Making Sense of Late Tissue Nodules Associated With Hyaluronic Acid Injections.

BACKGROUND: The pathogenesis of delayed-onset tissue nodules (DTNs) due to hyaluronic acid (HA) injections is uncertain. OBJECTIVES: To formulate a rational theory for DTN development and their avoidance and treatment. METHODS: A multidisciplinary and multicountry DTN consensus panel was established, with 20 questions posed and consensus sought. Consensus was set at 75% agreement. RESULTS: Consensus was reached in 16 of 20 questions regarding the pathogenesis of DTNs, forming the basis for a classification and treatment guide. CONCLUSIONS: The group believes that filler, pathogens, and inflammation are all involved in DTNs and that DTNs most likely are infection initiated with a variable immune response. Injected filler may incorporate surface bacteria, either a commensal or a true pathogen, if the skin barrier is altered. The initially high molecular weight HA filler is degraded to low molecular weight HA (LMWHA) at the edge of the filler. Commensals positioned within the filler bolus may be well tolerated until the filler is degraded and the commensal becomes visible to the immune system. LMWHA is particularly inflammatory in the presence of any local bacteria. Commensals may still be tolerated unless the immune system is generally heightened by viremia or vaccination. Systemic pathogenic bacteremia may also interact with the filler peripheral LMWHA, activating Toll-like receptors that induce DTN formation. Given this scenario, attention to practitioner and patient hygiene and early systemic infection treatment deserve attention. Classification and treatment systems were devised by considering each of the 3 factors-filler, inflammation, and infection-separately.

A systematic review of the uses of metformin in dermatology.

Metformin is an established staple drug in the management of Type 2 diabetes mellitus. In this systematic review, we sought to establish the clinical utility of metformin in a range of dermatological conditions. The pathophysiology of acne vulgaris and polycystic ovarian syndrome (PCOS) is well suited to the pharmacological profile of metformin, and we found evidence for its efficacy in managing these conditions. We found some evidence for the use of metformin particularly in acne and PCOS; however, the evidence base is of mixed quality. There is scope for clinicians to consider metformin as an adjunct therapy in acne and PCOS. There is generally insufficient evidence to recommend metformin in other dermatological conditions.

Ultrasonography in diagnostic dermatology: a primer for clinicians.

Ultrasound has long been a diagnostic staple throughout medicine, with extensive use in orthopaedics and obstetrics. In this review, we find there are a range of versatile uses for diagnostic ultrasound in dermatology, with particular clinical relevance in the imaging of skin tumours. Our review outlines that diagnostic ultrasound can play an important role as an adjunct, but shortfalls remain with inter- and intra-operator discrepancies in aptitude and accuracy.

Microdroplet Botulinum Toxin: A Review.

Microbotox is the administration of multiple microdroplets of botulinum toxin in intradermal plane. It is increasingly becoming popular owing to its more favorable outcome and better safety profile than the conventional technique. The intention is to treat fine lines and wrinkles without imparting an undesired "frozen face like" appearance. Besides facial rejuvenation, it has found its way into the management of other indications such as rosacea, hyperhidrosis, keloid, and seborrhea. Being a relatively newer method, knowledge about the various dilution methods, desired volume, and correct depth of injection involved in this technique remain scarce. In this article, the authors have highlighted various indications, procedures, adverse effects, and contraindications of microbotox.

Our experience using 1064 nm Nd:YAG in palmoplantar warts.

Common warts (verruca vulgaris) are the most commonly seen benign cutaneous tumors occurring in both males and females of various ages. However, warts on the hands and feet (plantar warts and palmar warts) often respond poorly to traditional treatments such as topical salicylic acid, cryotherapy, surgical excision, electrocautery, and bleomycin injection. Recently, the long-pulsed 1064 nm Nd:YAG laser (LPNYL) has attracted attention in the treatment of palmoplantar warts. This study aims to evaluate the effectiveness of the LPNYL in the treatment of palmoplantar warts. We conducted a comparative cross-sectional descriptive study in 88 patients (49 males and 39 females) with palmoplantar warts. During the period from 2018 to 2020, the patients underwent up to three treatment sessions at intervals of 2-4 weeks between sessions. The LPNYL parameters comprised a spot size of 5 mm, 30 ms pulse width, 1 Hz repetition rate, and a fluence range of 140-180 J/cm2. The patient mean age was 29.0 ± 14.5 years (range, 4-66 years). Good results were seen in 72.9% (64/88) of patients. The remaining 27.1% (24/88) felt their treatment was unsuccessful. As for adverse events, 5 (5.6%) patients reported hemorrhagic blistering after treatment. At the 3- and 6-month follow-up assessments, no recurrence was seen (Figures 2-4). Our study showed that the LPNYL treatment was safe and effective in the majority of palmoplantar warts. The duration of treatment was shorter than most traditional methods; however, the limitations of this method are that the treatment required several sessions, the procedure was painful, and adverse events occurred in just over 5% of the patients.

A core outcome domain set for clinical research on capillary malformations (the COSCAM project): an e-Delphi process and consensus meeting.

BACKGROUND: There is limited evidence on the best available treatment options for capillary malformations (CMs), mainly due to the absence of uniform outcome measures in trials on therapies. A core outcome set (COS) enables standard reporting of trial outcomes, which facilitates comparison of treatment results. OBJECTIVES: To develop a core outcome domain set (CDS), as part of a core outcome set (COS), for clinical research on CMs. METHODS: Sixty-seven potentially relevant outcome subdomains were recognized based on the literature, focus group sessions, and input from the COSCAM working group. These outcome subdomains were presented in an online Delphi study to CM experts (medical specialists and authors of relevant literature) and (parents of) patients with CM (international patient associations). During three e-Delphi study rounds, the participants repeatedly scored the importance of these outcome subdomains on a seven-point Likert scale. Participants could also propose other relevant outcome subdomains. Consensus was defined as ≥ 80% agreement as to the importance of an outcome subdomain among both stakeholder groups. The CDS was finalized during an online consensus meeting. RESULTS: In total 269 participants from 45 countries participated in the first e-Delphi study round. Of these, 106 were CM experts from 32 countries, made up predominantly of dermatologists (59%) and plastic surgeons (18%). Moreover, 163 (parents of) patients with CM from 28 countries participated, of whom 58% had Sturge-Weber syndrome. During the two subsequent e-Delphi study rounds, 189 and 148 participants participated, respectively. After the entire consensus process, consensus was reached on 11 outcome subdomains: colour/redness, thickness, noticeability, distortion of anatomical structures, glaucoma, overall health-related quality of life, emotional functioning, social functioning, tolerability of intervention, patient satisfaction with treatment results, and recurrence. CONCLUSIONS: We recommend the CDS to be used as a minimum reporting standard in all future trials of CM therapy. Our next step will be to select suitable outcome measurement instruments to score the core outcome subdomains. What is already known about this topic? Besides physical and functional sequelae, capillary malformations (CMs) often cause emotional and social burden. The lack of uniform outcome measures obstructs proper evaluation and comparison of treatment strategies. As a result, there is limited evidence on the best available treatment options. The development of a core outcome set (COS) may improve standardized reporting of trial outcomes. What does this study add? A core outcome domain set (CDS), as part of a COS, was developed for clinical research on CMs. International consensus was reached on the recommended core outcome subdomains to be measured in CM trials: colour/redness, thickness, noticeability, distortion of anatomical structures, glaucoma, overall health-related quality of life, emotional functioning, social functioning, tolerability of intervention, patient satisfaction with treatment results, and recurrence. This CDS enables the next step in the development of a COS, namely to reach consensus on the core outcome measurement instruments to score the core outcome subdomains. What are the clinical implications of this work? The obtained CDS will facilitate standardized reporting of treatment outcomes, thereby enabling proper comparison of treatment results. This comparison is likely to provide more reliable information for patients about the best available treatment options.

The versatility of azelaic acid in dermatology.

Azelaic acid has numerous pharmacological uses in dermatology. Its anti-inflammatory and anti-oxidant properties are thought to correlate with its efficacy in papulopustular rosacea and acne vulgaris, amongst other cutaneous conditions. We conducted a review of the literature on the use of azelaic acid in dermatology using key terms 'acne', 'azelaic acid', 'dermatology', 'melasma', 'rosacea', searching databases such as MEDLINE, EMBASE and PubMed. Only articles in English were chosen. The level of evidence was evaluated and selected accordingly listing the studies with the highest level of evidence first using the Oxford Center of Evidence-Based Medicine 2011 guidance.This review found the strongest evidence supporting the use of azelaic acid in rosacea, followed by its use off-label in melasma followed by acne vulgaris. Weaker evidence is currently available to support the use of azelaic acid in several other conditions such as hidradenitis suppurativa, keratosis pilaris and male androgenic alopecia.Azelaic acid, as a monotherapy or in combination, could be an effective first-line or alternative treatment, which is well-tolerated and safe for a range of dermatological conditions.

Ultrapulsed CO2 ablation in the treatment of xanthelasma palpebrarum: high satisfaction treatment with low recurrence.

Xanthelasma are localized accumulation of lipid deposits on the eyelids. Lesions are typically asymptomatic and treatment is often sought for cosmetic purposes. Unfortunately, there is paucity of strong evidence in the literature for the effective treatment of normolipidaemic xanthelasmas. Lasers have been used in the management of xanthelasma and in this article the experience with ultrapulsed CO2 laser is discussed with efficacy, complications and risk of recurrence explained.

Energy-based devices for the treatment of Acne Scars: 2022 International consensus recommendations.

BACKGROUND AND OBJECTIVES: Acne scars are one of the most distressing and long-term consequences of acne vulgaris, with damaging effect on a person's physical, mental, and social well-being. Numerous treatment options are available including surgical and nonsurgical techniques, depending on the clinical presentation. Although considerable advances in the development of new treatment technologies and applications have been made in the last decade, international treatment guidelines and reimbursement schemes have not yet caught up with current knowledge and practice in many centers. The authors intend to highlight the potential utility of energy-based devices (EBDs) for acne scarring, offer recommendations for safe and efficacious treatment, and provide consensus-based EBD treatment options based on varying presentations demonstrated in a series of real-life clinical photographs. STUDY DESIGN/MATERIALS AND METHODS: An international panel of 24 dermatologists and plastic surgeons from 12 different countries and a variety of practice backgrounds was self-assembled to develop updated consensus recommendations for the treatment of acne scars. A two-step modified Delphi method took place between March 2020 and February 2021 consisting of two rounds of emailed questionnaires. The panel members approved the final manuscript via email correspondence. RESULTS: The manuscript includes a comprehensive discussion and panel recommendations regarding the following topics: 1. the role of EBD in mitigating and treating acne scars in a patient with active acne, 2. the use of various EBDs for the treatment of different acne scar types with special focus on commonly used laser platform such as vascular lasers, ablative fractional lasers (AFLs) and non-AFLs (NAFLs), 3. treatment combinations, and 4. acne scar treatments in skin of color. The last part comprised of 10 photos of real-life clinical cases with the panel recommendation treatment plan to achieve best aesthetic outcome. CONCLUSION: Panel members were unanimous in their view that EBDs have a role in the management of acne scars, with AFLs, NAFLs, vascular lasers, and RF devices preferentially selected by most of the panel experts. EBDs are considered a first-line treatment for a variety of acne scar types and patients without access to these treatments may not be receiving the best available care for optimal cosmetic results. Future high-quality research and updated international treatment guidelines and reimbursement schemes should reflect this status.

Dual Toning Method with the Combination of Picosecond and Microsecond Nd:YAG in Refractory Melasma Unresponsive to Picosecond Alone.

BACKGROUND: Melasma is an acquired and treatment-resistant aging facial skin condition prevalent among the older Asian females. The Q-switched toning laser is the most widely used for the treatment of moderate to severe melasma in Asia. Recently, the picosecond laser has been introduced for various pigmentary disorders such as melasma. We evaluated the efficacy and safety of dual toning combined with 1064 nm Nd:YAG picosecond and quasi-long-pulsed laser in the treatment of severe melasma. SUBJECTS AND METHODS: Twenty Vietnamese females, mean age 41.9 ± 6.4 years, Fitzpatrick skin type IV, with clinical diagnosis of severe dermal and mixed-type melasma were treated by at least eight sessions picosecond Nd:YAG 1064 nm reducing Melasma Area and Severity Index (MASI) to less than 15%. Then they were treated with 3 sessions of dual toning combined picosecond Nd:YAG 1064 nm laser having an energy and spot size of 0.6-0.8 J/cm2 and 8 mm with micropulsed mode Nd:YAG 1064 nm laser (350 µs) having an energy and spot size of 2.6 J/cm2 and 15 mm with ICD off. Mild and even erythema was the endpoint (40-42°C using the infrared thermometer). Treatments were given every 4 weeks. Improvement was rated by MASI at the baseline (T1), after eight sessions of picotoning (T2), and three sessions of dual toning (T3). RESULTS: The mean MASI score of 20 patients at baseline (T1) was 16.24 ± 4.88 (min 6.0; max 28.8); after at least eight picotoning sessions, the mean MASI was 15.12 ± 4.69, representing a 7.44 ± 4.41% reduction in MASI score. The MASI score of the dual toning laser continued to decrease after three dual toning sessions from 15.12 ± 4.6 to 9.77 ± 3.86 (MASI score reduced by a mean of 5.35 ± 2.64), achieving 35.15 ± 13.51% reduction from T2 and 40.17 ± 12.14% reduction from baseline MASI (T1). There were no unexpected side effects in any patients. CONCLUSION: The dual toning method using the 1064 nm Nd:YAG picosecond and microsecond laser was safe and effective and well tolerated by all patients without downtime. However, larger number of studies should be conducted with more objective measurement techniques to confirm the results of this preliminary study.

Perioral dermatitis: Diagnosis, proposed etiologies, and management.

BACKGROUND AND AIMS: Perioral dermatitis is a common cutaneous condition characterized by acneiform facial eruptions often with an eczematous appearance. A granulomatous subtype exists in addition to the classic variant. While topical corticosteroids have been largely implicated in this condition, its etiology is not completely understood. METHODS: Using the keywords "corticosteroids," "dermatology," "fusobacteria," "perioral dermatitis," and "periorificial dermatitis," we searched the databases PubMed, MEDLINE, and EMBASE to find the relevant literature. Only articles in English were chosen. The level of evidence was evaluated and selected according to the highest level working our way downwards using the Oxford Centre of Evidence-Based Medicine 2011 guidance. RESULTS: This systematic review found the strongest evidence to support topical corticosteroid misuse as the principal causative factor in the pathogenesis of perioral dermatitis. CONCLUSION: In terms of treatment, further research is required to robustly investigate promising treatment options including tetracyclines, topical metronidazole, topical azelaic acid, adapalene gel, and oral isotretinoin.

Rosacea.

Rosacea is a common cutaneous condition affecting predominantly the face. It is historically characterised into four subtypes: erythematotelangiectatic, papulopustular, phymatous and ocular rosacea. This article describes the pathophysiology, clinical features and current treatment options for rosacea, and discusses updated diagnostic criteria. General guidance is required on the need to avoid possible triggers including dietary and environmental triggers. The strongest evidence supports the use of 0.75% metronidazole, topical azelaic acid or topical ivermectin for inflammatory rosacea. Erythema should be treated with brimonidine tartrate gel, oral medication such as beta blockers or vascular laser and light-based therapy. Oral doxycycline 40 mg modified release can be used as monotherapy or in combination with other treatments for recalcitrant disease. Further understanding of the pathogenesis of rosacea could allow identification and targeted avoidance of triggers and the development of new treatment modalities.

5-Fluorouracil in Dermatology: The Diverse Uses Beyond Malignant and Premalignant Skin Disease.

BACKGROUND: 5-fluorouracil (5-FU) is widely used for treatment of malignant and premalignant skin cancers; however, its use in other common cutaneous conditions has been less widely reported. OBJECTIVE: We investigated the off-label uses of 5-FU beyond malignant and premalignant skin disease. METHODS: We conducted a literature review searching multiple databases to evaluate the evidence for the off-label uses of 5-FU. The level of evidence was evaluated and selected accordingly listing the studies with the highest level of evidence first using the Oxford Centre of Evidence-Based Medicine 2011 guidance. RESULTS: We found underlying evidence to support the use of 5-FU for a wide range of noncancerous cutaneous indications including scarring (keloid, hypertrophic), pigmentary disorders (vitiligo, idiopathic guttate hypomelanosis), cutaneous infections (viral warts, molluscum contagiosum), inflammatory dermatoses (Darier's disease, Hailey-Hailey disease and sarcoidosis), and cosmetic indications (photoaging, treatment of filler nodules and granulomas). CONCLUSION: In selected patients, 5-FU can be as effective as more established treatments, with fewer side-effects.

Lessons Learned from the First Decade of Laser-Assisted Drug Delivery.

Laser-assisted drug delivery augments the distribution and penetration of topically applied treatments, leading to enhanced delivery and bioavailability. We discuss the therapeutic application of laser-assisted drug delivery in clinical practice in cases of non-melanoma skin cancer, vitiligo, melasma, scarring, and alopecia (female pattern hair loss, male pattern hair loss, alopecia areata) as well as for vaccination, local anaesthesia, analgesia, viral warts, infantile haemangiomas and cosmetic uses, and we review clinical studies that have used this technique over the last decade. Our review shows that the application of laser-assisted drug delivery enhances topical agent efficacy, potentially reducing the agent concentration and duration of topical treatment required. Future research into the use of laser-assisted drug delivery before topical therapies is needed to establish the optimal techniques to enhance drug delivery and thus improve patient outcomes.

Intralesional methotrexate in dermatology: Diverse indications and practical considerations.

Intralesional methotrexate (IL-MTX) is a long-established treatment, which is arguably underutilized by dermatologists. We describe the underlying evidence base and practical considerations for its broad range of cutaneous indications, including in cutaneous oncology (keratoacanthomas, squamous cell carcinomas, lymphomas), inflammatory dermatology (nail psoriasis, plaque psoriasis, pyoderma gangrenosum, cutaneous Crohn's disease, amyloidosis), cutaneous infections (viral warts) and for treatment of filler complications. In certain circumstances, IL-MTX can be more efficacious and less invasive than other treatments, with fewer adverse effects. Dermatologists should consider using IL-MTX for a range of recalcitrant cutaneous conditions, particularly for those patients not amenable to surgery or systemic therapy.

Guidance on infection control and plume management with Laser and Energy-Based Devices taking into consideration COVID-19.

BACKGROUND: The COVID-19 pandemic has disrupted the practice of medicine. Dermatologic laser and energy-based device (EBD) treatments carry a potential risk for the transmission of SARS-CoV-2 both for the patient and the practitioner. These risks include close practitioner to patient proximity, the treatment of higher viral load areas such as the face, the potential for infective bioparticles being carried by generated plumes and aerosols, and the direct contact between device, practitioner and patient. OBJECTIVES: SARS-CoV-2 is a highly infective respiratory pathogen transmitted by respiratory droplets, respiratory/mucosal secretions, medically generated aerosols and via its transfer from contaminated fomites. This requires a review of the appropriateness of infection control protocols in regard to dermatologic laser and energy-based device treatments. METHODS: A critical evaluation of patient skin preparation including skin asepsis, device disinfection, laser and electrosurgical plume management and PPE in regard to SARS-CoV-2 was performed. RESULTS: The adherence to a high standard of skin preparation and asepsis, device disinfection, laser and electrosurgical plume and aerosol management and appropriate PPE should help mitigate or reduce some of the inherent treatment risks. Head and neck treatments along with aerosol and laser plume generating treatments likely carry greater risk. CONCLUSIONS: COVID-19 needs to be considered in the clinic set-up along with the planning, treatment and post-treatment care of patients utilising EBD procedures. Some of these treatment precautions are COVID-19 specific; however, most represent adherence to good infectious disease and established laser and EBD safety precautions.

Hyaluronidase in Dermatology: Uses Beyond Hyaluronic Acid Fillers.

Hyaluronidase is mostly widely recognized for its off-label use in correction of complications of hyaluronic acid fillers. However, its utility in other aspects of dermatology is less widely acknowledged. We describe the varied uses of hyaluronidase in dermatology and the underlying evidence base for its dermatological indications. This includes its uses in enhancing drug delivery (for local anesthesia, keloid and hypertrophic scars, and for Kaposi’s sarcoma), in the treatment of disorders associated with mucin deposition (myxedema, scleroderma, scleredema, and cutis verticis gyrata) and its potential uses in surgery (as a pre-operative adjuvant in dermatofibrosarcoma protuberans, for periorbital edema, and for hematomas). In select circumstances, hyaluronidase might be more efficacious than more established treatments with fewer adverse effects. We propose hyaluronidase as the latest addition to our global dermatological armamentarium and implore dermatologists to consider its use to enhance their practice. J Drugs Dermatol. 2020;19(10):993-998. doi:10.36849/JDD.2020.5416.