Botulinum Toxin Type A: Adverse Events and Management.

Aesthetic medicine is witnessing an increasing exploitation of all the procedures. The demand has never been higher than it is today. The number of practitioners is also increasing year by year. Consequently complications and other kinds of related troubles and procedures are also rising. Never like today is fundamental, in case of troubles, how to properly manage with the most frequent issues. In aesthetic medicine field, botulinum toxin procedures are the safest. Lot of patients are worried about botulinum toxin despite the available scientific literature. Rare short-term complications are observed. In the most of cases, nothing severe occurs if the international recommendations and the most recent guidelines are closely followed, the majority of them are injection related. This study is a review of rare or common problems that can occur and how to manage or solve the situations.

Skin involvement in atypical hemolytic uremic syndrome.

Skin involvement in atypical hemolytic uremic syndrome (aHUS) is very uncommon and therefore often unrecognized as a specific symptom of aHUS. We describe 3 cases of patients with aHUS who developed skin lesions that completely recovered when disease-specific treatment was established. These cases suggest that in individuals with aHUS, when skin lesions of unknown origin occur, the possibility that they are due to thrombotic microangiopathy should be considered.

Inflammation and coagulation in urticaria and angioedema.

Urticaria is a skin disease characterised by short-lived surface swellings of the dermis (wheals) frequently accompanied by itching. It is classified as acute or chronic depending on whether the wheal recurrence occurs for less or more than six weeks. Acute urticaria is often due to a hypersensitivity reaction, whereas about 50% of the cases of chronic urticaria are regarded as autoimmune. Urticaria may occur alone or in association with a deeper swelling (angioedema) involving the subcutaneous and/or submucosal tissues, and last from hours to a few days. Angioedema can also develop alone, and may be idiopathic or be caused by allergies, inherited or acquired deficiencies of C1-inhibitor protein, or adverse drug reactions. An interplay between inflammation and coagulation has been proposed as a pathomechanism in urticaria and urticaria-associated angioedema (in which histamine and thrombin are involved), as well as in angioedema due to C1-inhibitor deficiency, which involves various biological systems. An increase in the plasma markers of thrombin generation, fibrinolysis and inflammation has been documented during exacerbations of urticaria and angioedema, with the marker levels decreasing to normal during remission. However, the hypercoagulable state in chronic urticaria and angioedema has not been reported to be associated with any increased risk of thrombosis, although there have been a number of reports of cardiovascular events occurring during episodes of acute urticaria. These observations have provided the rationale for the clinical evaluation of anticoagulant and antifibrinolytic drugs, the efficacy of which has sometimes been demonstrated.

Vulvar pyoderma gangrenosum with renal involvement.

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis of unknown etiology which usually occurs over the lower extremities; however, unusual presentations such as that involving the genital region have been described. Extracutaneous involvement of PG in the form of sterile neutrophilic infiltrates in various organs has infrequently been reported. We hereby describe a case of PG that was limited to the vulvar and perianal area in a 37-year-old female, with associated renal involvement in the form of a slight increase in the serum creatinine, microhematuria of glomerular origin and proteinuria. The patient had a rapid response of both her mucocutaneous lesions and renal dysfunction after the initiation of systemic steroids. The present case highlights the importance of evaluating all patients with PG for extracutaneous disease to avoid potentially harmful diagnostic or therapeutic procedures. Two other reasons for interest are the localized presentation of disease on the genital region and the presence of vascular involvement, albeit without signs of true vasculitis, vascular changes possibly being a histological hallmark of PG involving genitalia.

Pyoderma gangrenosum: study of 21 patients and proposal of a 'clinicotherapeutic' classification.

BACKGROUND: Pyoderma gangrenosum (PG) is a rare, relapsing inflammatory disorder classified within the neutrophilic dermatoses. It can be idiopathic or associated with various conditions. The management of PG includes several immunosuppressants, but definite guidelines are still lacking. OBJECTIVE: To propose a 'clinicotherapeutic' classification for PG; namely, a therapeutic algorithm for this disease on the basis of the clinical extent of lesions. METHODS: Twenty-one patients with PG referred to our department during the last 3½ years were prospectively studied. They were subdivided into three subsets - localized, multilesional and disseminated - on the basis of the number of lesions and percentage of involved body surface area. RESULTS: The end point was fulfilled in all the aforementioned settings of PG. Topical tacrolimus proved to be useful in localized PG. Multilesional PG was successfully treated with prednisone alone or in combination with cyclosporine. Disseminated PG responded well to prednisone plus cyclosporine, except for refractory cases in which infliximab was employed. CONCLUSIONS: This clinicotherapeutic classification seems to work well in PG, although its impact on the incidence of relapses is poorly evaluable due to the short follow-ups in our study; controlled trials are needed to confirm its value.

Topical tacrolimus for the treatment of localized, idiopathic, newly diagnosed pyoderma gangrenosum.

Pyoderma gangrenosum (PG) is a rare neutrophilic dermatosis which may present in a classic ulcerative form or in atypical bullous, vegetative or pustular variants. It can be associated with several disorders or be idiopathic. Although systemic immunosuppressants remain the choice therapy for most cases of PG, a local approach should be considered in localized disease. Recently, topical tacrolimus has successfully been used as an off-label drug in localized PG. In the present study, five patients with localized, idiopathic, newly diagnosed PG were treated with topical tacrolimus monotherapy. Localized PG was defined as disease involving no more than 5% of the body surface area and presenting with no more than three lesions. Cultures performed on PG lesions both before and during tacrolimus treatment were negative. In all five patients complete remission was achieved within a mean time of 6 weeks and no relapses occurred; in three cases, tacrolimus was discontinued, while the remaining two patients were applying the drug as maintenance therapy at the time of writing. Thus, we suggest that topical tacrolimus monotherapy could represent the first-line treatment for PG that fulfils the following criteria: localized disease, idiopathic form and recent onset with negative microbiological tests on PG lesions.