"Cloned" hairlines: the use of bisected hair follicles to create finer hairlines.

BACKGROUND: One living hair follicle, if horizontally bisected in the proper location, can be induced to subsequently produce two growing follicles. Their unpredictable growth rate, often less than 50%, has limited their use on a large scale. Their resultant finer caliber, however, can be used to benefit patients undergoing hair replacement surgery. OBJECTIVE: To determine whether horizontally bisected hairs can be employed to create finer, feathered anterior and temporal hairlines. METHODS: Twenty autologous terminal donor hairs were bisected as closely as possible to the "bulge" area immediately inferior to the zone of attachment of the arrector pili muscle. The 20 hair "shafts" were implanted along the left hairline. Twenty "bulbs" were implanted along the right hairline. Growth was evaluated and tabulated 2.5-8 months after transplant surgery. The procedure has been performed on 14 patients to date. Follow-up has been obtained on six patients ranging in age from 29 to 57 years. RESULTS: Overall, patients exhibited 46% growth from hair "shafts" (upper portion) and 47% growth from "bulbs" (lower portion). These bisected hairs were finer in caliber (diameter) than the original donor hairs. CONCLUSION: Horizontally bisected donor hairs can be implanted to create finer hairlines than otherwise would be expected from the theory of donor dominance. Further study is necessary in order to evaluate long-term success and additional applications of this technique.

Dermal grafting.

At the 1999 American Academy of Dermatology symposium on soft-tissue augmentation, Dr. Arnold Klein mentioned 31 different [figure: see text] filler substances now available world-wide. Of these 31, 29 were either synthetic or modified, and only two (dermis and fat) were autologous material reimplanted without significant alteration. Dermal grafts have stood the test of time. Before skin surfacing is performed, one must fill up depressions not improved by the resurfacing technique. The dermatologist or plastic surgeon should seriously consider adding dermal grafting to his or her armamentarium. Patients will likely be grateful!

Azone enhances clinical effectiveness of an optimized formulation of triamcinolone acetonide in atopic dermatitis.

BACKGROUND: Atopic dermatitis is a chronic, relapsing condition affecting up to 14% of the population in Western countries. Topical corticosteroids are the mainstay of treatment. Triamcinolone acetonide, a corticoid of intermediate potency, has proven useful in the treatment of atopic dermatitis. AIM: To evaluate the effectiveness of a triamcinolone acetonide-laurocapram combination in the treatment of atopic dermatitis. METHODS: One hundred and fifty patients were enrolled in a three-arm, parallel group, controlled clinical trial evaluating the effectiveness of a triamcinolone acetonide (0.05%) and laurocapram combination, applied twice daily for 2 weeks, in the treatment of atopic dermatitis. Fifty patients received triamcinolone acetonide-laurocapram (TNX), 50 triamcinolone acetonide (TN), and 50 a vehicle control formulation (AN). Response to treatment was evaluated by change in disease severity at 6 h, at 3, 8, and 15 days after the start of treatment, and by the global change in disease status. RESULTS: TNX effected a significantly higher degree of improvement in the signs and symptoms of atopic dermatitis (erythema, induration, and pruritus) and a greater overall improvement in disease status compared with treatment with TN or AN. Treatment-associated side-effects were local reactions, occurring in three, two, and six patients in the TNX, TN, and AN groups, respectively. CONCLUSIONS: The results suggest that the incorporation of laurocapram in the formulation enhances the effectiveness of triamcinolone acetonide, without compromising its safety profile.

Treatment of axillary hyperhidrosis: combination of the starch-iodine test with the tumescent liposuction technique.

OBJECTIVE: To evaluate and permanently improve axillary hyperhidrosis. BACKGROUND: Excessive sweating of the axillae is a common problem for which patients frequently seek dermatologic advice and therapy. Many treatments, including aluminum chloride, topical and systemic anticholinergic agents, tranquilizers, iontophoresis, direct surgical excision, botulinum toxin injection, and thoracic sympathectomy, have been employed to control this problem. All have drawbacks of one sort or another. METHODS: The starch-iodine technique for delineation of preoperative and postoperative axillary sweating is described in detail. A method of sweat gland removal utilizing tumescent liposuction is discussed. RESULTS AND CONCLUSION: The combination of the starch-iodine technique and tumescent liposuction is safe and effective for therapy of axillary hyperhidrosis.

Hair repair surgery. Corrective measures for improvement of older large-graft procedures and scalp scars.

BACKGROUND: Implanted hair follicles generally take and grow well. This can be desirable or undesirable, depending on the skill and aesthetic eye of the surgeon. Older methods employing larger grafts often produced pluggy, bristle brush, or "Barbie doll" hairlines that were unsightly and conspicuous. OBJECTIVE: Since patients possessing these outcomes often seek corrective measures, a search was undertaken to find effective, corrective repair methods. Unfortunately, relatively little has been published on this subject. METHODS AND RESULTS: Discussion will center on recipient site repair, donor site repair, and scar repair. Recipient sites can be improved with a combination of laser ablation, electrolysis, punch removal, and fill-in micrografting. Donor sites can be improved by reexcision, undermining, tissue expansion, and layered closure. Anterior scalp scars may be improved by punch excision and micrografting. CONCLUSIONS: Satisfactory improvement for untoward hair transplantation outcomes may be obtained with one or more corrective procedures in many patients.

Intratumoral chemotherapy with fluorouracil/epinephrine injectable gel: a nonsurgical treatment of cutaneous squamous cell carcinoma.

BACKGROUND: We attempted to originate a nonsurgical treatment alternative for cutaneous squamous cell carcinoma (SCC), and we evaluated intratumoral modified-release chemotherapy with fluorouracil/epinephrine injectable gel (5-FU/epi gel). OBJECTIVE: To assess the safety and efficacy, we conducted an open-label pilot study of 5-FU/epi gel in 25 patients with biopsy-proven SCC lesions on the face, head, neck, trunk, arms, and hands. METHODS: Each tumor site was injected intradermally with up to 1.0 ml of 5-FU/epi gel. One SCC per patient was treated weekly for up to 6 weeks, then observed for 4 months at which time the tumor site and margins were excised for histologic examination. RESULTS: Overall, 96% (22 of 23) of evaluable treated tumors had histologically confirmed complete tumor clearing. No clinically significant systemic reactions or unexplained treatment-related adverse medical events occurred. The evaluations of the cosmetic appearance of the treated sites, judged subjectively by clinicians and patients, were mostly good to excellent and generally in close agreement. CONCLUSION: Treatment of superficial SCC with 5-FU/epi injectable gel results in a high rate of histologically confirmed complete tumor responses and may provide a nonsurgical treatment alternative in selected patients.

Treatment of acne with a combination clindamycin/benzoyl peroxide gel compared with clindamycin gel, benzoyl peroxide gel and vehicle gel: combined results of two double-blind investigations.

BACKGROUND: It has previously been shown that a combination of erythromycin and benzoyl peroxide is superior to either ingredient when used alone in the treatment of acne. A clindamycin/benzoyl peroxide combination gel might have an advantage over erythromycin/benzoyl peroxide gel because the former does not require refrigeration after it is dispensed. OBJECTIVE: Our purpose was to determine the efficacy and safety of a combination clindamycin/benzoyl peroxide gel when compared with benzoyl peroxide, clindamycin, or vehicle gels. METHODS: In two double-blind, randomized, parallel, vehicle-controlled trials, patients were treated for 11 weeks with once-nightly application of one of the above preparations. Evaluations were performed at 2, 5, 8, and 11 weeks and included lesion counts and assessment of global responses and irritant effects. RESULTS: A total of 334 patients completed the study. All three active preparations were significantly superior to the vehicle in global improvement and in reducing inflammatory lesions and noninflammatory lesions. The combination gel was significantly superior to the two individual agents in global improvement and reduction of inflammatory lesions and also to the clindamycin gel in reducing noninflammatory lesions. There was no significant difference in tolerance to the active gels versus the vehicle gel. CONCLUSION: In the treatment of acne, topical clindamycin/benzoyl peroxide combination gel is well tolerated and superior to either individual ingredient.

Relationship of genital wart burden to therapeutic response to fluorouracil/epinephrine injectable gel.

The efficacy of a single cycle of a new therapy for genital warts, intradermal fluorouracil/epinephrine (5-FU/epi) injectable gel, has been evaluated in 2 large pivotal trials; the objective of this study was to evaluate a second cycle of treatment. Twenty-two patients with total wart areas of 5-447 mm2 were treated with up to 2 cycles of < or =6 treatments of 5-FU/epi gel. After the first cycle of treatments, patients with warts showing a partial response or no response or new warts were continued into a second cycle. Seventy-three per cent (16/22) of patients had complete responses. Patients with total wart areas < or = 100 mm2 tended to respond completely in the first cycle of treatment (average 4.7 treatments). Patients with numerous warts or large total wart areas (>100 mm2) required an average of 7.5 treatments to achieve a complete response. Thus, a second treatment cycle may be appropriate for difficult-to-treat patients with numerous warts or large total wart areas.

A randomized trial to assess once-daily topical treatment of tinea corporis with butenafine, a new antifungal agent.

BACKGROUND: Tinea corporis treatment usually requires topical application of an antifungal agent for 2 to 3 weeks. OBJECTIVE: We evaluated short-term treatment of tinea corporis with butenafine hydrochloride, a new benzylamine with in vitro fungicidal activity. METHODS: Patients (n = 78) were randomly selected to apply butenafine or its cream vehicle alone once daily for 14 days and were periodically assessed until day 42. RESULTS: Butenafine recipients had significantly higher rates of mycologic cure beginning at day 7 (64% vs 9%) with continued improvements through day 42 (88% vs 17%). They also had higher rates of effective treatment (mycologic cure and 90% to 100% symptom improvement) at day 7 (33% vs 0%) with increasing rates through day 42 (81% vs 14%). CONCLUSION: Butenafine provides rapid and persistent antifungal activity and symptom relief in patients with tinea corporis. Significant effects were observed within 7 days of therapy initiation, and increasing effectiveness was observed 4 weeks after therapy.

Clinical efficacy and safety comparison of adapalene gel and tretinoin gel in the treatment of acne vulgaris: Europe and U.S. multicenter trials.

BACKGROUND: Adapalene is a new chemical entity that exhibits tretinoin-like activities in the terminal differentiation process. OBJECTIVE: We evaluated a dose range effect of two concentrations of adapalene gel as acne treatment and compared adapalene 0.1% gel with tretinoin 0.025% gel in the treatment of acne patients in two large multicenter studies. METHODS: Multicenter, investigator-masked, parallel group studies including 89 acne patients in the dose range study and 591 patients in the concurrent controlled studies were conducted. RESULTS: Adapalene gel 0.1% was significantly more effective in treating acne lesions than 0.03% adapalene gel. Adapalene gel 0.1% was significantly more effective than 0.025% or tretinoin gel in one study and of the same effectiveness in the other study. Adapalene gel was always better tolerated than tretinoin gel. CONCLUSION: Adapalene 0.1% gel is a safe and effective treatment of acne vulgaris.

Intralesional fluorouracil/epinephrine injectable gel for treatment of condylomata acuminata. A phase 3 clinical study.

BACKGROUND AND DESIGN: A new intralesional sustained-release chemotherapy is under development as a treatment for condylomata acuminata; it is administered as an injectable gel that consists of fluorouracil and epinephrine with a purified bovine collagen as the gellant (fluorouracil/epinephrine gel). In this randomized, double-blind study, we evaluated the safety and efficacy of this intralesional treatment in 401 patients, using 2 active drug formulations (fluorouracil/epinephrine gel and fluorouracil gel alone) and a placebo. Each lesion was injected once a week for up to 6 weeks, and patients were followed up for 3 months. RESULTS: A total of 359 patients with 1926 condylomata underwent evaluation. For all lesions treated with fluorouracil/epinephrine gel, the complete response (CR) rate was 77%. For all patients treated with fluorouracil/epinephrine gel, the CR rate was 61%. The fluorouracil/epinephrine gel was significantly more effective (P < .002) in treating condylomata than the fluorouracil gel without epinephrine (CR rate, 43%); both were superior to placebo (CR rate, 5%). At 3 months after completion of treatment, recurrence rates in patients with CRs were as follows: fluorouracil/epinephrine gel group, 50%; fluorouracil gel group, 58%. No clinically significant drug-related systemic reactions occurred. Finally, the type and severity of local tissue reactions of patients with a positive pretreatment collagen skin test result (6/401 [1.5%]) were similar to those of patients with a negative collagen skin test result. CONCLUSION: The fluorouracil/epinephrine injectable gel is a safe and effective treatment for condylomata acuminata.

Development of intralesional therapy with fluorouracil/adrenaline injectable gel for management of condylomata acuminata: two phase II clinical studies.

OBJECTIVES: To evaluate a sustained release chemotherapy for treating condylomata acuminata with an injectable gel containing fluorouracil and adrenaline (5-FU/adrenaline gel). Study 1-- To assess contributions of the components of 5-FU/adrenaline gel to efficacy. Study 2--To assess therapeutic contribution of adrenaline and safety and efficacy of the formulations. DESIGN: Randomised, double blind, placebo controlled studies. SETTING: Private practices and university clinics in the United States. PATIENTS: Men and women with new, recurrent, or refractory external condylomata acuminata. INTERVENTION: Six injections over 8 weeks; follow up visits at weeks 1, 4, 8, and 12. EFFICACY: patient/wart response, times to complete response, recurrence rates. SAFETY: injection reactions, tissue conditions, other adverse events, laboratory studies. RESULTS: Study 1: 132 evaluable patients. Complete response (CR) rate was highest for the 5-FU/adrenaline gel group, followed by the 5-FU/adrenaline solution group, then the 5-FU gel group. 5-FU, adrenaline, and the collagen gel vehicle (in the presence of 5-FU) significantly affected CR and strongly influenced time to CR. The effects of 5-FU and adrenaline were statistically significant. Cutaneous reactions were mild to moderate. Study 2: 187 evaluable patients. Patients treated with 5-FU/adrenaline gel had a significantly higher CR rate and lower cumulative 90 day recurrence rate than those treated with 5-FU gel without adrenaline. Treatments were generally well tolerated, with only three treatment related, serious adverse events. CONCLUSION: 5-FU/adrenaline gel is safe and efficacious for treatment of condylomata acuminata, and when compared with individual or various combinations of components, this formulation provided the greatest therapeutic advantage.

Scalp lifting. Anatomic and technical considerations.

BACKGROUND: Extensive scalp lifting, though offering the potential for tremendous benefit to the patient with extensive male-pattern alopecia, has not been widely accepted or understood. OBJECTIVE: The anatomic and technical features of extensive scalp lifting are discussed. METHODS: The performance of extensive scalp lift surgery must be preceded by a thorough understanding of the specific goals, anatomic considerations, surgical techniques, and specific methods for successful completion of this operation. A knowledge of preoperative preparation, anesthesia, intraoperative methods, undermining, hemostasis, means of scalp advancement, and proper closure are essential for minimizing side effects and complications of this beneficial procedure. One must understand the dynamics of scalp stretching and lifting in order to achieve optimum removal of baldness and to successfully predict the outcome of the operation. CONCLUSION: Present and future advantages of scalp lifting over traditional scalp reduction have been enumerated and discussed.

Extensive scalp lifting. Decrease in complications utilizing unilateral occipital artery ligation and other modifications.

The superior yield from extensive scalp lifting has been detracted from by complications, including hemorrhage, scalp necrosis, and the need for greater anesthesia. Intraoperative unilateral occipital artery ligation, with extensive undermining to the nape of the neck on only one side, can minimize the risk of postoperative scalp necrosis or telogen effluvium. Careful hemostasis, extensive infusion of dilute anesthetic, and modifications in instrumentation can decrease the morbidity associated with this procedure. The advantages of the operation include removal of the large amounts of bald scalp, excellent intraoperative visualization, and lack of stretchback and asymmetry.

Mogul skier's palm: traumatic hypothenar ecchymosis.

A unique purpuric--golden lesion on the hypothenar eminence of each palm is described in a mogul skier. These painful lesions, resulting from vigorous repetitive pole planting in the "bumps" at a ski area, are postulated to represent a form of localized soft tissue injury.

Salicylic acid ointment peeling of the hands and forearms. Effective nonsurgical removal of pigmented lesions and actinic damage.

A methyl salicylate-buffered, croton oil-containing 50% salicylic acid ointment peel, following pretreatment with topical tretinoin and localized 20% trichloroacetic acid, is extremely effective for removal of lentigines, pigmented keratoses, and actinically damaged skin from the dorsum of the hands and forearms. The ease of application, uniform results, decreased risk of scarring, and one-time application of this peel, in comparison with other methods used for treatment of these aging-skin changes, warrants consideration by the dermatologic surgeon.