and/or unmet needs in (1) the care of AKs, (2) outcome measurement of AKs in clinical trials and, (3) the measurement of AKs in clinical practice. The results were qualitative, with a response rate of 47%. Responses included reform of outcome measures for clinical trials, a methodology for evaluating the efficacy of preventative measures, and a comparison of treatments to establish a treatment protocol, among other efforts. This paper will also provide a brief overview of the current state of the AK outcome measures, emphasizing the heterogeneity of the measures and detailing the AK workgroup's future efforts to create a reliable and applicable core outcome measure set. J Drugs Dermatol. 2022;21(2):128-134. doi:10.36849/JDD.6360.

Photodynamic Therapy with 5-aminolevulinic Acid 10% Gel and Red Light for the Treatment of Actinic Keratosis, Nonmelanoma Skin Cancers, and Acne: Current Evidence and Best Practices.

Photodynamic therapy (PDT) can be an effective treatment for actinic keratosis (AK) as well as selected non-melanoma skin cancers (NMSCs), such as Bowen's disease and superficial basal cell carcinoma. PDT has also demonstrated effectiveness in the management of acne vulgaris. Results from controlled clinical trials have shown the safety and efficacy of PDT for these conditions with the use of different photosensitizers and a wide range of light sources. PDT has been employed effectively as monotherapy and in combination with other topicals and alternate light or laser energy therapies. This article provides expert practical guidance for the use of the newest 5-aminolevulinic acid (ALA) product (ALA 10% gel) plus red light as monotherapy for AKs, NMSC, and acne. Here, information from clinical guidelines and a summary of supporting evidence is provided for each cutaneous condition. The authors also provide detailed guidance for employing ALA 10% gel, a photosensitizer precursor, for each of these applications.

Thermal Photodynamic Therapy for Actinic Keratoses on Facial Skin: A Proof-of-Concept Study.

BACKGROUND: Warming the skin during the incubation of 5-aminolevulinic acid (ALA) has the potential to improve the efficacy and efficiency of cutaneous photodynamic therapy (PDT) through multiple mechanisms. The aim of this proof-of-concept study is to investigate the efficacy and tolerability of thermal PDT on facial skin and evaluate porphyrin production objectively during the warming period. METHODS: Facial skin of 10 subjects was heated during a 20-minute incubation with ALA followed by 10 J/cm blue light illumination. Lesion counts were performed at baseline and 2 months. Porphyrin images were captured and the intensity of fluorescence was measured. The mean intensity of fluorescence after incubation with ALA was compared with baseline. RESULTS: Ten subjects with 363 actinic keratoses completed the study. The average temperature during incubation with the warming mask was 38 to 42°C. Porphyrin intensity increased significantly after the incubation period (p = .001). The average lesion clearance rate was 91.48%. Five subjects had complete lesion clearance (50%). CONCLUSION: This small proof-of-concept study shows that warming facial skin within the range of physiologic tolerability during the incubation of ALA is well tolerated by patients and that porphyrins are efficiently and effectively produced during this defined time and temperature range.

Temperature-Modulated Photodynamic Therapy for the Treatment of Actinic Keratosis on the Extremities: A One-Year Follow-up Study.

BACKGROUND: The efficacy of photodynamic therapy (PDT) using topical 5-aminolevulinic acid (ALA) for the treatment of actinic keratosis (AK) is lower on the distal extremities compared with head and neck areas. A recent pilot study demonstrated increased efficacy of ALA PDT when the skin is warmed during ALA incubation. Prolonged clearance rates on the heated extremity were noted in 3 subjects that were evaluated after the study ended. The aim of this study was to evaluate the longevity of clearance rates after temperature-modulated PDT for the treatment of AKs on the extremities. MATERIALS AND METHODS: A total of 18 subjects (20 pairs of extremities) with at least 10 AKs on the upper or lower extremities were enrolled in the single-center study. Twenty percent ALA was applied to both extremities and heated during the 1-hour incubation period, followed by exposure to 10 J/cm 417-nm blue light. Lesions were photographed, counted, and templated at baseline, 1 week, and 3, 6, 9, and 12 months after treatment. RESULTS: A total of 17 subjects completed the 1-year study. The total number of lesions counted at baseline was 724 Grade 1 and 2 AKs (median 15 on each extremity). The lesion count at 3 and 12 months was 70 (9.6%) and 72 (9.9%), respectively. Grade 3 AKs did not resolve with treatment. The median baseline temperature of the treated extremities was 31.6°C. The median maximum temperature during the 1-hour incubation period was 41.2°C. The median clearance at 3 months was 90% and the same was maintained at 12 months. No new AK lesions formed in the treated areas within the 12-month follow-up period. CONCLUSION: Warming the skin after application of ALA is well tolerated, does not increase side effects, and increases the long-term efficacy of PDT for the treatment of AKs. The authors suggest that mild skin warming may both improve efficacy and reduce variability of response to PDT in practice.

Temperature-modulated photodynamic therapy for the treatment of actinic keratosis on the extremities: a pilot study.

BACKGROUND: The efficacy of photodynamic therapy (PDT) using topical 5-aminolevulinic acid (ALA) for the treatment of actinic keratosis (AKs) is lower on the distal extremities compared with the head and neck areas. The strong temperature dependence of porphyrin synthesis in biologic tissue suggests that heating skin during incubation may improve the efficacy of PDT, particularly in areas where biologic temperatures are naturally lower. The aim of this study was to evaluate the efficacy and tolerability of temperature-modulated PDT for the treatment of AKs on the extremities. METHODS: In this IRB-approved, single-center study, the upper or lower extremities of 20 subjects were treated with 20% ALA under occlusion, followed by 10 J/cm, 417-nm blue light. One of the 2 extremities treated was heated during the 1-hour incubation. Outcome measures included lesion counts, tolerability, and global improvement at baseline, 1 week, and 2 and 6 months after treatment. RESULTS: The median temperatures of the heated and control sides were 38.8°C and 29.4°C, respectively. The median clearance for the heated side was significantly greater than the control side at 2 and 6 months (p < .0001). Typical PDT side effects were greater on the heated side compared with the control yet were well tolerated by all subjects. CONCLUSION: Warming the skin during incubation of ALA seems to improve the efficacy of PDT in the treatment of AKs on the extremities and is well tolerated when heat application is controlled within the limits of safety.

Diagonal tarsal suture technique sine marginal sutures for closure of full-thickness eyelid defects.

PURPOSE: Precise apposition of the tarsal plates and meticulous alignment of the eyelid margins are essential to ensure a seamless repair and avoid notching of the eyelid margin. The authors present a simple and reliable technique that firmly apposes and precisely aligns the eyelid margin in the x, y, and z axes, obviating the need for marginal sutures. METHODS: A retrospective audit of electronic medical records was performed for all patients who underwent reconstructive procedures that included the repair of a full-thickness defect in the eyelid margin using the diagonal suture technique from 2003 to 2012. RESULTS: Of the 652 surgeries performed in the past 9 years, 9 incidences of notching occurred, all of which were associated with infections. CONCLUSIONS: The diagonal tarsal suture technique is a simple and effective method for the repair of full-thickness defects with a high degree of patient satisfaction.

Prospective multicenter clinical trial of a minimally invasive temperature-controlled bipolar fractional radiofrequency system for rhytid and laxity treatment.

BACKGROUND: A minimally invasive fractional bipolar radiofrequency (FRF) was developed. OBJECTIVE: To evaluate safety and efficacy of FRF in reducing face and neck rhytides and laxity. MATERIALS AND METHODS: This prospective, open-label, multicenter clinical trial enrolled 100 subjects with mild to severe facial and neck rhytides and laxity at seven centers in a per-protocol analysis. One single-pass FRF treatment was administered through five 32 g-needle electrode pairs at a preselected real-time fixed temperature of 62 to 78°C, energy duration for 3 to 5 seconds, and impedance restrictions of 200 to 3,000 Ohms, ensuring intradermal delivery. Five blinded dermatologists and plastic surgeons graded randomized standardized baseline and follow-up photographs of 53 and 42 subjects at 3- and 6-month follow-up intervals, respectively, using the Fitzpatrick wrinkle and Alexiades-Armenakas laxity scales. Subject assessments and adverse events were recorded in 100 subjects. RESULTS: Blinded evaluations revealed correct pre- and post-treatment identification in 100% of scored cases, mean improvement of 25.6% on the Fitzpatrick Wrinkle Scale and 24.1% on the Alexiades-Armenakas laxity scale at 6 months, and 100% response rate for rhytides and 95% for laxity. Subgroup analysis revealed maximal rhytid reduction in the mean target temperature of 66.7, energy duration of 4.2 seconds, and volume of denatured collagen of mm(3) denatured collagen group. Adverse events included transient erythema, edema, and ecchymoses, resolving within 1 to 5 days, and two incidents of temporary pinpoint depressions. More than 90% of subjects were satisfied or very satisfied. CONCLUSION: Real-time temperature-controlled FRF is a highly reproducible, safe, effective nonsurgical treatment of face and neck rhytides and laxity and provides important insights into neocollagenesis, neoelastogenesis, and clinical outcomes.

Elastometry and clinical results after bipolar radiofrequency treatment of skin.

BACKGROUND: The healing process of a novel radiofrequency bipolar system was recently shown to produce a profound increase in collagen and elastin content. OBJECTIVE: To determine the relationship between subjective clinical improvement scores and changes in objective measures of mechanical skin properties. METHODS AND MATERIALS: Elastometry measurements were made at baseline and 3 months after treatment. All patients received a treatment zone on the lower face. Patient assessments of results and physician ratings of wrinkle and skin laxity were collected at baseline and 3 and 6 months after treatment. Elastometry and clinical results were then compared. RESULTS: Three months after treatment, elastometry measurements showed statistically significant improvement (5-12% decrease in Young's Modulus and 10-16% decrease in retraction time). The average improvement correlated to a 2.6-year improvement in skin property. Physician scores at 3 months showed a statistically significant improvement of 1.42 grades on the Fitzpatrick scale for wrinkles and 0.66 grades on the Alexiades scale for skin laxity, increasing to 1.57 and 0.70 improvement, respectively, at 6 months. Eighty-nine percent and 91% of patients were satisfied or very satisfied with the procedure at 3- and 6-month follow-up, respectively. CONCLUSION: Elastometry data showed an average decrease in Young's Modulus and retraction time, both of which suggest that radiofrequency bipolar treatment resulted in more youthful skin. Better mechanical characteristics were consistent with improvements in wrinkles, laxity, and skin quality and appearance.

Reduction in the incidence of squamous cell carcinoma in solid organ transplant recipients treated with cyclic photodynamic therapy.

BACKGROUND AND OBJECTIVES: Squamous cell carcinomas (SCCs) produce significant morbidity in solid organ transplant recipients (SOTRs), particularly in patients who develop multiple tumors. Topical photodynamic therapy (PDT) has been shown to decrease the number of keratotic lesions in SOTRs, but the duration of the beneficial effect is limited. The aim of this study was to evaluate the potential benefit of cyclic PDT in the prevention of new SCCs in SOTRs. METHODS: Twelve high-risk SOTRs received cyclic PDT treatments at 4- to 8-week intervals for 2 years. The development of new SCCs (invasive and in situ) performed 12 and 24 months after the start of cyclic PDT were compared with the number of SCCs developed during the year before initiation of cyclic PDT. RESULTS: The median reduction in the 12- and 24-month post-treatment counts from the 1-month pretreatment counts was 79.0% (73.3-81.8%) and 95.0% (87.5-100.0%), respectively. Treatments were well tolerated. CONCLUSION: Cyclic PDT with 5-aminolevulinic acid may reduce the incidence of SCC in SOTRs. Additional studies with larger numbers of patients and optimized protocols are necessary to further explore the potential benefits of cyclic PDT in the prevention of skin cancer in this high-risk patient population.

Tinea capitis mimicking cicatricial alopecia: what host and dermatophyte factors lead to this unusual clinical presentation?

Tinea capitis is the most common dermatophyte infection in children. The clinical presentation varies from subtle asymptomatic scaling to inflammatory suppurative nodules and draining tracks. Both chronic and acute inflammatory infections may damage the hair follicle leading to secondary cicatricial alopecia. In rare instances, the initial presentation can mimic a primary cicatricial alopecia. We present three cases of tinea capitis in children masquerading as cicatricial alopecia and discuss the possible host immune and fungal antigenic factors that may influence the course of disease and its clinical presentation. An understanding of the clinical morphology of tinea capitis in the context of both host and fungal factors may improve treatment strategies and direct future paradigms of therapy.

Modified single-sling myocutaneous island pedicle flap: series of 61 reconstructions.

BACKGROUND: Bilevel undermining above and below the transverse nasalis muscle in the construction of a myocutaneous island pedicle flap produces a bilateral or unilateral muscular sling with exceptional vascular supply for reconstruction of defects on the distal nose. We present further modification of the single-sling myocutaneous island pedicle flap that expands its application to a wide variety of nasal defects and further defines its usefulness in nasal reconstruction. METHODS: A series of 61 consecutive myocutaneous island pedicle flap reconstructions performed after Mohs surgery between March 2005 and July 2006 are presented. Flap modifications are presented, and advantages and limitations are discussed. RESULTS: Flap modifications introduce additional reach and rotational mobility to the flap that permit extension of the flap to defects on the nasal tip and distal ala. CONCLUSION: Modifications of the bilevel approach to the single-sling nasalis myocutaneous island pedicle flap further define its practicality in nasal reconstruction and expand its application to a variety of nasal defects.

Black-spot poison ivy.

In black-spot poison ivy dermatitis, a black lacquerlike substance forms on the skin when poison ivy resin is exposed to air. Although the Toxicodendron group of plants is estimated to be the most common cause of allergic contact dermatitis in the United States, black-spot poison ivy dermatitis is relatively rare.