A comparative study of pain perception during the microfocused ultrasound procedure between topical anesthesia and combined topical anesthesia with forced air cooling.

BACKGROUND: The experience of pain during microfocused ultrasound with visualization (MFU-V) treatment is common and crucial for dictating patient satisfaction and retention. OBJECTIVE: To compare the pain perception during the MFU-V procedure between two pain reduction methods (topical anesthesia alone versus combined topical anesthesia with forced air cooling). MATERIALS AND METHODS: This was a prospective, single-blinded, randomized controlled trial. A square area on the inner side of both arms of healthy volunteers was marked as an experimental site and randomly assigned to receive each pain reduction method: topical anesthesia or combined topical anesthesia with forced air cooling. Thereafter, MFU-V was performed with a 4.5 MHz, 4.5 mm transducer (10 lines, 0.9 J) followed by a 7 MHz, 3.0 mm transducer (10 lines, 0.3 J). The visual analog scale (VAS) for pain was measured immediately after 4.5 mm transducer (T1a), immediately after 3.0 mm transducer (T1b), and after the entire procedure (T2). RESULTS: Twenty-one participants with a mean (SD) age of 34.67 (±6.18) years were enrolled. The mean (±SD) pain score of combined topical anesthesia with forced air cooling-treated area was 5.40 (±1.64), 4.80 (±1.63), and 5.40 (±1.56) at T1a, T1b, and T2, respectively. The mean pain score for topical anesthesia-treated areas was 5.89 (±1.45), 5.00 (±1.72), and 5.76 (±1.67) at T1a, T1b, and T2, respectively. There were no statistically significant differences in the pain perception between the two methods. CONCLUSION: The addition of forced air cooling is not beneficial for pain reduction during the MFU-V procedure because its temperature reduction effect cannot be delivered to the deep parts of the skin, which is the target site of MFU-V.

The role of topical capsaicin gel in pain management during microfocused ultrasound treatment for neck laxity.

BACKGROUND: The transient receptor potential vanilloid 1 (TRPV1) provides a heat and pain sensation (nociception). Capsaicin, a TRPV1 agonist, has been shown to induce a refractory period in the nerve terminal expressing TRPV1 and create long-term nerve terminal defunctionalization. OBJECTIVE: To evaluate the efficacy of capsaicin for pain reduction during microfocused ultrasound with visualization (MFU-V) treatment. METHODS AND MATERIALS: A randomized, split-side study including 24 subjects was conducted. A combined 0.025% capsaicin gel and topical anesthetic were randomly applied on one side of the neck, and a topical anesthetic monotherapy was applied on the contralateral side for 30 min before MFU-V treatment. Pain score (visual analog scale, 0-10) was evaluated at T1 (before MFU-V), T2a (after the 4.5-mm transducer treatment), T2b (after the 3.0-mm transducer treatment), and T3 (after the entire treatment). Side effects were recorded. RESULTS: Mean pain scores at T2a for combined and single regimens were 5.19 (±2.26) and 6.91 (±1.72), respectively (p < 0.001). The capsaicin-treated side had a lower pain score at T2b and T3 (p < 0.001). Redness was longer on the capsaicin-treated side (112.67 vs. 10.68 min, p < 0.001). No other adverse events including contact dermatitis were reported. CONCLUSION: A single application of a combined 0.025% capsaicin gel with topical anesthesia produces a significantly lesser pain score during the MFU-V treatment. Defunctionalization of TRPV1 may explain the alleviation of painful sensations caused by heat from MFU-V.

Combined isobutylamido thiazolyl resorcinol and low-fluence Q-switched Nd: YAG laser for the treatment of facial hyperpigmentation: A randomized, split-face study.

BACKGROUND: Isobutylamido thiazolyl resorcinol (ITR) is a novel anti-tyrosinase recently shown to be effective in the treatment of hyperpigmentation. Low-fluence Q-switched Nd:YAG 1064-nm laser (LFQS) has proven to be effective for various hyperpigmentary conditions. However, there is no study on the efficacy and safety of combined ITR and LFQS treatment. OBJECTIVES: To compare the efficacy and safety of combined ITR and LFQS with LFQS monotherapy for facial hyperpigmentation. MATERIALS AND METHODS: Patients with symmetrical facial hyperpigmentation were treated with five sessions of once weekly LFQS on the whole face. One side was randomly treated with ITR and the other side received a placebo cream for 12 weeks. Patients were followed for 8 weeks after the last laser treatment. Relative lightness index (RL*I), Facial Hyperpigmentation Severity Score on the malar area (FHSSm ), patient satisfaction, recurrence, and adverse events were recorded. RESULTS: Twenty-four patients completed the study. Both sides demonstrated significant reductions of mean RL*I and mean FHSSm from baseline (P < .01). At the 4th week, the ITR-treated side showed more improvement of mean RL*I than the placebo-treated side (62.5% vs 47.3% improvement, P < .05). The mean FHSSm on the ITR-treated was reduced at a significantly higher percentage than the placebo-treated side (54.4% vs 40.2% reduction, P < .05). Partial recurrence was observed on both sides. No serious side effects were noted. CONCLUSION: Combined ITR and LFQS therapy was more superior than LFQS monotherapy in the treatment of facial hyperpigmentation. ITR may serve as adjuvant for patients with such condition.

A comparative study of combined treatment with fractional carbon dioxide and targeted ultraviolet B phototherapy for facial vitiligo.

Facial vitiligo is associated with considerable psychological impact. The management is challenging and requires multidisciplinary treatment. Adding fractional carbon dioxide (CO2) to the conventional treatment has been reported as an effective modality. This study aimed to evaluate the efficacy of combined fractional CO2 laser, targeted ultraviolet B (UVB) phototherapy, and topical steroid on facial vitiligo. A prospective, randomized, split face study was conducted on 14 patients with symmetrical non-segmental facial vitiligo. Ten sessions of fractional CO2 laser was performed on the lesions on one side of face with 2-week interval. Immediately after laser, the lesions on both side of face were treated with 10 sessions of 2-week interval targeted UVB phototherapy and twice daily application of topical 0.05 % clobetasol propionate cream. The patients were followed up for 12 weeks after the last treatment. Clinical improvement was graded by blinded dermatologists and patients using a quartile grading scale. Twelve out of 14 patients completed the study. The degree of improvement was not different between both sides in nine patients. One patient showed more improvement on the combined laser side, and two patients showed inferior results on the combined laser side. Two patients with lesser improvement on the laser-treated side had positive Koebner phenomenon on the non-facial area. The combined treatment with laser, targeted UVB, and topical steroids are not superior to targeted UVB and topical steroids in facial vitiligo. Furthermore, laser may retard the response to the standard treatment in patients with Koebner phenomenon on non-treated areas.

Effects of a preceding fractional carbon dioxide laser on the outcome of combined local narrowband ultraviolet B and topical steroids in patients with vitiligo in difficult-to-treat areas.

BACKGROUND AND OBJECTIVE: Conventional treatment of vitiligo on hands and feet often produces an unsatisfactory result. Various ablative treatment methods were tried with favorable results in facial, neck, and truncal areas. The aim of this study is to evaluate the efficacy and safety of combined fractional CO2 laser, narrowband UVB (NB-UVB) phototherapy, and topical clobetasol propionate in managing stable vitiligo in difficult-to-treat areas. STUDY DESIGN: A prospective randomized-intraindividual study was conducted on 27 patients with 27 pair-lesions of non-segmental vitiligo on both hands. The lesions were randomized to receive treatment with fractional CO2 laser, NB-UVB phototherapy, and 0.05% clobetasol propionate cream (Group A) or NB-UVB phototherapy and 0.05% clobetasol propionate cream (Group B). Fractional CO2 laser was performed at 1-week interval for 10 sessions. NB-UVB phototherapy was administered twice weekly for 20 sessions. Patients were evaluated 12 weeks after the last treatment. Outcome was evaluated objectively based on standard digital photographs, patient satisfaction, and adverse events. RESULTS: Twenty-six patients completed the study. Six vitiligious lesions (23.1%) in group A achieved good to excellent repigmentation compared with one lesion (3.9%) in group B (P = 0.065). The overall mean improvement score was 1.35 (± 1.38) in group A and 0.50 (± 0.95) in group B (P = 0.0004). Patients' satisfaction score was significantly higher for the lesions in group A than group B. Lesions on the dorsum of the hand showed a higher response rate than those on the fingers. No serious side-effects were noted. CONCLUSION: This study demonstrates that adding fractional CO2 laser treatment to NB-UVB phototherapy and topical steroids improves the repigmentation rate of vitiliginous lesions on hands in some patients. This technique may be offered to vitiligo patients who are unresponsive to other treatments.

Treatment of melasma in men with low-fluence Q-switched neodymium-doped yttrium-aluminum-garnet laser versus combined laser and glycolic acid peeling.

BACKGROUND: Low-fluence Q-switched neodymium-doped yttrium-aluminum-garnet 1,064-nm laser (LFQS) and glycolic acid (GA) peeling have been reported as a treatment option for melasma. However, there are limited data on their efficacy in men. OBJECTIVE: To compare the efficacy and safety of LFQS monotherapy with combined LFQS and 30% GA peeling in male patients with melasma. MATERIALS AND METHODS: Fifteen males with mixed type melasma were randomized to receive 5 weekly sessions of LFQS on one side of the face and LFQS plus 30% GA peeling on the contralateral side and were followed for 12 weeks. Twelve patients completed the protocol. RESULTS: Mean relative lightness index (RL*I) of the combined treatment side was lowered throughout the study period, with the maximal improvement of 52.3% reduction at the fourth week follow-up (p = .023). Patient self-assessment was favorable in the combined treatment. However, the mean RL*I increased at 8 and 12 weeks of follow-up. One subject (8.3%) developed guttate hypopigmentation, which did not resolve by the 12-week follow-up. CONCLUSION: Low-fluence Q-switched neodymium-doped yttrium-aluminum-garnet 1,064-nm laser combined with GA peeling temporarily reduced melasma in men, but the incidence of side effects does not justify the short-lived benefits of this procedure. This technique requires further study.

Five-Year Retrospective Review of Acute Generalized Exanthematous Pustulosis.

Background. Acute generalized exanthematous pustulosis (AGEP) is an acute pustular eruption characterized by widespread nonfollicular sterile pustules. The aim of this study is to characterize the etiology, clinical features, laboratory findings, management, and outcome of patients with AGEP in Asians. Patient/Methods. A retrospective analysis was performed on patient who presented with AGEP between August 2008 and November 2012 in a tertiary center in Thailand. Results. Nineteen patients with AGEP were included. AGEP was generally distributed in seventeen patients (89.5%) and localized in two (10.5%). Fever and neutrophilia occurred in 52.6% and 68.4%, respectively. Hepatitis was found up to 26.3%. The most common etiology was drugs (94.7%), comprising of antibiotics (73.6%), proton pump inhibitors (10.5%), nonsteroidal anti-inflammatory drugs (5.3%), and herbal medicine (5.3%). Beta-lactams were the most common causal drug, particularly carbapenems and cephalosporins. This is the first report of Andrographis paniculata as an offending agent for AGEP. We found no differences between various treatment regimens (topical corticosteroid, systemic corticosteroid, and supportive treatment) regarding the time from drug cessation to pustules resolution (P = 0.171). Conclusions. We have highlighted the presentation of AGEP among Asians. We found high association with systemic drugs. Carbapenems were one of the leading culprit drugs. Finally, a localized variant was observed.

Psoriasis in African-Americans: a caregivers' survey.

BACKGROUND: Psoriasis is a common skin disease in Caucasians but less common in African-Americans. AIMS: Our aim is to evaluate caregiver opinions regarding the clinical presentations and treatment of psoriasis in African-Americans compared to Caucasians. PATIENTS/METHODS: A survey was sent to 29 dermatologists who are opinion leaders in the field of psoriasis. The survey included a number of questions regarding the characteristics of the patients seen in their practice. RESULTS: A total of 29 surveys were completed and returned. All of the dermatologists use the extent of disease as a criterion to determine the severity of the disease. Other criteria include scale, thickness, erythema, associated general symptoms, and dyspigmentation. About 66% of the respondents reported the different manifestations of disease, such as more dyspigmentation, thicker plaques, and less erythema in African-Americans. The most common first-line treatments for mild to moderate disease were highpotency topical steroids (68%) followed by topical vitamin D analogues (41%). For moderate to severe disease, the most commonly used first-line treatments were high-potency topical steroids (54%) and phototherapy (46%). CONCLUSIONS: The clinical manifestations of psoriasis in African-Americans are not exactly the same as in Caucasians. Physicians should be aware of the difference in clinical manifestations in African-Americans. Further research and large-scale studies are necessary to elucidate the differences in the clinical presentation, natural course of the disease, and the criteria used for the evaluation of severity among ethnic groups.

Cutaneous Mycobacterium abscessus Infection Associated with Mesotherapy Injection.

Non-tuberculous mycobacterial skin infections have an increasing incidence. In immunocompetent patients, they usually follow local trauma. We present a case of cutaneous Mycobacterium abscessus infection following mesotherapy. The lesions were successfully treated with a combination of clarithromycin, ciprofloxacin, and doxycycline. Atypical mycobacterial infection should be suspected in patients who develop late-onset skin and soft tissue infection after cutaneous injury, injection, and surgical intervention, particularly if they do not respond to conventional antibiotic treatment.