Effective treatment of corticosteroid-induced facial erythema using fractional radiofrequency microneedling.

OBJECTIVES: To investigate the efficacy of Fractional Radiofrequency Microneedling (FRM) in treating corticosteroid-induced facial erythema. METHODS: A retrospective study was conducted involving eight patients diagnosed as corticosteroid-induced facial erythema. Each patient underwent a single session of FRM. Evaluative measures included Clinician's Erythema Assessment (CEA), Patient's Self-Assessment (PSA), assessment of telangiectasia severity, procedure-associated pain (10-point scale), patient satisfaction (3-point scale) and secondary outcomes. RESULTS: The study found a 75% success rate and 100% effectiveness rate in alleviating erythema symptoms. CEA and PSA scores decreased by 67.7% and 78.1%, respectively. No cases of erythema rebound were recorded during the 3-month follow-up period. CONCLUSIONS: FRM demonstrated effectiveness and safety in treating facial erythema, offering promising advancement in dermatologic therapeutics.

Dupilumab Facial Redness/Dupilumab Facial Dermatitis: A Guide for Clinicians.

Dupilumab facial redness (DFR), or the development of an eczematous rash of the face and neck with dupilumab use, has been observed in recent case reports. It is estimated to impact between 4 and 43.8% of dupilumab users, including children and adults. Aside from reviewing the pathogenesis and clinical presentation, we present potential diagnostic steps (such as skin scraping, serologies, biopsy, and patch testing) and management options for DFR ranging from allergen avoidance to dupilumab interruption. It is hoped that this article will serve as a means for clinicians to familiarize themselves with DFR regarding the differential diagnosis, diagnostic tools, and treatment options associated with this phenomenon.

Complex Decongestive Therapy in the Physical Therapist Management of Rosacea-Related Edema (Morbus Morbihan Syndrome): A Case Report With a New Approach.

OBJECTIVE: The aim of this case report was to describe the use of complete decongestive therapy (CDT) with a new approach in the management of a male with facial edema related to Morbus Morbihan Syndrome (MMS). METHODS: An 18-year-old male with MMS after acne treatment was the subject of this case report. Volume assessment was performed with distance measurements of the facial area using standard reference points, the overflow method, and the measurement of the percentage of subdermal fluid. Participant-reported symptoms of lymphedema (feeling of swelling and tightness) and body image perception were evaluated with the visual analogue scale, and the severity of anxiety was evaluated with the State and Trait Anxiety Inventory. In addition, the participant's perception of improvement was determined using a Likert-type scale. Evaluations were performed at baseline, week 4 (during the treatment), and week 8 (immediately after treatment). CDT was applied to the participant in a total of 24 sessions, 3 d/wk for 8 weeks. RESULTS: Compared with the baseline measurement, the facial distances (tragus-mental cavity, tragus-mouth corner, mandibula-nasal canal, mandibula-internal orbita, mandibula-external orbita, mental cavity-internal orbita, mental cavity-mandibula, right-left tragus, and hairline in the forehead-mental cavity), the volume, and the percentage of subdermal fluid of facial area were decreased at the week 4 and 8 measurements. The anxiety score, participant reports of feelings of swelling and tightness, and body image perception improved after the 8 weeks of treatment compared with baseline. CONCLUSION: This case report described the use of CDT in treating edema and participant symptoms in an individual with facial lymphedema related to MMS. Body image and level of anxiety improved.

Rosacea: New Concepts in Classification and Treatment.

Rosacea is a chronic inflammatory dermatosis mainly affecting the cheeks, nose, chin, and forehead. Rosacea is characterized by recurrent episodes of flushing or transient erythema, persistent erythema, phymatous changes, papules, pustules, and telangiectasia. The eyes may also be involved. Due to rosacea affecting the face, it has a profound negative impact on quality of life, self-esteem, and well-being. In addition to general skin care, there are several approved treatment options available for addressing these features, both topical and systemic. For some features, intense pulse light, laser, and surgery are of value. Recent advances in fundamental scientific research have underscored the roles of the innate and adaptive immune systems as well as neurovascular dysregulation underlying the spectrum of clinical features of rosacea. Endogenous and exogenous stimuli may initiate and aggravate several pathways in patients with rosacea. This review covers the new phenotype-based diagnosis and classification system reflecting pathophysiology, and new and emerging treatment options and approaches. We address new topical and systemic formulations, as well as recent evidence on treatment combinations. In addition, ongoing studies investigating novel therapeutic interventions will be summarized.

Efficacy and Safety of Intense Pulsed Light With a KTP/PDLlike Filter for the Treatment of Facial Telangiectasias.

BACKGROUND: An intense pulsed light (IPL) narrowband "KTP/PDL-like" filter (525–585 nm) may combine the tolerability of the IPL with the precision of KTP and PDL lasers. This study evaluated the impact of IPL with a KTP/PDL-like filter on telangiectasias. METHODS: This was a single-center, prospective study of 17 subjects with facial telangiectasias and skin types I–III. Three monthly treatments were performed using this specific filter, with follow-up visits at 1, 3, and 6 months. Telangiectasia improvement was assessed by the investigator and subjects using a 5-point scale. Facial photographs and safety assessments were obtained at each visit. Subject discomfort was evaluated using a visual analog scale (VAS) immediately posttreatment, and subject downtime was recorded at each subsequent visit. RESULTS: All facial telangiectasias significantly improved. At 1-month follow-up, >50% lesion clearance was noted in 97.1% of facial (n=36) and 85.7% of non-facial (n=7) lesions, with 73% of subjects satisfied or very satisfied. An increase in mean social downtime (0, 2.3, and 3 days) and VAS scores (3.5, 4.5, and 4.8) with treatments 1, 2, and 3, respectively, mirrored a stepwise increase in fluence with subsequent sessions. CONCLUSIONS: The use of a novel IPL narrowband KTP/PDL-like filter can significantly improve facial and non-facial telangiectasias with minimal downtime. J Drugs Dermatol. 2020;19(9):844-850. doi:10.36849/JDD.2020.4834.

Microneedling of Scars: A Large Prospective Study with Long-Term Follow-Up.

BACKGROUND: In recent years, microneedling has been increasingly used to treat a number of dermatologic conditions, including scars. Although initial studies demonstrated improvement of (mostly) atrophic scars with microneedling, the number of patients evaluated was relatively small, and the devices and treatment protocols used and posttreatment follow-up varied widely. Through this prospective observational study, the results of microneedling on 120 patients with a variety of scars are described. METHODS: One hundred twenty consecutive patients (skin phototypes I through VI) with facial and nonfacial scars from a variety of etiologic sources (acne, trauma, surgery) were treated using a mechanical microneedling device. No additional treatments (topical or intralesional) were applied. Two assessors blinded to treatment protocol rated clinical improvement of scars 1, 3, 6, and 12 months after treatment on a five-point scale. Side effects were monitored and tabulated. RESULTS: Patients received one to six consecutive monthly microneedling treatments. All scars improved at least 50 percent after an average of 2.5 treatments. Over 80 percent of patients had 50 to 75 percent improvement, and 65 percent of patients demonstrated over 75 percent improvement. No significant clinical differences were observed in treatment responses of facial scars versus nonfacial scars nor between responses of atrophic acne scars and traumatic or surgical scars. CONCLUSIONS: This study supports the use of microneedling for various facial and nonfacial scars across a broad range of skin phototypes with minimal risk of adverse effects. Further studies will help to establish standardized protocols to optimize treatment outcomes for different scar types. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Fat Grafting for the Treatment of Scleroderma.

BACKGROUND: Scleroderma is a chronic connective tissue disease that results in fibrosis of the skin and internal organs. Although internal organ involvement corresponds with poor prognosis, systemic agents are effective at improving the effects of scleroderma on internal organs. In contrast, skin manifestations are universally present in all patients diagnosed with scleroderma, yet no systemic agents have been shown to be successful. Fat grafting has been shown to improve skin quality and improve contour irregularities and may be helpful in the treatment of patients with scleroderma. METHODS: The authors performed a thorough review of the pathophysiology of scleroderma and the current treatment options for scleroderma. The efficacy of fat grafting for the treatment of scleroderma and the mechanism by which fat grafting improves outcomes was also discussed. RESULTS: Scleroderma is characterized by chronic inflammation and vascular compromise that leads to fibrosis of the skin and internal organs. Fat grafting has recently been the focus of significant basic science research. It has been shown to reduce inflammation, reduce fibrosis by limiting extracellular matrix proteins and increasing collagenase activity, and provide structural support through stem cell proliferation and differentiation. The adipocytes, adipose stem cells, endothelial cells, and vascular smooth muscle cells in the processed fat likely contribute to the effectiveness of this treatment. CONCLUSIONS: Fat grafting in scleroderma patients likely improves skin manifestations by recreating fullness, correcting contour deformities, and improving skin quality. The injected fat provides a mixture of cells that influences the recipient site, resulting in improved outcomes.

New Insight in Noninvasive Rejuvenation: The Role of a Rhodamine-Intense Pulsed Light System.

Background: Rhodamine-intense pulsed light (r-IPL) is a noncoherent, noncollimated, polychromatic light energy optimized for a double-peak wavelength emission, ranging between 550-680 and 850-1200 nm. Traditional IPL works within visible and infrared spectra, targeting hemoglobin and melanin, are effective to treat rosacea and pigmentary disorders. r-IPL, a new technology in dermatology, emits high-intensity light with a wavelength peak similar to the one of the pulsed dye lasers, showing a good safety and efficacy profile in nonablative photorejuvenation. Objective: Assess efficacy and safety of r-IPL on photodamaged facial skin showing hyperpigmentation, telangiectasias, fine lines, and textural changes. Methods: Five sessions of r-IPL treatment (fluence ranged between 13.5 and 14 J/cm2) have been performed on one 75-year-old lady affected by facial photodamaged skin. Efficacy of treatment was evaluated using the Fitzpatrick Elastosis and Wrinkles Scale (FEWS) and the Global Aesthetic Improvement (GAI) Scale assessed by an investigator, compared with baseline. Treatment safety and tolerance were also evaluated using the Visual Analog Scale (VAS). Results: Photographic and multispectral evaluation demonstrated relevant improvement (vascular, pigment, and texture) of photodamaged facial skin. One month after the last treatment, significant improvement in facial wrinkle and texture was noted. FEWS scores decreased significantly from 7 to 2. According to the GAI scale, the patient had an improvement in skin texture. Immediate response included mild-to-moderate erythema and only trace-mild edema in the treatment area. Pain during the treatment was minimal with a mean VAS pain score of 3/10. No other adverse events were reported. No post-treatment downtime was recorded. Conclusions: r-IPL may represent a valid therapeutic approach in noninvasive photorejuvenation.

Primary Localized Cutaneous Nodular Amyloidosis in the Absence of Systemic Disease.

A 41-year-old man presented with an asymptomatic, slowly enlarging plaque on the lower aspect of his left cheek, present for approximately 4 months. His past medical history was remarkable for allergic rhinitis. Three years before, he had had a nearly identical lesion surgically excised by Mohs method at the same site. On examination, there was a waxy, yellowish plaque, measuring 2.1 cm × 1.0 cm on the left cheek in proximity to the oral commissure (Figure 1). A shave biopsy revealed an atrophic epidermis with nodular aggregates of eosinophilic material in the dermis (Figure 2). Higher magnification showed an inflammatory infiltrate composed largely of plasma cells, which stained positively for CD20 and κ light chains (Figure 3). Congo red staining confirmed the diagnosis of nodular amyloidosis (Figure 4).

An Unusual Cause of Papules on the Face.

Dear Editor, Angiolymphoid hyperplasia with eosinophilia (ALHE) is a rare, locally proliferating disorder that affects predominantly the head and neck region (1,2). There seems to be a higher incidence in middle-aged Caucasian women (2,3). A 28-year-old female patient with no relevant personal or family medical history and only taking an oral contraceptive, presented to our department with multiple, well delimited, infracentimetric erythematous papules with a smooth surface on the left frontal, temporal, and preauricular regions (Figure 1). The lesions had appeared 7 months earlier, with progressive growth in number and dimensions since. The patient reported pruritus and denied previous trauma, topical application of any sort, insect bite at these locations, and any other accompanying symptoms. A thorough physical examination revealed no additional abnormalities. An excisional biopsy of one of the left temporal papules revealed a prominent lymphoid component, with a dense multinodular infiltrate in the superficial and deep dermis, with reactive germinative centers of considerable dimensions (Figure 2). Large and atypical lymphocytes were confined to the germinative centers, with reactive characteristics. Lymphocytes surrounding the germinative centers were predominantly small, accompanied by a significant number of scattered eosinophils. CD3 and CD20 immunohistochemical staining revealed B-cells predominantly in the nodular areas corresponding to the germinative centers, while T-cells displayed a diffuse peripheral distribution. There was severe neovascularization, with thick-walled vascular channels lined by enlarged plump endothelial cells with an "epithelioid" appearance. These findings supported the diagnosis of angiolymphoid hyperplasia with eosinophilia (ALHE). Laboratory workup did not show any abnormalities, including eosinophilia or elevation of immunoglobulin E levels. Due to pruritus and aesthetic concerns, surgical excision of the larger and most symptomatic papules was performed. The patient was assured of the benign nature of the disease and informed about the possible development of new lesions. Kept under clinical surveillance, the patient remained free of new lesions at 6-month follow-up. ALHE generally presents as solitary or multiple erythematous or hyperpigmented dome-shaped papulonodules. Lesions can be pruritic or painful and do not tend to resolve spontaneously (4). The pathogenesis of ALHE remains controversial, although some theories have been suggested. The most widely accepted hypothesis is that it is an angioproliferative process, accompanied by an inflammatory infiltrate, reactive to several stimuli (3). Some authors believe it is an allergic reaction, but no specific sole agent has been identified (5). Others claim ALHE may represent a T-cell lymphoproliferative disorder of benign or low-grade malignant nature (6). Some recent studies suggest that ALHE pathogenesis may be related to a vascular malformation secondary to a subcutaneous arteriovenous shunt (1-3). Histologically there are both vascular and inflammatory components, with an abnormal vascular proliferation and diffuse lymphocytic infiltrates with eosinophils. The vascular component is formed by capillaries clustered around arterial or venous vessels, dilated and atypical, with a protruded endothelium (3). The main differential diagnosis of ALHE is Kimura's disease, and there has been some discussion regarding the relationship between these two entities due to their clinical and histopathological similarities. However, most studies currently agree that they are distinct diseases. The differential diagnosis also includes angiosarcoma, particularly the epithelioid variant, epithelioid hemangioendothelioma, Kaposi sarcoma, pyogenic granuloma, and cutaneous metastasis (3). ALHE usually requires treatment as spontaneous regression, although reported in the literature, is rare (1,3). Many options have been suggested, with variable levels of success, but there is no definitive treatment for this condition (2). Surgical excision is the preferred choice, but recurrence may happen if the excision is incomplete (1). Mohs micrographic surgery with excision of abnormal vessels at the base of the lesion may be more effective in reducing recurrences (4). Other treatments reported include laser therapy (pulsed dye, CO2, copper vapor), systemic or intralesional corticosteroid injection, cryotherapy, imiquimod, tacrolimus, isotretinoin, radiotherapy, interferon alfa 2a, anti-interleukin-5 antibody, photodynamic therapy, and methotrexate (1). In the present case the diagnosis of ALHE was established through the conjunction of clinical and histological findings. Although a rare entity, its predominantly facial involvement in young adults and the absence of a satisfactory treatment can produce a significant impact that can include the quality of life of the patients.

Combination of 30% Salicylic Acid Peels and Mechanical Comedo Extraction for the Treatment of Favre-Racouchot Syndrome.

Dear Editor, Favre-Racouchot syndrome is a cutaneous disease characterized by cysts, comedones, and elastotic nodules in actinically damaged skin, typically on the face (1). It has been specifically connected to sun exposure and heavy smoking, which may act synergistically (2). Available medical and surgical therapies are of variable efficacy. We present a combined therapeutic approach: 30% salicylic acid peels followed by manual extraction of cystic and comedonal material in the same visit. Five male patients, aged between 60-75 years with the clinical diagnosis of Favre-Racouchot syndrome, were treated with salicylic acid peel 30% followed by cyst and mechanical comedo extraction. Local anesthesia was considered unnecessary. Patients were subjected to the above therapies every two weeks for a series of four treatments. Photographs were taken before the beginning of treatment, as well as before and after each session (Figures 1a, b and 2a, b). At the end of the study, physician and patient global assessment scale was used to evaluate the efficacy of the treatment (0-25% indicated poor response, 25-50% fair, 50-75% good, and 75-100% excellent response). We have previously used this assessment scale in published research. Safety was assessed by evaluating early and delayed adverse events. Physician assessment found a fair to good improvement in 80% of the patients based on the reduction of comedones and solar elastosis, as well as the improvement in overall skin appearance and texture. The numbers for each specific categories of improvement were as follows: 1 patient poor; 3 patients fair, and 1 patient good improvement. Based on the patients' self-assessment, all patients (100%) acknowledged an improvement. Three patients rated the improvement fair (60%) and two rated it good (40%). The treatment was well-tolerated and no side-effects were noted. No clinical progression was observed on 6-month follow-up visit. Favre-Racouchot syndrome was originally described in 1932 by Favre and later reviewed in detail by Favre and Racouchot in 1951. Lesions are usually distributed on the temporal and periorbital areas. However, there have been reports of similar findings in atypical locations such as the forearms and chest. The underlying skin is sun-damaged, diffusely thickened, and furrowed (1). The eruption is usually bilaterally symmetrical. The precise pathogenesis of Favre-Racouchot syndrome is not known. Nevertheless, it most commonly presents in patients with a history of long-term sun exposure, heavy smoking, and, although rare, a history of radiation exposure. Unilateral manifestation of the disease has been previously described and was attributed to prolonged occupational unilateral sun exposure or observed following radiation therapy (3). It is mostly reported in Caucasian men (with a prevalence of 6% in adults older than 50 years). Its incidence increases with age, although it has been reported in younger patients. Differential diagnosis includes dermatoses that present with lesions of similar morphologies, such as acne vulgaris, epidermoid cysts, sebaceous hyperplasia, and colloid milium (4). Diagnosis is primarily clinical. Although the histologic features of the disease are very characteristic, skin biopsy is rarely required. The comedones found are histologically indistinguishable from the primary comedones of acne vulgaris, with the exceptions of a lack of inflammation and the presence of a marked actinic elastosis in the surrounding dermis (epidermal atrophy and massive basophilic degeneration of the upper dermis). Measures to stop the progression of the disease include smoking cessation and sun protection. Treatment options include topical retinoids, excision, curettage, dermabrasion, comedo extraction, and carbon dioxide laser ablation. Daily oral isotretinoin (0.05-0.10 mg/kg/day) used in conjunction with topical tretinoin has also been found effective. Treatment results are usually unsatisfactory when these techniques are used independently, but when used in conjunction with one another they may provide a very favorable outcome (1). For the best therapeutic outcome, solar elastosis, the nodulocystic lesions, and the comedones that require mechanical removal should be targeted. Salicylic acid is a lipophilic beta-hydroxy acid possessing keratolytic, comedolytic, and anti-inflammatory properties. At concentrations between 20% and 30% it is used in the treatment of acne vulgaris and mild photodamage. It decreases sebum secretion and disrupts intercorneocyte cohesion, leading to desquamation (5). Its lipid solubility permits better penetration into the pilosebaceous unit. Salicylic acid extends up to the mid-portion of the follicular canal (upper dermis) where excessive keratinization, the initial event in comedo formation, takes place. Furthermore, it activates epidermal basal cells and underlying fibroblasts, resulting in reorganization of the epidermis and a rebuilding of the superficial dermal connective tissue. The above actions of salicylic acid may be responsible for the reduction in comedonal lesions and the improvement in solar elastosis and overall skin texture. Additionally, its keratolytic effect facilitates comedo extraction. On the basis of our results, we suggest an alternative therapeutic approach with salicylic acid peels followed by mechanical comedo extraction in patients suffering from Favre-Racouchot syndrome.

Ten-Year and Beyond Follow-up After Treatment With Highly Purified Liquid-Injectable Silicone for HIV-Associated Facial Lipoatrophy: A Report of 164 Patients.

BACKGROUND: Highly purified liquid-injectable silicone (LIS) has been established as a permanent agent for off-label correction of HIV-associated facial lipoatrophy (HIV-FLA). However, controversy exists about long-term safety. OBJECTIVE: To establish the safety and efficacy at 10 years or greater of LIS for HIV-FLA. METHODS: Patients from 3 practices with 10-year or greater in-person office follow-up were analyzed to determine the number of LIS treatments and total volume required to achieve optimal correction. The nature of any treated adverse events was noted. RESULTS: One hundred sixty-four patients had 10-year or greater in-office follow-up. All subjects maintained long-term correction with an average of 9 treatments, average of 1.56 mL per treatment, and an average total of 14.1 mL. Two patients had severe adverse events manifesting as temporary facial edema. Four patients experienced mild-to-moderate excess fibroplasia presenting as perceived overcorrection, and 6 patients had nondisfiguring subcutaneous firmness. All adverse events were successfully treatable, mostly with intralesional 5-fluorouracil and triamcinolone. CONCLUSION: Liquid-injectable silicone is an effective long-term treatment option for HIV-FLA. When injected in small quantities with the microdroplet serial puncture technique at monthly or greater intervals, optimal correction appears durable for more than 10 years. Adverse events consisted mostly of excess fibroplasia and were treatable.