New Classification Schemata of Hypersensitivity Adverse Effects After Hyaluronic Acid Injections: Pathophysiology, Treatment Algorithm, and Prevention.

BACKGROUND: Side effects during hyaluronic acid (HA) injection are considered mild and reversible; however, an alarming trend of increased hypersensitivity reactions has recently been reported. OBJECTIVE: The goal of this article is to review the hypersensitivity reactions reported in the literature and, in combination with the authors' experience, to create a classification system to sort the timing and clinical manifestations of these reactions, as well as a treatment schema to manage their clinical course. METHODS: A literature search using PubMed, Ovid MEDLINE, and Embase databases was performed with no date restrictions. Search terms included "hyaluronic acid and hypersensitivity" and "hyaluronic acid and nodules." Data analyzed included study type, number of subjects, HA filler type, injection location, adverse reaction, timing, treatment, and outcomes. RESULTS: Thirty-six studies were identified, documenting hypersensitivity reactions to HA treatment. Twelve cases described events occurring within a week, 6 within a month, and 31 after a month of treatment. Combined with the authors' experience, a new classification system and management of hypersensitivity reactions to HA fillers is proposed of early (up to a week), intermediate (a week to a month), and late (over a month) hypersensitivity reactions. CONCLUSION: The classification system proposed provides objective measurements and management options that can be helpful for physicians to navigate these hypersensitivity reactions and design treatment protocols that provide the best clinical outcomes for their patients.

Lassueur-Graham-Little-Piccardi syndrome.

A 52-year-old man presented for evaluation of patchy alopecia of the scalp, axilla, and groin and of follicular spiny papules. Histopathologic examination showed a dense, follicular, lymphocytic infiltrate and interfollicular interface changes. Lassueur-Graham-Little-Piccardi syndrome is characterized by the triad of scarring, patchy alopecia of the scalp, non-cicatricial alopecia of the axillae and pubis, and a keratotic, follicular eruption. There may be an etiologic relationship with lichen planus. Treatment is difficult, although isolated reports have demonstrated success with cyclosporin and thalidomide.

Lichen planus actinicus.

A 53-year-old woman presented for evaluation and treatment of discrete, violaceous, annular plaques on the forehead and cheeks. The biopsy specimen and the clinical presentation were consistent with lichen planus actinicus. Lichen planus actinicus is a photosensitive variant of lichen planus that can present with annular, melasma-like, dyschromic, or violaceous plaques in sun-exposed areas. The clinical manifestations of lichen planus actinicus and treatments are discussed.

Epidermolysis bullosa acquisita.

A 29-year-old woman presented with 8 months of multiple vesicles, erosions, and milia on the dorsa of her hands and feet. Histopathologic examination demonstrated a subepidermal blister, with a paucity of eosinophils and a lack of blood vessel wall thickening or caterpillar bodies. A direct immunofluorescence test showed a linear deposit of IgG at the dermo-epidermal junction. These findings were consistent with a diagnosis of epidermolysis bullosa acquisita. This case is a classic example of this rare blistering disease, in which patients produce autoantibodies to collagen VII, which is the major component of the anchoring fibrils.

Eruptive vellus hair cysts.

A 20-year-old man presented with multiple, asymptomatic, follicular papules that were distributed over his abdomen. Microscopic examination showed classic features of a vellus hair cyst. The term eruptive vellus hair cysts refers to a benign condition, which may be inherited or acquired. Apart from occasional pruritus, cosmetic disability is the chief concern of most patients. An estimated 25 percent of lesions remit spontaneously; however, treatment of persistent lesions is often challenging with disappointing results.

Implementation of dermato-epidemiology curriculum at Case Western Reserve University dermatology program.

Dermato-epidemiology curriculum has been identified by the American Academy of Dermatology (AAD) as an important foundation for dermatology residency training. However, no one has yet reported implementation of dermato-epidemiology curriculum. To evaluate and relate our experience carrying out a dermato-epidemiology resident education initiative, based on recommendations by the AAD Epidemiology Committee. Monthly lectures based on topics suggested by the AAD Epidemiology Curriculum. Pre- and post-test multiple choice and free-form question measures were employed to examine performance, assess resident enthusiasm, and solicit feedback from the initiative. Quantitative achievement on multiple-choice items improved slightly, but insignificantly, from 53 percent to 58 percent. Resident level of enthusiasm and perceived efficacy for the intervention varied from 3.3 to 4.0 on a 5-point Likert scale where "1" indicates strongly disagree and "5" indicates strongly agree with measures of effectiveness. Dermato-epidemiology curriculum is desirable and achievable even in dermatology programs without full-time epidemiologists. A successful epidemiology curriculum should be clinically and board-examination relevant, incorporating aspects of problem-based, interactive learning.

The impact of the basic skin cancer triage curriculum on providers' skills, confidence, and knowledge in skin cancer control.

BACKGROUND: Primary care providers (PCPs) are in the unique position of being able to deliver preventive health care services to the majority of the general population. Early detection of skin cancer may reduce mortality, but many PCPs do not participate in skin cancer control activities due to lack of training and confidence. We sought to evaluate the effect of a 2-h, Basic Skin Cancer Triage (BSCT) curriculum in overcoming these barriers. METHODS: A convenience sample of 28 primary care providers participated in a 2-h training curriculum. Assessments included skills (evaluated by a 20-item slide quiz), confidence, knowledge, and attitudes measured pre- and post training. RESULTS: Provider ability to accurately diagnose and triage lesions significantly improved (46 to 64%, P < 0.0001, and 61 to 71%, P < 0.0001, respectively). The greatest improvement in triage ability occurred in providers ability to appropriately reassure patients about lesions (49 to 70%, P < 0.0001). There were also significant improvements in both knowledge of skin cancer control practices (68 to 74% correct answers, P = 0.026) and confidence in ability to provide skin cancer preventive services (2.95 to 4.13 on a 1 to 5 scale, P < 0.0001). CONCLUSIONS: Participation in the BSCT curriculum may improve providers' diagnostic and triage accuracy of skin cancer as well as increase their knowledge of skin cancer and confidence in their provision of skin cancer control activities. Defining the full potential impact of this curriculum requires further evaluation.

Sp3 expression in immune cells: a quantitative study.

We previously reported the lack of expression of the bifunctional transcription factor Sp3 in peripheral blood mononuclear cells from most patients with multiple sclerosis (MS) (Grekova et al, 1996). An RT-PCR technique was developed to evaluate Sp3 mRNA levels in peripheral blood mononuclear cell subsets. Semi-quantitative and quantitative competitive RT-PCR assays were used to compare the level of Sp3 expression among subjects and among immune cell subsets. The competitor DNA fragment contained a deletion from the normal Sp3 cDNA sequence. The wild-type Sp3 cDNA and the competitor DNA fragment amplified with equal efficiency, and the two PCR products were distinguished by size. These studies demonstrated that normal CD4(+) and CD8(+) T cells, B cells, and macrophages expressed comparable amounts of Sp3 mRNA. No Sp3 expression could be detected in normal natural killer cells nor in any of these cell types from Sp3-negative MS patients. We propose that transcription of the Sp3 gene is blocked in immune cells from most patients with MS and that this contributes to the development of central nervous system inflammation in the disease.