A Practice Approach to Acne Fulminans in Adolescents.

Acne fulminans (AF) is a severe form of inflammatory acne commonly associated with adolescents. It is characterized by an abrupt onset of painful nodules and plaques and can progress to suppurative, ulcerative, and hemorrhagic lesions. AF can be associated with systemic symptoms such as fever, arthralgia, and bone pain. The etiology of AF is unknown but it has been linked to the use of certain medications and has been rarely found in autoinflammatory syndromes. In previous years, there have been reports of <200 cases in the literature; however, AF may be more common in clinical practice than reported. The most common presentation of AF is seen in adolescents starting isotretinoin therapy. Diagnosis of AF is determined based on its clinical findings. The main purpose of this article is to provide clinicians with a practical approach to treating AF. Current evidence for its treatment is limited to case reports and case series. The mainstay treatment of AF is a combination of prednisone and isotretinoin. It is important to taper or discontinue any exacerbating or precipitating medications such as isotretinoin, antibiotics, or androgens when AF is identified. Along with treatment of AF, it is important to treat associated scarring. Early identification and treatment of AF in adolescents is crucial to minimize both acute symptoms and long-term scarring, and further research is needed to determine optimal management.

Advances in the Application of Noninvasive Skin Imaging Techniques in Acne Scars.

Acne scarring is a common sequela of acne vulgaris, which seriously affects facial esthetics. The treatment options for acne scars vary depending on the development stage, color, type, and location of scarring. The objective and precise assessment of acne scars is a prerequisite for treatment, and it is also an important means of monitoring the treatment effect. The traditional methods to evaluate the types and severity grade of acne scars are primarily based on subjective assessment by physicians, which lacks objectivity and accuracy. Novel noninvasive skin imaging techniques, such as skin surface imaging analysis systems, dermoscopy, reflectance confocal microscopy (RCM), high-frequency ultrasound (HFUS), optical coherence tomography (OCT), and multiphoton tomography (MPT), provide new tools for the rapid and objective assessment of acne scars. This article reviews the progress of skin imaging techniques in the diagnosis, classification, and efficacy evaluation of acne scars.

Comparing the efficacy and safety of microneedling and its combination with other treatments in patients with acne scars: a network meta-analysis of randomized controlled trials.

This study aimed to analyze the efficacy and safety of microneedling (MN), both alone and in combination with other treatments, to refine the approach for treating acne scars using MN. We systematically searched Pubmed, Cochrane Library, Embase, and Web of Science for randomized controlled trials examining MN or its combinations in patients with acne scars. All statistical analyses were performed using Stata 18 software. A total of 24 studies involving 1546 participants were included. The analysis revealed that MN combined with chemical peels (CP) exhibited the best results in terms of degree of improvement, patient satisfaction, and treatment efficacy compared to other treatments examined, including MN alone, MN with hyaluronic acid (HA), MN with botulinum toxin­A (TA), MN with platelet-rich plasma (PRP), PRP alone, CP, and laser therapy. The results for MN combined with additional treatments were obviously better than for MN alone. Side effects such as erythema, pain, and post-inflammatory hyperpigmentation showed no significant differences across all treatments assessed.

Subcision with platelet-rich plasma and microneedling versus subcision with saline and micro-needling in posttraumatic scars.

BACKGROUND: In treating post-traumatic scars, this study compared the safety and effectiveness of combined subcision with saline and microneedling versus combined subcision with platelet-rich plasma and microneedling. Combined subcision with saline and microneedling or combined subcision with platelet-rich plasma and microneedling were used to treat 36 consecutive individuals with post-traumatic scarring. The Modified Manchester score was used to assess texture change, pigmentation, and surface distortion changes. Each change was given a score between 1 and 4. A lower score (range: 3-12) indicates a better result. The mean of the three individual scores was determined. For best outcomes, each patient needed four treatment sessions for each scar, with a one-month follow-up period following the final treatment. The three variables in group B had mean scores of 1.4 ± 0.5, 2 ± 0.8, and 2.2 ± 0.9, respectively, for texture change, pigmentation, and surface distortion. With a mean score of 1.4 ± 0.5, texture change had the best response out of the three variables we evaluated. The investigator determined that the mean improvement score for patients in group B's overall appearance was 5.61 ± 1.19. The study has shown that the combination of subcision with platelet-rich plasma, and microneedling appears to be a promising treatment for posttraumatic scars due to its low risk and high efficacy. Our findings suggest that this is a safe method for treating posttraumatic scars, with few side effects and a low chance of recurrence. IRB LOCAL APPROVAL NUMBER: 04-2023-300279. CLINICAL TRIAL REGISTRY: NCT06135480.

Barbed vs conventional sutures for cesarean uterine scar defects: a randomized clinical trial.

BACKGROUND: The role of barbed sutures in preventing myometrial defects and enhancing postpartum outcomes after cesarean section (C-section) is uncertain. OBJECTIVE: This study compared clinical and ultrasonographic outcomes of uterine scar defects after C-section with barbed and conventional smooth thread sutures. STUDY DESIGN: This was a multicenter, parallel-group, randomized, controlled clinical trial. Four obstetrics and gynecology departments across three Japanese healthcare regions were included. The participants were women requiring their first cesarean delivery between May 2020 and March 2023. Of the 1211 participants enrolled, 298 underwent C-section and 253 were followed up until July 2023. Participants with singleton pregnancies were randomly assigned (1:1 ratio) to receive either conventional or spiral thread sutures with a double-layer continuous suture. The study period comprised the time of consent to the 6- to 7-month examination. The primary endpoint was the rate of scar niches >2 mm evaluated using transvaginal ultrasonography at 6 to 7 months after surgery. Additional metrics included the total operative time, suture application time, operative blood loss, number of additional sutures required for hemostasis, maternal surgical complications, postoperative infections, surgeon's years of experience, and individual subscale scores. RESULTS: All data of the 220 participants (barbed suture group: 110; conventional suture group: 110) were available, thus enabling a full analysis set. A comparison of the barbed and conventional suture groups, respectively, revealed the following: niche length, 2.45±1.65 mm (range: 1.0-6.7) vs 3.79±1.84 mm (range: 1.0-11.0) (P<.001); niche depth, 1.78±1.07 mm (range: 1.0-5.7) vs 2.70±1.34 mm (range: 1.0-7.3) (P<.001); residual myometrial thickness (RMT), 8.46±1.74 mm (range: 4.8-13.0) vs 7.07±2.186 mm (range: 2.2-16.2) (P<.001); and niche width, 1.58±2.73 mm (range: 0.0-14.0) vs 2.88±2.36 mm (range: 0.0-11.0) (P<.001), respectively. The barbed suture group exhibited no defects and an RMT <3 mm. Furthermore, the barbed suture group had a lower rate of uterine niches (29.1%; n=32/110) than the conventional suture group (68.2%; n=75/110). Secondary outcomes showed no significant differences in operative times, maternal surgical complications, or postoperative complications. CONCLUSION: Double-layer barbed sutures during cesarean delivery may prevent C-section scar defects and postoperative complications. El resumen está disponible en Español al final del artículo.

Split face randomized, evaluator blinded study on the effect of multiple subcisions on rolling acne scars.

Acne scarring results from a common inflammatory condition present in many people. These scars can have an impact on quality of life by influencing self-esteem and social acceptance. Current acne scarring treatments, such as chemical peels and laser treatments, often have limited success due to their time-consuming nature and the variability of acne scar types. The subcision technique has shown promise for the treatment of rolling acne scars. There are few studies to date that examine the effects of multiple subcision treatments on rolling acne scars. We evaluated whether the use of multiple subcision treatments improved the appearance of rolling acne scars compared to no treatment. Five patients with rolling acne scars on both sides of their face who met inclusion and exclusion criteria were enrolled in the study. One side of the face was randomized to receive treatment, while the contralateral side of the face received no treatment. Subjects underwent five sequential subcision treatments, spaced 4 weeks apart, with two follow-up visits at weeks 20 and 36 from the 1st treatment. Photographs were taken before and after the initial treatment visit and at each subsequent visit. Acne scar appearance was evaluated by the subject, a blinded live rater, and two double-blinded dermatologist raters. Evaluations of treatment outcomes involved overall acne scar appearance on a 5-point scale, acne scar improvement on a percentage scale, a modified quantitative global scarring grading system, and potential treatment side effects. There was a greater decrease in global scarring scores in the multiple subcision side compared to the control side. There was a greater difference in the average acne scar appearance scores between the Week 36 follow-up visit and baseline for the multiple subcision side compared to that of the control side. 50% of patients reported being more satisfied with the treatment side compared to the control side in regard to overall improvement. The study results suggest that multiple subcision treatments may improve the appearance of rolling acne scars compared to no treatment.

'Y' Modification of the cutaneous incision of the preseptal transconjunctival approach for the management of zygomatico-maxillary complex fractures: A prospective clinical study.

AIM: The purpose of this clinical study was to evaluate the efficacy of the preseptal transconjunctival approach with Y modification of the cutaneous extension for the management of zygomaticomaxillary complex (ZMC) fractures. METHODS: This prospective interventional study was conducted at our institute from 2012 to 2020. The study included patients aged 15-65 years with displaced ZMC fractures. Patients with uncontrolled systemic conditions, infected and/or comminuted fractures were excluded. The variables evaluated were age, gender, mechanism of injury, fracture side, clinical features, surgical exposure time, adequacy of exposure, complications, scar evaluation scores and cosmetic outcomes. The parameters for comparison were operated versus non operated side Eye Fissure Index (EFI) and surgical exposure time was compared with respect to the types of scars. RESULTS: A total of 49 patients were included in this study. The average exposure time was 18.87 ± 1.92 min. The exposure of fracture site was excellent in 73.5 % and satisfactory in 26.5 %. The mean EFI of operated side was 34.2 ± 5.04 mm while that of non-operated side was 34.22 ± 5 mm. On comparison of the same there was no significant difference. Invisible scars were noted in 71.4 % and barely visible scars in 22.4 %. The comparison of exposure time with type of scars showed a significant association (p = 0.02). The complications noted were chemosis, lower eyelid edema, conjunctival granuloma and entropion. Cosmetic outcomes were fairly satisfactory. CONCLUSION: The Y modification of the transconjunctival approach can provide excellent surgical exposure without the need for a second incision. Although this approach is technique sensitive and requires experience, the advantages outweigh the learning curve. Since this approach has been widely studied, a systematized review is recommended to further substantiate its reliability and advantages.

Reduced rates of substance use disorder in patients with alopecia: An all of us case-control study.

Alopecia areata (AA), depression, anxiety, and decreased quality of life are highly associated in the literature. It has been noted that there is an increased risk of substance use in those with AA to help cope with the psychological burdens and perceived stigmatization. This study aims to explore the relationship between substance use disorder (SUD) and scarring/non-scarring alopecia using the All of Us database. Of the 9,385 patients with alopecia, 8.4% had SUD of any kind. Multivariable regression revealed that alopecia is a potential protective factor against SUD when controlling for other covariates of significance, with a decreased odds of 0.73. Substance use disorder prevalence was not different between scarring and non-scarring alopecia. This may be the result of patients fearing exacerbation of hair loss, or due to increased mental health and community support in patients with alopecia. Dermatologists and primary care providers should continue to promote psychotherapy and community support to patients whose diagnosis of alopecia has a negative psychosocial impact.

Treatment of Acne Scars with Microneedling and Chemical Reconstruction of Scarred Skin Therapy (CROSS) Using Penol/Croton Oil Combination.

BACKGROUND: Microneedling has been shown to release growth factors, which improves the appearance of acne scars by itself and in combination with different therapy modalities. Combining microneedling with Chemical Reconstruction of Scarred Skin (CROSS) therapy using a 60% phenol and 0.2% croton oil combination results in a significant improvement of acne scarring. OBJECTIVE: To assess the safety and efficacy of combination treatments using microneedling in combination with CROSS therapy that contains 60% phenol and 0.2% croton preparation in patients with Fitzpatrick skin types III to V.  Materials and Methods: Patients were treated over a 5-year period for atrophic acne scars using microneedling combined with CROSS. Most of the patients had combination atrophic scarring. High-quality before and after photographs were taken of the patients to assess the improvement in the scars.  Results: Most of the patients (89.5%) had Fitzpatrick skin types IV through V.  Analysis was done on a maximum of 3 microneedling sessions with 1 to 3 CROSS sessions. Photographic evaluation using the Global Aesthetic Improvement Scale showed an 18% grade-1 improvement and 81% grade-2 improvement. The Goodman and Baron Qualitative scar grading system showed a 62% grade-1 improvement and 38% grade-2 improvement. CONCLUSION: Combination treatments work best for atrophic scars. This is the first published report of using microneedling with a 60% phenol/0.2% croton oil combination. It proved to be very effective and safe in treating atrophic acne scars in Fitzpatrick skin types III to V, with minimal side effects and a quick recovery. J Drugs Dermatol. 2024;23(6):418-422.     doi:10.36849/JDD.7657.

The Association of Systemic Immune-Inflammation Index (SII), Systemic Immune-Response Index (SIRI), and Neutrophil-to-Lymphocyte Ratio (NLR) with Cesarean Scar Pregnancy (CSP).

OBJECTIVE: To evaluate the association of the Systemic Immune-Inflammation Index (SII), Systemic Immune-Response Index (SIRI), and Neutrophil-to-Lymphocyte Ratio (NLR) with Cesarean Scar Pregnancy (CSP) METHODS: This prospective case-control study was conducted in Ankara City Hospital perinatology clinic between 2022 and 2023. The diagnosis of CSP was made by transabdominal and transvaginal ultrasound. NLR, SII, and SIRI values were compared between those diagnosed with CSP (n=23) and healthy pregnancies (n=126) at the time of first admission. RESULTS: The study group had significantly higher NLR, SII, and SIRI values compared to the controls. Optimal cut-off values were 3.79 (69 % sensitivity, 78.2 % specificity), 1180.6 (76.7 % sensitivity, 72.7 % specificity), and, 1.9 (83.3 % sensitivity, 72.7 % specificity) for NLR, SII, and SIRI, respectively. When NLR, SII and SIRI values were compared between CSP cases and pregnant women who had previous history of cesarean section but did not have CSP, significantly higher SII values were observed in the CSP group. The optimal cut-off value of SII was found to be 804.4 in predicting CSP among cases with previous history of cesarean delivery (73.9 % sensitivity, 66.2 % specificity). CONCLUSION: SII, SIRI, and NLR may be useful in predicting cesarean scar pregnancy in pregnant women.

Subcision with and without suction for acne scars: a split-faced, rater-blinded randomized control trial.

Therapeutic options for acne scars include subcision and suction with microdermabrasion, but these treatment modalities have not been studied in conjunction. To compare effectiveness of subcision alone versus subcision with suction for the treatment of facial acne scars. Randomized, split-faced, evaluator-blinded control trial. Participants underwent one subcision treatment on both sides of the face followed by 10 sessions of suction to one side. Photographs at baseline, 1-month, and 4-months were assessed. Primary outcome measures were the validated Acne Scar Severity Scale (ASSS) (0 = no acne scarring, 4 = severe), Acne Scar Improvement Grading Scale (ASIGS) (-100 to 100%), and modified Quantitative Global Scarring Grades (QGSG) (point-based questionnaire instrument), as well as subject preference. Twenty-eight treatment areas and 154 treatments were analyzed. Dermatologist raters found no differences between subcision alone and subcision-suction at 1-month or 4-months. Mean subject-assessed percent improvement for subcision-suction was higher than that for subcision alone at 1-month (37% versus 24%, p = 0.04) but not at 4-months (p = 0.37). Subjects preferred combination therapy to monotherapy at 1-month (50% vs. 21%) and 4-months (43% vs. 21%). While blinded raters did not detect significant differences, subjects perceived combination treatment as working more quickly than monotherapy, and preferred combination treatment at all time points.Clinical trial registration NCT01696513 on Clinicaltrials.gov.

Genetic determinants of renal scarring in children with febrile UTI.

BACKGROUND: Febrile urinary tract infections (UTIs) are among the most severe bacterial infections in infants, in which a subset of patients develops complications. Identifying infants at risk of recurrent infections or kidney damage based on clinical signs is challenging. Previous observations suggest that genetic factors influence UTI outcomes and could serve as predictors of disease severity. In this study, we conducted a nationwide survey of infant genotypes to develop a strategy for infection management based on individual genetic risk. Our aims were to identify genetic susceptibility variants for renal scarring (RS) and genetic host factors predisposing to dilating vesicoureteral reflux (VUR) and recurrent UTIs. METHODS: To assess genetic susceptibility, we collected and analyzed DNA from blood using exome genotyping. Disease-associated genetic variants were identified through bioinformatics analysis, including allelic frequency tests and odds ratio calculations. Kidney involvement was defined using dimercaptosuccinic acid (DMSA) scintigraphy. RESULTS: In this investigation, a cohort comprising 1087 infants presenting with their first episode of febrile UTI was included. Among this cohort, a subset of 137 infants who underwent DMSA scanning was subjected to gene association analysis. Remarkable genetic distinctions were observed between patients with RS and those exhibiting resolved kidney involvement. Notably, the genetic signature indicative of renal scarring prominently featured mitochondrial genes. CONCLUSIONS: In this nationwide study of genetic susceptibility to RS after febrile UTIs in infancy, we identified a profile dominated by mitochondrial polymorphisms. This profile can serve as a predictor of future complications, including RS and recurrent UTIs.

Malignant melanoma arising in a burn scar.

Secondary malignancies are rare but devastating complications of longstanding burn scars. Squamous cell carcinoma is the most common, followed by basal cell carcinoma and melanomas. There are fewer than 50 total reported cases of malignant melanomas arising in burn scars. We report a case of malignant melanoma arising within a longstanding burn scar confirmed by histology, FISH, and PRAME staining to further characterize melanomas arising in burn scars and to illustrate the diagnostic challenges they present.

Automated prediction of isthmus areas in scar-related atrial tachycardias using artificial intelligence.

INTRODUCTION: Ablation of scar-related reentrant atrial tachycardia (SRRAT) involves identification and ablation of a critical isthmus. A graph convolutional network (GCN) is a machine learning structure that is well-suited to analyze the irregularly-structured data obtained in mapping procedures and may be used to identify potential isthmuses. METHODS: Electroanatomic maps from 29 SRRATs were collected, and custom electrogram features assessing key tissue and wavefront properties were calculated for each point. Isthmuses were labeled off-line. Training data was used to determine the optimal GCN parameters and train the final model. Putative isthmus points were predicted in the training and test populations and grouped into proposed isthmus areas based on density and distance thresholds. The primary outcome was the distance between the centroids of the true and closest proposed isthmus areas. RESULTS: A total of 193 821 points were collected. Thirty isthmuses were detected in 29 tachycardias among 25 patients (median age 65.0, 5 women). The median (IQR) distance between true and the closest proposed isthmus area centroids was 8.2 (3.5, 14.4) mm in the training and 7.3 (2.8, 16.1) mm in the test group. The mean overlap in areas, measured by the Dice coefficient, was 11.5 ± 3.2% in the training group and 13.9 ± 4.6% in the test group. CONCLUSION: A GCN can be trained to identify isthmus areas in SRRATs and may help identify critical ablation targets.

Catheter ablation of parahisian premature ventricular complexes in patients with and without cardiac scar.

BACKGROUND: Ablation of premature ventricular complexes (PVCs) originating from the parahisian area is challenging. Late gadolinium-enhanced cardiac magnetic resonance (LGE-CMR) scar may influence procedural outcomes; the impact of cardiac scar on parahisian PVCs has not been described. OBJECTIVE: The objective of this study was to examine the incidence and significance of LGE-CMR scarring in patients undergoing ablation for parahisian PVCs. METHODS: Consecutive patients who underwent preprocedure LGE-CMR imaging and ablation of parahisian PVCs were included. Acute and long-term outcomes were examined. RESULTS: Forty-eight patients were included (male, n = 37; age, 66 ± 10 years; ejection fraction, 50% ± 12%; preprocedure PVC burden, 21% ± 12%). Intramural LGE-CMR scar was present in 33 of 48 (69%) patients. Cryoablation was used in 9 patients; ablation in multiple chambers was required in 28 (58%) patients. The PVC site of origin (SOO) was intramural (n = 25 patients), left ventricular (n = 5), and right ventricular (n = 18). Patients with LGE-CMR scar were more likely to have intramural PVCs (64% vs 27%; P < .04) and to require ablation in multiple cardiac chambers (58% vs 13%; P < .02). Patients with intramural scar required longer duration of ablation delivery (31 ± 20 minutes vs 17 ± 8 minutes; P < .02). Acute procedural success was 69%; PVC burden on follow-up was 6% ± 9% and similar for those with and without scar. CONCLUSION: Ablation of parahisian PVCs often requires mapping and ablation of multiple cardiac chambers, with an intramural SOO identified in most patients. An intramural scar was associated with an intramural SOO of the PVCs requiring more extensive ablation procedures, with similar long-term outcomes compared with those without scar.