Autofluorescence Excitation Imaging of Nonmelanoma Skin Cancer for Margin Assessment Before Mohs Micrographic Surgery: A Pilot Study.

BACKGROUND: Autofluorescence photography can detect specific light-tissue interactions and record important pathophysiological changes associated with nonmelanoma skin cancer (NMSC), which has been ascribed to the fluorescence of an aromatic amino acid, tryptophan. OBJECTIVE: To assess the impact of a novel, autofluorescence imaging (AFI) device on margin control for NMSCs before Mohs micrographic surgery (MMS) in an effort to decrease overall operating time. METHODS: Before the initial stage of MMS, NMSCs were measured with a 2-mm margin as standard of care (normal margin). The tumor was then imaged with the AFI device. A 2-mm margin was drawn around the fluorescent area captured by the AFI device and was referred to as the camera margin. The tumor was excised based on the normal margin and evaluated on frozen histological section. RESULTS: Imaging based on the AFI device resulted in appropriate recommendations for margin control in 8 of 11 tumors. Four of these tumors did not fluoresce and demonstrated a lack of tumor residuum on stage I specimen, as anticipated. There were no side effects from the AFI device. CONCLUSION: This is an initial pilot study that supports the use of a novel, noninvasive imaging device to help with margin assessment before MMS. On optimization, this device has potential to extend applicability to surgical excisions for tumors that do not fulfill criteria for MMS.

Assessment of the American Academy of Dermatology diagnostic criteria for pediatric atopic dermatitis and modification into a checkbox form: A cross-sectional study.

BACKGROUND/OBJECTIVES: Diagnostic criteria for atopic dermatitis (AD) are limited in their performance and/or usability. The American Academy of Dermatology (AAD) consensus criteria include hierarchical categories of disease features to improve these metrics but have not been validated. Our objective was to create and validate a checkbox form of the AAD consensus criteria in the pediatric population. METHODS: We performed a cross-sectional study of 100 pediatric patients with AD (n = 58) and diseases in the differential diagnosis of AD (n = 42). RESULTS: Having three or more "Essential," ≥2 "Important," ≥1 "Associated" features of the AAD criteria was optimal for the diagnosis of AD in children. This combination was 91.4% (95% CI, 84.2%-98.6%) sensitive and 95.2% (88.8%-100%) specific. The UK working party criteria and the Hanifin-Rajka criteria had sensitivities of 96.6% (95% CI 91.9%-100%) and 98.3% (95% CI 94.9%-100%) and specificities of 83.3% (95% CI 72.1%-94.6%) and 71.4% (95% CI 57.8%-85.1%), respectively. The AAD criteria had significantly greater specificity than the Hanifin-Rajka criteria (p = .002). CONCLUSIONS: This study represents an important step in validating the AAD consensus criteria and formulating a useable checkbox form for diagnosing AD in the pediatric population.

Severe acne and its variants: Exploring its natural history and heritability.

BACKGROUND: Acne vulgaris varies in clinical severity, from minimal comedonal disease to severe hemorrhagic and ulcerative lesions with scarring. While a family history confers a higher risk for developing acne, the correlation between heritability and clinical severity remains unclear. OBJECTIVE: To examine the natural history and heritability of severe acne with scarring in patients undergoing isotretinoin therapy. METHODS: A total of 101 subjects with severe acne with scarring and its variants, including acne conglobata and acne fulminans, were enrolled. All subjects and adult family members underwent an interview regarding their acne, and a corresponding "historical" Investigator's Global Assessment (hIGA) score (0 = clear, 1 = almost clear, 2 = mild, 3 = moderate, 4 = severe, 5 = very severe) was assigned. Study assessors performed an "examination" Investigator's Global Assessment (eIGA) based on the clinical examination of each subject (0 = clear, 1 = almost clear, 2 = mild, 3 = moderate, 4 = severe, 5 = very severe). A detailed family history and pedigree were documented. RESULTS: Most subjects were Caucasian (44.5%) and male (79.2%) who had previously used doxycycline and/or minocycline (86.1%). The mean eIGA and hIGA scores were 2.7 and 4.4, respectively. 37.2% of subjects had one first-degree relative with a history of moderate or severe acne with scarring; of note, of the patients with hemorrhagic disease, 30% had at least one parent with moderate or severe acne. CONCLUSIONS: Severe forms of acne often "cluster" in families, underscoring the heritable nature of acne and the prognostic value of a family history of moderate or severe disease.

Optimizing Parameters for Smoke Evacuation.

BACKGROUND: Current literature lacks recommendations regarding the ideal organization of the smoke evacuation system to minimize inhalation of surgical smoke. OBJECTIVE: This study determines optimal parameters of the smoke evacuation system with respect to the surgical field. MATERIALS AND METHODS: This study was conducted in an outpatient surgical facility at a tertiary care center. After 30 seconds of continuous electrocautery of tissue, particulate measurements were recorded using the TSI DustTrak Aerosol Monitor 8520 (>2.5 µm particles) and the TSI P-Trak Ultrafine Particle Counter 8525 (<1 µm particles) while changing the angle and distance of the smoke evacuation system. RESULTS: Particulate matter measurements were lower when suction angle was at 45° than at 90°. For both small-sized and large-sized particles, the lowest particulate matter was recorded when the evacuator was maintained at a 45° angle, 2 to 4 inches away from the cauterizing procedure. Particulate matters dramatically increased after increasing the distance of the smoke evacuator beyond 8 inches from the procedural site. CONCLUSION: In an effort to reduce smoke inhalation, the authors recommend that smoke evacuation should be placed at a 45° suction angle, no further than 8 inches away from the surgical site, while preserving the surgeon's field of vision.

Association of Demographic Factors and Infantile Hemangioma Characteristics With Risk of PHACE Syndrome.

Importance: A 2010 prospective study of 108 infants estimated the incidence of PHACE (posterior fossa malformations, hemangioma, arterial anomalies, cardiac defects, eye anomalies) syndrome to be 31% in children with facial infantile hemangiomas (IHs) of at least 22 cm2. There is little evidence regarding the associations among IH characteristics, demographic characteristics, and risk of PHACE syndrome. Objectives: To evaluate demographic characteristics and comorbidities in a large cohort of patients at risk for PHACE syndrome and assess the clinical features of large head and neck IH that may be associated with a greater risk of a diagnosis of PHACE syndrome. Design, Setting, and Participants: This multicenter, retrospective cohort study assessed all patients with a facial, head, and/or neck IH who were evaluated for PHACE syndrome from August 1, 2009, to December 31, 2014, at 13 pediatric dermatology referral centers across North America. Data analysis was performed from June 15, 2017, to February 29, 2020. Main Outcomes and Measures: The main outcome was presence or absence of PHACE syndrome. Data included age at diagnosis, sex, patterns of IH presentation (including size, segment location, and depth), diagnostic procedures and results, and type and number of associated anomalies. Results: A total of 238 patients (mean [SD] age, 2.96 [4.71] months; 184 [77.3%] female) were included in the analysis; 106 (44.5%) met the criteria for definite (n = 98) or possible (n = 8) PHACE syndrome. A stepwise linear regression model found that a surface area of 25 cm2 or greater (odds ratio [OR] 2.99; 95% CI, 1.49-6.02) and involvement of 3 or more locations (OR, 17.96; 95% CI, 6.10-52.85) to be statistically significant risk factors for PHACE syndrome. Involvement of the parotid gland (OR, 0.39; 95% CI, 0.18-0.85) and segment S2 (OR, 0.38; 95% CI, 0.16-0.91) was associated with a lower risk. Race and ethnicity may also be associated with PHACE syndrome risk, although more studies are needed. Conclusions and Relevance: This cohort study further described factors associated with both a higher and lower risk of PHACE syndrome. The presence of multiple anatomical sites and large surface area were associated with greater risk, whereas S2 or parotid IHs were associated with lower, but still potential, risk. These findings can help in counseling families and decision-making regarding evaluation of infants with large head and neck IHs.

Incorporating Aesthetic Devices into a Dermatologic Practice.

Background: Lasers and energy-based devices allow physicians to provide quality care to patients and achieve optimal clinical results. Objective: We sought to review the benefits and drawbacks of purchasing and leasing energy-based devices and to highlight key factors that are important to consider when incorporating these devices into a practice. Methods: A PubMed search was conducted for articles on purchasing or leasing lasers and energy-based devices in dermatology. Key reports and personal commentaries on incorporating these technologies into practice are summarized in this review. Results: Energy-based devices are clinical and financial investments and can provide outstanding results for patients and result in substantial gratification for a practice. There are a variety of factors to consider when selecting specific lasers and energy-based devices. Conclusions: Capital resources, aesthetic practice values, expertise in using the device, patient demographics, location of the practice, clinic space requirements, and regulations should be considered when buying or leasing a device.

The Evolving Story of Laser Therapeutics for Basal Cell Carcinoma.

BACKGROUND: The increasing burden from basal cell carcinoma (BCC) has stimulated the development of alternative treatments for these tumors. OBJECTIVE: This review focuses on upcoming laser treatments for BCC and highlights the limitations of these therapies. METHODS: A PUBMED search was conducted for articles on laser therapy of BCC. Key studies involving lasers to treat BCC were reviewed. Novel approaches to BCC are also described. RESULTS: Vascular-specific laser therapy has increasingly been studied as an addition in the therapeutic armamentarium of BCC. Although these studies demonstrate efficacy for nonaggressive BCC, optimization of this technique is ongoing to minimize scarring. A more targeted approach to the treatment of BCC, such as immunized photothermal therapy or laser-assisted chemotherapeutic delivery, may result in less scarring, while maintaining efficacy similar to that of lasers targeting tumor vasculature. CONCLUSION: Vascular-specific laser therapies show promise in treating low-risk BCC; however, scarring is not an uncommon adverse event. Although only animal studies have been performed to date, laser-activated gold nanoparticle therapy and laser-assisted drug delivery of vismodegib are potential therapies that theoretically confer a more selective approach. Laser modalities demonstrate promise in the treatment of nonaggressive BCC, although long-term studies have yet to be published.

Analysis of U.S. Food and Drug Administration Data on Soft-Tissue Filler Complications.

BACKGROUND: With the rising popularity of dermal fillers, the number of complications associated with fillers has increased. OBJECTIVE: To identify and review reports of adverse events involving cosmetic injectable soft-tissue fillers from the FDA Manufacturer and User Facility Device Experience (MAUDE) database from June 1993 to August 2014. MATERIALS AND METHODS: The authors conducted a search of adverse events within the U.S. Food and Drug Administration database that involved injectable dermal fillers for soft-tissue augmentation from June 1993 to August 2014. Search terms included generic and trade names of commercially available soft-tissue fillers. RESULTS: Three thousand seven hundred eighty-two complications involving dermal fillers were identified in the MAUDE database. Forty-four percent of complications implicated hyaluronic acid fillers, 40% involved poly-L-lactic acid fillers, 15% complications included calcium hydroxylapatite fillers, and <1% complications arose from polymethylmethacrylate fillers. Common adverse events included lumps, infection, allergic reaction, ischemia, and swelling. Rare events included trigger of autoimmune reactions, visual disturbances, and stroke. CONCLUSION: Although complications with dermal fillers are infrequent in comparison with the growing number of filler procedures being performed in the United States every year, this study underscores the importance of appropriate skill and training when administering dermal fillers. Physicians using injectable dermal fillers should be trained to recognize potential complications and know how to appropriately manage them.

Recurrent herpes labialis in the pediatric population: Prevalence, therapeutic studies, and associated complications.

Recurrent herpes labialis (RHL) is an incredibly common condition, though the medical literature evaluating pediatric aspects is limited. This paper assesses prevalence and therapeutic studies of pediatric RHL as well as disease complications. A comprehensive literature search of English-language citations based on PubMed queries of selected terms was performed, with exclusion if methodology was not discussed, or if studies had 10 or fewer patients. RHL prevalence in pediatrics has been assessed by measures of point and periodic prevalence, though methodologic limitations may under- or over-estimate the true prevalence of RHL. Studies have been conducted to evaluate therapeutic safety, tolerability, and efficacy of antivirals in the pediatric population. Pediatric RHL point prevalence ranges from 0.72% to 5.2% depending on the population study and the methodologies used. Pediatric RHL carries a significant public health burden and is often implicated in patients with eczema herpeticum, erythema multiforme, reactive infectious mucositis eruptions, and hypersensitivity reactions. There are few studies that evaluate the rates of occurrence of these sequelae associated with pediatric RHL.

Photosensitivity and photoprotection in patients with lupus erythematosus.

Lupus erythematosus (LE) represents a spectrum of inflammatory autoimmune disease comprising varying clinical entities ranging from primary cutaneous to systemic disease. There is a clear relationship between ultraviolet irradiation (UVR) and the clinical manifestations of LE in both adult and pediatric populations. Although it has been established that UVR exacerbates pre-existing LE, it remains unclear whether UVR induces the development of the disease. This review serves to discuss effective photoprotective measures in LE and describe the pathogenic relationship of UVR and LE.

The psychological and aesthetic impact of age-related hair changes in females.

BACKGROUND: While dermatologists focus on practices to promote anti-aging, thinning hair that frames a more rejuvenated face can affect age perception and cosmesis. OBJECTIVES: To characterize the effects of age-related hair changes on age determination and perceived attractiveness. METHODS: A search was conducted for articles on intrinsic and extrinsic aging as it relates to hair. Key studies on the hair aging process and its effects on self-perception, confidence, and anti-aging were reviewed. RESULTS: According to several studies, hair density peaks about 27 years of age or earlier and then decreases from the mid-thirties onward. This serves as an opportunity to prevent or treat hair loss in a similar way we treat aging skin. Without optimizing appearance of hair, overall cosmesis to foster self-perception can be curtailed despite multiple efforts to rejuvenate and restore the aging face. CONCLUSION: The discrepancy between rejuvenated faces and thinner appearing hair that frames the face highlights the importance of a holistic approach to the anti-aging consultation. To more comprehensively address the aesthetic patient, we need to promote awareness of the onset of these hair changes in order to incorporate prevention and therapeutic strategies to preserve hair to complement overall appearance.

Lasers and energy-based devices marketed for vaginal rejuvenation: A cross-sectional analysis of the MAUDE database.

INTRODUCTION: The FDA issued a statement on July 30, 2018, expressing concern over the marketing of lasers and energy-based devices to promote "vaginal rejuvenation." The FDA stated that there is insufficient data to recommend this modality for optimization of sexual function and alleviation of genitourinary syndrome of menopause (GSM)-related symptoms in postmenopausal or postpartum women. This analysis aims to characterize the mandatory and voluntary reports concerning laser and energy-based procedures marketed for vaginal rejuvenation. METHODS: Cross-sectional analysis of the FDA database, Manufacturer and User Facility Device Experience (MAUDE), for events related to laser and energy-based devices for vaginal rejuvenation. RESULTS: Between October 2015 and January 2019, 45 distinct events describing 46 patients were recorded and reviewed. The most commonly reported adverse event related to the procedure was pain (vulvar, bladder, urethral, or unspecified) (n = 19). The majority of patients sought medical care for their injuries, which included evaluation by urgent care, urology, gynecology, neurology, gastroenterology, pelvic floor therapy, primary care providers, and the device operator. Thirty-three patients indicated chronicity of their injury, which included long-term pain, numbness, burning, bladder disturbances, infections, scarring, dyspareunia, worsening symptoms, aggravation of lichen sclerosis, and disfigurement. CONCLUSIONS: A variety of adverse events associated with the use of laser and energy-based devices for "vaginal rejuvenation" was reported to the MAUDE database. Although the circumstances surrounding these events were unclear, these reports signify the importance of clinical trials that investigate the efficacy and safety profile of laser and energy-based devices for optimization of sexual function and treatment of GSM-related symptoms. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

The microbiome in preadolescent acne: Assessment and prospective analysis of the influence of benzoyl peroxide.

BACKGROUND/OBJECTIVES: The pathogenesis of preadolescent acne has not been well studied, and it is uncertain if Cutibacterium acnes is a predominant organism in the microbiome in this age group. The aim of this study was to analyze the microbiome of preadolescent females and to assess whether benzoyl peroxide impacts the microbiome. METHODS: The study enrolled girls, aged 7-12 years, with evidence of at least six acne lesions who had not been previously treated. Participants' skin surface of forehead, cheeks, nose, chin, left retroauricular crease, and extruded contents of a comedonal lesion were sampled at baseline. Participants used benzoyl peroxide 4% wash for 6-8 weeks and returned for skin surface sampling and extraction collection. Microbiome analysis was performed using 16S ribosomal RNA gene amplicon sequencing on all swab and lesional extraction samples. RESULTS: Fifty-one participants were enrolled with a median IGA score of 2 (mild). Changes in microbiome diversity were associated with increasing age and number of acne lesions (P = 0.001). C. acnes had higher abundances on forehead and nose, as opposed to cheeks and chin (P = 0.009). Bacterial diversity (alpha diversity) of the skin microbiome was comparable between preadolescent at baseline and after treatment with benzoyl peroxide. CONCLUSION: This is the first large assessment characterizing female acne microbiome in early and late preadolescence. Results show that preadolescent acne can vary in its microbial profile, reflecting surrounding changes associated with the onset of puberty. Although benzoyl peroxide use was associated with decreased acne counts, its effect on microbial diversity was not demonstrated in our study.

Outcomes of long-pulsed 1064 nm Nd:YAG laser treatment of basal cell carcinoma: A retrospective review.

BACKGROUND AND OBJECTIVE: Recent prospective trials have supported treatment of nonfacial BCC with long-pulsed 1064 nm Nd:YAG laser based on short-term histologic clearance rates. Studies have yet to identify the long-term clinical clearance rates of this specific laser therapy for BCC. STUDY DESIGN/MATERIAL AND METHODS: This is a retrospective review of BCC treated with long-pulsed 1064 nm Nd:YAG laser, which have been clinically monitored for at least 6 months, to assess for recurrence and cosmetic outcomes of the treated area. RESULTS: 16 BCC lesions (11 subjects) treated with 1064 nm Nd:YAG laser were enrolled. Our analysis revealed 100% clearance rate in all subjects (16 of 16 BCC) treated with long-pulsed Nd:YAG laser based on mean follow-up of 9 months (range 6-15 months). Minimal scarring and no long-term adverse events were noted. CONCLUSIONS: This study supports the use of 1064 nm Nd:YAG laser as a therapeutic modality for BCC based on the absence of clinical recurrence upon a mean follow-up of 9 months. As studies progress, we are beginning to observe a potential role for laser as an alternative to patients who refuse surgery, have multiple co-morbidities, or decline non-surgical therapies. Laser treatment with 1064 nm Nd:YAG is an evolving, promising story that we continue to investigate to optimize parameters. Lasers Surg. Med. 51:34-39, 2019. © 2018 Wiley Periodicals, Inc.

Diagnosis, comorbidity, and psychosocial impact of atopic dermatitis.

Atopic dermatitis (AD) is a chronic inflammatory skin disease, with a remitting relapsing course. The central diagnostic features of AD include pruritus, xerosis, eczematous lesions with a characteristic morphology and distribution, and a personal or family history of atopic disease. Several clinical studies have emphasized the link between AD and other atopic disorders including asthma, allergic rhinitis, and food allergies. More recent studies indicate possible links between AD and other nonatopic disorders, including ADHD, sleep disturbance, and mental health disorders, suggesting an even more profound impact of this disease. Furthermore, the social, emotional, and personal impact of AD for patients and their caregivers is substantial. Understanding both the clinical characteristics and implications of AD is critical to lessening the psychosocial, clinical, and economic burden of this disease.