Oral Methotrexate Treatment of Delayed-Onset Inflammatory Reactions to Dermal Fillers.

Background: In aesthetic practice, delayed-onset (late) inflammatory reactions (DIRs) to dermal fillers are encountered. The treatment of DIRs can be challenging, with a response to established therapies, including oral antibiotics, intralesional and oral steroids, and hyaluronidase injection, occasionally reported as unsatisfactory. Objectives: Evaluate the efficacy of low-dose oral methotrexate (MTX) therapy in treating recalcitrant DIRs. Methods: We retrospectively reviewed cases of recalcitrant DIRs treated with oral MTX. Data collected included individuals' gender and age, medical history, filler type, facial area(s) injected, previous treatments attempted to dissolve the DIR, MTX treatment dosage and duration, and outcome. Adverse events were monitored throughout the treatment. Results: Thirteen females with a mean age of 52.6 years (range, 31-67 years) who developed recalcitrant DIRs to dermal filler injection are included. Eight reactions were triggered by the injection of hyaluronic acid (HA) fillers, 4 by liquid injectable silicone (LIS), and 1 by polymethylmethacrylate (PMMA). The average starting dosage of MTX was 12.1 mg/week (range, 7.5-12.5 mg/week). Patients were treated for 2 to 3 months in most cases. The average follow-up post-MTX therapy was 11.8 months (range, 2-36 months). A complete response to MTX treatment was observed in 10 patients (6 HA and 4 LIS cases), partial response in 1 (HA case), and an unsatisfactory response in 2 (HA and PMMA cases). Treatment was well tolerated. Conclusions: A short course of low-dose oral MTX is a possible treatment for DIRs that have not responded to established therapies. The promising results of this report require validation by powered studies.

Hyaluronidase for Dermal Filler Complications: Review of Applications and Dosage Recommendations.

BACKGROUND: Hyaluronidase (Hyal) can reverse complications of hyaluronic acid (HA) fillers, which has contributed substantially to the popularity of such procedures. Still, there are differing opinions regarding Hyal treatment, including dosage recommendations in filler complication management. OBJECTIVE: We aimed to address unanswered questions regarding Hyal treatment for HA filler complications, including timing and dosage, skin pretesting, properties of various Hyals and interactions with HA gels, and pitfalls of the treatment. METHODS: PubMed and Google Scholar databases were searched from inception for articles on Hyal therapy for filler complications. Articles were evaluated regarding their contribution to the field. The extensive literature review includes international leaders' suggestions and expert panels' recommendations. RESULTS: There are limited controlled data but increasing clinical experience with Hyal treatment. The currently used Hyals provide good results and have an acceptable safety profile. Nonemergent complications such as the Tyndall effect, noninflamed nodules, and allergic or hypersensitivity reactions should be treated with low or moderate Hyal doses. Hyal should be considered with prior or simultaneous oral antibiotic treatment in managing inflammatory nodules. Hyal may be tried for granulomas that have not responded to intralesional steroids. Emergent complications such as vascular occlusion and blindness require immediate, high-dose Hyal treatment. Regarding blindness, the injection technique, retrobulbar versus supraorbital, remains controversial. Ultrasound guidance can increase the efficacy of the above interventions. CONCLUSIONS: Hyal is essential in aesthetic practice because it can safely treat most HA filler complications. Immediate Hyal treatment is required for emergent complications. Aesthetic practitioners should be versed in using Hyal and effective dosage protocols.

A Screening Proposal for Zoom Dysmorphia in Virtual Settings.

Zoom dysmorphia (ZD) is a facial dysmorphia that is triggered or aggravated by frequent virtual meetings. The frequent use of videoconferencing platforms has been linked to a distorted perception of facial images as individuals have an increased awareness of their appearance, given constant video feedback. As a result, dysmorphic concerns can develop. It is crucial to identify ZD as this condition interferes with an individual's life and can trigger or aggravate body dysmorphic disorder (BDD). A standardized approach for screening ZD in non-psychiatric settings has yet to be defined. We discuss the features of ZD and the challenges of screening for ZD in a virtual setting. To facilitate the recognition of ZD in telehealth consultations, we propose a comprehensive ZD screening questionnaire that includes questions related to typical ZD features and a BDD-focused question. The questionnaire is concise and allows the identification of individuals with a potential ZD. A BDD assessment in such individuals should follow.

A critical review of COVID-19 course and vaccination in dermatology patients on immunomodulatory/biologic therapy: recommendations should not differ between non-pregnant and pregnant individuals.

COVID-19 can have detrimental effects on immunosuppressed patients. Here, we evaluate the evidence regarding continuing immunomodulatory/biologic (IMBI) therapy in pregnant dermatology patients during the COVID-19 pandemic. Also, we discuss the risks of COVID-19 vaccination in pregnant dermatology patients on IMBI therapy. As indicated in this review, regarding continuing IMBI therapy in pregnant dermatology patients during the pandemic, there is no compelling reason for treating them differently than non-pregnant. The body of evidence indicates that mRNA COVID-19 vaccines are safe during pregnancy. Studies on rheumatology patients, a group that overlaps significantly with the dermatology group, provided essential findings. IMBI in a non-pregnant rheumatology patient was not associated with COVID-19 mortality (except for rituximab), and vaccination of the rheumatology patient during pregnancy improved the obstetric outcomes compared to the unvaccinated patient. Based on this data, it can be stated that after weighing the benefit-risk profile of the available COVID-19 vaccines, the recommendation for the pregnant dermatology patient speaks in favor of the COVID-19 vaccination. COVID-19 vaccine recommendations in pregnant dermatology patients on IMBI should not differ from those for their non-pregnant counterparts.

Psychology of aesthetics: Beauty, social media, and body dysmorphic disorder.

The perception of beauty is fluid within society and can morph based on cultural practices and societal interaction, such as social media exposure. The exposure to digital conference platforms has increased significantly, leading users to check their appearance constantly and find flaws in their perceived virtual appearance. Studies have shown that frequent social media use may lead to unrealistic body image ideals, a significant concern with appearance, and anxiety. Also, social media exposure can worsen body image dissatisfaction, social networking site addiction, and comorbidities of body dysmorphic disorder (BDD) such as depression and eating disorders. Additionally, excessive social media use can increase preoccupation with imagined image defects among BDD patients leading them to pursue minimally invasive cosmetic and plastic surgery procedures. This contribution aims to provide an overview of the evidence surrounding the perception of beauty, cultural aspects of aesthetics, and social media's consequences, especially on BDD's clinical specifics.

Beauty perception: A historical and contemporary review.

The power of beauty influences many aspects of modern society and daily life-perceptions surrounding beauty date back to ancient philosophers and have evolved significantly throughout history. Still, there appear to be universally accepted physical characteristics of beauty that span different cultures. Human beings have an inherent ability to distinguish between attractive and nonattractive based on physical features that include facial averageness, symmetry, skin homogeneity, and sexual dimorphism (sex-typical characteristics). Although beauty standards have changed over time, youthful appearance has remained a permanent influential component of facial attractiveness. Each person's perception of beauty is influenced by environment and perceptual adaptation, an experience-based process. Perception of beauty varies by race and ethnicity. We discuss typical features of White, Asian, Black, and Latino beauty. We also review the effects of globalization on spreading foreign beauty culture and discuss how social media change traditional beauty stereotypes within the different races and ethnicities.

Body dysmorphic disorder: A critical appraisal of diagnostic, screening, and assessment tools.

Body dysmorphic disorder (BDD) is a psychiatric condition characterized by profound concern about a minor or imagined defect in the appearance of individuals and increased preoccupation with the imagined/perceived defect. Individuals with BDD often undergo cosmetic intervention for the perceived imperfection but rarely experience improvement in their signs and symptoms after such treatment. It is recommended that aesthetic providers evaluate individuals face-to-face and screen for BDD with approved scales preoperatively to determine the candidate's suitability for the procedure. This contribution focuses on diagnostic and screening tools and measures of disease severity and insight that providers working in nonpsychiatric settings can use. Several screening tools were explicitly developed for BDD; others were designed to evaluate body image/dysmorphic concern. The BDD Questionnaire (BDDQ)-Dermatology Version (BDDQ-DV), BDDQ-Aesthetic Surgery (BDDQ-AS), Cosmetic Procedure Screening Questionnaire (COPS), and Body Dysmorphic Symptom Scale (BDSS) have been developed explicitly for BDD and validated in cosmetic settings. The limitations of screening tools are discussed. Given the increasing use of social media, future revisions of BDD instruments should consider incorporating questions relevant to patients' behaviors on social media. Current screening tools can adequately test for BDD despite their limitations and a need for updates.

The role of lipids in vitiligo and schizophrenia.

The pathogenesis of vitiligo and schizophrenia has not been adequately clarified. We explore the role of lipids in these diseases. Both conditions have been associated with stress in several observations and studies. Research data indicate complex interactions between oxidative stress and metabolic syndrome-with lipid abnormalities being a significant component of the latter-in these diseases. The impaired membrane lipid homeostasis mechanism is related to the increased phospholipid remodeling caused by excessive oxidative stress in schizophrenia. We indicate that sphingomyelin is possibly involved in the pathogenesis of these diseases. Statins have anti-inflammatory and immunomodulating effects and an effect against oxidative stress. Preliminary clinical studies show that these agents may be beneficial in both vitiligo and schizophrenia, but their therapeutic value should be studied further.

Through the looking glass: Skin signs that help diagnose eating disorders.

Eating disorders (EDs) such as anorexia nervosa and bulimia nervosa have a plethora of skin manifestations. They can be categorized into skin signs of self-purging, skin signs of starvation, skin signs related to drug abuse, skin signs of psychiatric comorbidity, and miscellaneous signs. "Guiding signs" are valuable because they are pointers to the diagnosis of an ED. They include hypertrichosis (lanugo-like hair), Russell's sign (knuckle calluses), self-induced dermatitis, and perimylolysis (tooth enamel erosion). Practitioners should recognize such skin signs promptly, as this helps to diagnose early, which may improve the prognosis of ED. Management requires a multidisciplinary approach that focuses on psychotherapy combined with attention to medical complications, nutritional needs, and nonpsychiatric findings such as cutaneous manifestations. Psychotropic medications that are currently used in EDs include pimozide and atypical antipsychotic agents, such as aripiprazole and olanzapine, fluoxetine, and lisdexamfetamine.

Annular Basal Cell Carcinoma Expanding Around Central Hypertrophic Scarring: A Case Report.

A case of annular basal cell carcinoma (BCC) with central atrophic scarring that developed secondary to spontaneous regression has been reported. We present a novel case of a large, expanding nodular and micronodular BCC with annular morphology with central hypertrophic scarring. A 61-year-old woman presented with a two-year history of a mildly itchy lesion on the right breast. Previously diagnosed as an infection, the lesion persisted after treatment with topical antifungal agents and oral antibiotics. Physical examination revealed a 5x6 cm plaque consisting of a pink-red arciform/annular edge with an overlying scale crust and a large, centrally positioned, firm, alabaster-colored portion. A punch biopsy of the pink-red rim revealed nodular and micronodular BCC features. A deep shave biopsy of the central bound-down plaque showed histopathology of scarring fibrosis with no findings of BCC regression. The malignancy was treated with two sessions of radiofrequency destruction, which led to the resolution of the tumor with no recurrence to date. Contrary to the previously reported case, BCC in our case was expanding, associated with hypertrophic scarring, and showed no signs of regression. We discuss several possible etiologies of the scarring centrally. With further awareness of this presentation, more such tumors can be detected at early stages to facilitate prompt treatment and prevent local morbidity.

Idiopathic Acroosteolysis: A Novel Cutaneous Sign Can Help Identify the Condition Early.

Acroosteolysis (AO) is a rare condition characterized by resorption of the distal phalanges of the fingers and/or toes. It can be familial, idiopathic (IAO), occupational, or secondary. Other authors suggest a classification into primary (genetic disorders, lysosomal storage disorders) or secondary AO. Various skin and nail changes have been reported in this condition. However, the cutaneous change on the affected digit(s)/toe(s) during the natural course of AO has been poorly documented. A 5-year-old girl presented with a 3-month history of a distinct transverse boundary between normal skin proximally and affected crusted skin overlying osteolysis distally ("split" sign) on the plantar surface of the third toe. This boundary gradually elongated circumferentially to involve the dorsal surface. The mother gave a similar history of a delimitation line on the 2nd, 4th, and 5th toes of the right foot with durations of 3 months, 1 year, and 2 years, respectively, that disappeared before she noticed a shortening of those toes. X-rays revealed partial resorption of the terminal phalanx of the third toe and several lytic changes in the middle and terminal phalanx of the second, fourth, and fifth toes. The clinical features, radiology findings, and a workup that helped rule out conditions associated with AO (secondary AO) helped establish the diagnosis of IAO in our patient. This case study highlights that the natural course of IAO includes distinct skin findings, such as the "split" sign that we describe. This sign can help identify the condition early.

Complications of fillers in the lips and perioral area: Prevention, assessment, and management focusing on ultrasound guidance.

An ever-increasing interest in perioral rejuvenation with dermal fillers reflects the esthetic importance of this region. However, filler injections in the lips and perioral area have been associated with various complications. Such complications are classified according to severity (mild, moderate, severe) or by the time of onset: immediate (within 24 h after injection), early (24 h to 4 weeks post-procedure), and late or delayed (>4 weeks after injection). While most complications are mild and manageable, vascular compromise, infections, and the development of delayed-onset nodules may significantly undermine the ultimate esthetic outcome and cause substantial morbidity. These more serious complications often require more invasive treatment modalities. This article details the prevention and management of such adverse events and discusses safe filler injection principles, including safety recommendations for the lips. Lastly, we highlight the use of ultrasound guidance in complication prevention (vascular mapping, filler identification, location, and extent), assessment (identification of intravascular embolus or external vascular compression by the filler implant), and management (real-time imaging of hyaluronidase or other drug injection in the affected area). Esthetic practitioners should be versed in injection anatomy, and the prevention, recognition, and management of filler complications in the perioral area.

Erosive Pustular Dermatosis: Delving into Etiopathogenesis and Management.

Erosive pustular dermatosis (EPD) is a chronic inflammatory skin disorder that usually affects mature individuals. It predominantly affects the scalp and can lead to scarring alopecia. Risk factors include actinic damage and androgenetic alopecia. A traumatic insult to the skin is considered a vital trigger of the condition. EPD is a diagnosis of exclusion; thus, several neoplastic, infectious, vesiculobullous, and inflammatory conditions should be ruled out. Biopsy and clinicopathologic correlation are required to differentiate between EPD and these entities. A dysregulated, chronic immune response is considered central to the etiopathogenesis of EPD. We performed an evidence-based systematic review of the management options. There were predominantly studies with level IV and V evidence and only two with level III. Despite the responsiveness of EPD to potent topical steroids, such as clobetasol propionate, recurrence occurs after treatment withdrawal. With the available data, tacrolimus 0.1%, curettage-assisted aminolevulinic acid-photodynamic therapy, and systemic retinoids can be considered second-line options for EPD with a role in maintenance regimens. However, controlled data and more powerful studies are needed to make solid recommendations.

Carboxytherapy in dermatology.

Carboxytherapy is a medical technique during which a sterile gas-carbon dioxide-is injected into the subdermal tissue. The utility of carbon dioxide injections has enhanced the practical relevance of carboxytherapy as a method for the management of multiple disorders. We have evaluated its use in the treatment of dermatologic conditions by searching electronic databases (ie, MEDLINE and PubMed) for contributions in the English language through January 2021. Carboxytherapy provides an attractive aesthetic option in skin rejuvenation, atrophic scars, striae distensae (stretch marks), cellulite-fibrolipodystrophy adhesions after liposuction, and certain types of alopecia. We discuss the drawbacks of the procedure including inadvertent lipolysis, long-lasting emphysema, and suboptimal outcomes.

Evaluating resurfacing modalities in aesthetics.

Skin resurfacing for cutaneous rejuvenation has evolved with the development of a plethora of nonsurgical and minimally invasive modalities. We have highlighted the advances in laser therapy, chemical peels, radiofrequency, microneedling, and platelet-rich plasma therapy. We have also included studies providing head-to-head comparisons between procedures and discussed relevant debates in the field. We have examined additionally combination treatments and resurfacing in acne scars, melasma, and skin of color.

Hormonal Therapies in the Management of Acne Vulgaris.

Acne vulgaris is a multifactorial chronic disorder of the pilosebaceous unit. Established treatments include topical retinoids, antibiotics in mild cases, and oral antibiotics and isotretinoin in moderate to severe cases. Anti-androgens and other hormonal therapies constitute another group of drugs in the armamentarium of acne management. These can be used in patients who do not respond to the aforementioned treatments or when other systemic drugs cannot be tolerated. Recent approval of topical androgen receptor blocker is an additional armamentarium for the management of acne. Considering limited systemic exposure and good efficacy, it has potential for wide usage in patients with acne. In this article, we critically review currently available hormonal treatment options based on published literature search of an electronic database (MEDLINE/PubMed) performed through June 2021. J Drugs Dermatol. 2022;21(6):618-623. doi:10.36849/JDD.6494.

Aminolevulinic Acid-Photodynamic Therapy for Erosive Pustular Dermatosis of the Scalp: Comparison of Two Treatment Protocols and Participant Satisfaction.

Treatment of erosive pustular dermatosis of the scalp (EPDS) is challenging. Topical and systemic medications have achieved limited success, and destructive modalities have been associated with EPDS recurrence because of the tendency of the condition to recur after any treatment that induces trauma to the skin. Our group has have recently reported two series of EPDS treated with aminolevulinic acid-photodynamic therapy (ALA-PDT). Here, we aimed at comparing the protocols utilized in those series regarding efficacy, cost, and patient satisfaction. The first protocol included one visit for curettage of the hyperkeratosis and a second one for ALA-PDT. The revised (second) protocol included all procedures (curettage and ALA-PDT) in one visit. A novel silicone gel was applied immediately after completion of PDT, and patients were instructed to apply it twice daily over the treated areas until their follow-up visit. Both protocols were efficacious and provided similar length of remission. The second protocol was less costly. Patients treated using the second protocol were more satisfied due to the ease of treatment completion in one visit and better postoperative healing. (SKINmed. 2022;20:107-112).

Critical Review of the Sentinel Lymph Node Surgery in Malignant Melanoma.

Malignant melanoma is one of the most aggressive solid tumors but has low morbidity if treated at an early stage. Over the past decade, the advent of targeted therapy and immunotherapy have productively enriched the treatment options for advanced melanomas and further improved the prognosis. The treatment of melanoma is a rapidly evolving field. In patients with sentinel lymph node (SLN)-positive (SLN+) melanoma, the role of complete lymph node dissection (CLND) is still a matter of debate. Sentinel lymph node biopsy (SLNB) is a staging procedure for melanoma that is routinely offered to patients with tumor thickness ≥1 mm or ≥0.8 mm with additional risk factors and is widely accepted as an important diagnostic and prognostic tool, since SLN+ patients can receive adjuvant targeted treatment or immunotherapy. Currently, the role of CLND has largely been replaced by often recommended adjuvant therapies since their approval. This article provides an overview of sentinel lymph-node surgery in cutaneous melanoma. J Drugs Dermatol. 2022;21(5):510-516. doi:10.36849/JDD.6198.