Human Histology and Persistence of Various Injectable Filler Substances for Soft Tissue Augmentation.

An increasing number of soft tissue filler substances have been introduced to the beauty market outside the U.S. which lackexperimental and clinical data in support of their claim. Ten commercially available filler substances were examined for biocompatibility and durability: 0.1 cc of each substance was injected deep intradermally into the volar forearm of one of the authors and observed for clinical reaction and permanence. At 1, 3, 6, and 9 months the test sites were excised, histologically examined, and graded according to foreign body reactions classification. Collagen (Zyplast) was phagocytosed at 6 months and hyaluronic acid (Restylane) at 9 months. PMMA microspheres (Artecoll) had encapsulated with connective tissue, macrophages, and sporadic giant cells. Silicone oil (PMS 350) was clinically inconspicuous but dissipated into the tissue, causing a chronic foreign body reaction. Polylactic acid microspheres (New-Fill) induced a mild inflammatory response and had disappeared clinically at 4 months. Dextran microspheres (Reviderm intra) induced a pronounced foreign body reaction and had disappeared at 6 months. Polymethylacrylate particles (Dermalive) induced the lowest cellular reaction but had disappeared clinically at 6 months. Polyacrylamide (Aquamid) was well tolerated and remained palpable to a lessening degree over the entire testing period. Histologically, it dissipated more slowly and was kept in place through fine fibrous capsules. Polyvinylhydroxide microspheres suspended in acrylamide (Evolution) were well tolerated, slowly diminishing over 9 months. Calcium hydroxylapatite microspheres (Radiance FN) induced almost no foreign body reaction but were absorbed by the skin at 12 months.Host defense mechanisms react differently to the various filler materials, but all substances- resorbable or nonresorbable-appeared to be clinically and histologically safe, although all exhibit undesirable side effects. Since the mechanism of late inflammation or granuloma formation is still unknown, early histological findings are not useful in predicting possible late reactions to filler substances.

The Relationship of Wound Healing with Psoriasis and Multiple Sclerosis.

Significance: Better understanding of wound healing could lead to improved treatment(s) of multiple sclerosis (MS) and psoriasis (Pso). Recent Advances: New concepts in the events of wound healing, such as the roles of the innate and adaptive immune systems, have generated targets for treating these debilitating diseases. Innovation: That in MS and Pso defective wound healing is responsible for the diseases' progression has not been hypothesized to date. Conclusion: Impaired initiation of wound repair by oligodendrocyte precursor cells or oligodendrocytes may play a role in MS, and a lack of inhibition of the proliferative phase in wound healing may explain the pathophysiology involved in Pso.

Outcomes of Melanoma In Situ Treated With Mohs Micrographic Surgery Compared With Wide Local Excision.

Importance: Melanoma in situ (MIS) is increasing in incidence, and expert consensus opinion recommends surgical excision for therapeutic management. Currently, wide local excision (WLE) is the standard of care. However, Mohs micrographic surgery (MMS) is now used to treat a growing subset of individuals with MIS. During MMS, unlike WLE, the entire cutaneous surgical margin is evaluated intraoperatively for tumor cells. Objective: To assess the outcomes of patients with MIS treated with MMS compared with those treated with WLE. Design, Setting, and Participants: Retrospective review of a prospective database. The study cohort consisted of 662 patients with MIS treated with MMS or WLE per standard of care in dermatology and surgery (general surgery, otolaryngology, plastics, oculoplastics, surgical oncology) at an academic tertiary care referral center from January 1, 1978, to December 31, 2013, with follow-up through 2015. Exposure: Mohs micrographic surgery or WLE. Main Outcomes and Measures: Recurrence, overall survival, and melanoma-specific survival. Results: There were 277 patients treated with MMS (mean [SD] age, 64.0 [13.1] years; 62.1% male) and 385 treated with WLE (mean [SD] age, 58.5 [15.6] years; P < .001 for age; 54.8% male). Median follow-up was 8.6 (range, 0.2-37) years. Compared with WLE, MMS was used more frequently on the face (222 [80.2%] vs 141 [36.7%]) and scalp and neck (23 [8.3%] vs 26 [6.8%]; P < .001). The median (range) year of diagnosis was 2008 (1986-2013) for the MMS group vs 2003 (1978-2013) for the WLE group (P < .001). Overall recurrence rates were 5 (1.8%) in the MMS group and 22 (5.7%) in the WLE group (P = .07). Mean (SD) time to recurrence after MMS was 3.91 (4.4) years, and after WLE, 4.45 (2.7) years (P = .73). The 5-year recurrence rate was 1.1% in the MMS group and 4.1% in the WLE group (P = .07). For WLE-treated tumors, the surgical margin taken was greater for tumors that recurred compared with tumors that did not recur (P = .003). Five-year overall survival for MMS was 92% and for WLE was 94% (P = .28). Melanoma-specific mortality for the MMS group was 2 vs 13 patients for the WLE group, with mean (SD) survival of 6.5 (4.8) and 6.1 (0.8) years, respectively (P = .77). Conclusions and Relevance: No significant differences were found in the recurrence rate, overall survival, or melanoma-specific survival of patients with MIS treated with MMS compared with WLE.

Regression and classification methods for nasolabial folds: a possible paradigm for computer-aided diagnosis of skin diseases.

Classification of facial features, for example, nasolabial folds, still relies mainly on clinical assessment, resulting in significant costs because of high intra- and interrater variability. Further, diagnosing skin diseases, for example, malignant melanoma, also can present challenges. In an attempt to reduce cost of medical care in future, we determined the utility of methods in image processing and statistical analysis to automatically quantify, for example, the structure of nasolabial folds. To the best of our knowledge, this is the first report of the application of computer technology to grading of nasolabial folds. When classifying severity of wrinkles on a scale of 1-5, the computer achieved an accuracy of 87% compared to the dermatologist, taken as the gold standard. Further, the computer program's capacity to sort the order of wrinkles from least to most wrinkled was 98% as accurate as the clinician(s). We conclude that by using computer technology, nasolabial folds can be categorized almost as accurately as by using grading by dermatologists, suggesting that computer technology may be a useful tool to grade nasolabial folds because a computer is always consistent. We hypothesize that, after additional studies, this technology also may be a useful tool to aid in diagnosing skin diseases.

Psoriatic keratinocytes are resistant to tumor necrosis factor alpha's induction of mRNA for the NMDA-R2C subunit.

Psoriatic individuals demonstrate accelerated healing and the Koebner phenomenon, suggesting that psoriatic proliferation of keratinocytes is not inhibited appropriately after skin injury. Serial analysis of gene expression in TNFα-exposed keratinocytes shows the greatest alteration in expression of NMDA-R2C. Expression of the NMDA receptor is altered in diseased skin containing TNFα, and TNFα plays a prominent role in psoriasis. An abnormality in induction of NMDA-R2C by TNFα in psoriatic keratinocytes may explain their lack of growth inhibition. We compared the capacity of TNFα to induce expression of NMDA-R2C in normal and psoriatic (involved and uninvolved) keratinocytes in vitro. After 72 h of incubation with TNFα, normal keratinocytes demonstrated a significant induction of NMDA-R2C mRNA compared with control cultures, whereas psoriatic keratinocytes showed no induction. In an in vitro model of wounding (scratches on monolayers), TNFα inhibited migration/proliferation of keratinocytes only at the edge of NMDA-R2C expressing wounded monolayers of normal keratinocytes.

Massage increases oxytocin and reduces adrenocorticotropin hormone in humans.

CONTEXT: Human beings are highly social creatures who often touch each other during social interactions. Although the physiologic effects of touch are not understood fully, it appears to sustain social bonds and to increase cooperative behaviors. Oxytocin (OT) is a hormone known to facilitate social bonding, and touch may affect OT release. Previous studies seeking to relate massage and oxytocin in humans have been inconsistent in their findings. OBJECTIVES: This study examined the effect of massage on oxytocin and also measured its effect on other physiologic factors, including adrenocorticotropin hormone (ACTH), nitric oxide (NO), and beta-endorphin (BE). DESIGN: The research team advertised that the trial would study relaxation and assigned participants randomly to the intervention or the control group. A lab administrator assigned a random numeric code to participants to mask their identities. SETTING: The study took place at the University of California Los Angeles (UCLA), Los Angeles, CA. PARTICIPANTS: Ninety-five people from UCLA gave written informed consent for participation in the study, with the team paying them to participate. The intervention group included 65 participants and the control group 30 participants. INTERVENTION: For the intervention (massage) group, the research team drew participants' blood and followed the blood draw with 15 minutes of moderate-pressure massage of the upper back. The control (rest) group rested quietly for 15 minutes after the blood draw. A second blood draw followed for both groups. OUTCOME MEASURES: The research team assayed OT, ACTH, NO, and BE. The team used four survey instruments to examine the relationship between personality factors and the physiologic measures of interest. The team analyzed data using SPSS 15.0 for Windows. RESULTS: Massage was associated with an increase in OT and reductions in ACTH, NO, and BE. Comparing the effects of massage for the massage group with those for the rest group, the research team found significant differences between groups for changes in OT, ACTH, NO, and BE. CONCLUSIONS: This study is the first using a large sample of mixed gender that demonstrates that massage increases OT and decreases ACTH, NO, and BE. These findings may help explain the mechanisms through which social connections reduce morbidity and mortality.

Patients with palmoplantar pustulosis have increased IL-17 and IL-22 levels both in the lesion and serum.

Recent findings about the pathogenesis of pustulosis palmaris et plantaris (PPP), also known as palmoplantar pustulosis, suggest that IL-17 expression in the acrosyringium as well as infiltration of IL-17 positive cells, e.g. Langerhans cells may play important roles. However, to date, it has not been established whether circulating IL-17 related cytokines are involved in PPP. We studied the circulating IL-17 related cytokines as well as the mRNA levels in lesional skin. IL-17 related cytokine mRNAs were increased in the PPP lesions compared with the control tissues (five patients vs five controls). The serum levels of TNF-alpha, IL-17, IL-22 and IFN-gamma also were significantly increased in PPP, but not IL-23 and IL-8 (48 patients vs 20 controls). Our findings document that not only the serum IL-17 but also tissue IL-17 are elevated in PPP and may be in the pathogenesis of this disorder.

Use of gelatin sponges in Mohs micrographic surgery defects and staged melanoma excisions: a novel approach to secondary wound healing.

BACKGROUND/AIMS: surgical closure or reconstruction is commonly used to treat wounds generated by Mohs micrographic surgeries (MMS) and staged melanoma excisions, which may result in contractures and scarring. The authors' objective was to determine the value of using gelatin sponges to promote secondary intention healing for surgical defects after MMS and staged melanoma excisions. METHODS: sixty-four surgeries from 54 predominantly elderly patients (median age=76 years) were treated with gelatin sponges to promote healing by secondary intention in this prospective investigation. Patients rated their satisfaction with outcomes on a scale of 1 (highly dissatisfied) to 5 (highly satisfied). RESULTS: in all patients, the wounds healed within four to 16 weeks (median=five weeks). Forty-five patients were highly satisfied with their results (mean score=4.9). CONCLUSION: healing by secondary intention using gelatin sponges was associated with improved hemostasis, excellent cosmesis and a high level of patient satisfaction.

Acrosyringium is the main site of the vesicle/pustule formation in palmoplantar pustulosis.

Pustulosis palmaris et plantaris or palmoplantar pustulosis (PPP) is a refractory pustular eruption on the palms and soles with unknown etiology. Numerous eccrine sweat pores exist on the palms and soles, suggesting the involvement of eccrine sweating in the pathogenesis of PPP. To the best of our knowledge, however, no definite abnormality in sweating has been documented in PPP. Accordingly, we analyzed the eccrine sweat duct involvement in the mechanism of vesicle formation in PPP. Dermatoscopy showed that PPP vesicles are located on the top of the ridges but not in the furrows. The sweat secretion in the lesional area was much lower than that in the nonlesional area, with or without pain stimulation to induce sweating. Immunostaining of horizontal sections of the lesions using antibodies against gross cystic disease fluid protein-15 (GCDFP-15) and epithelial membrane antigen (EMA) showed that these markers were localized in the cells lining the intraepidermal vesicles. Although the sweat antimicrobial peptides, dermcidin and human cathelicidin antimicrobial peptide 18 (hCAP-18)/LL-37, were detected in the fluid of the vesicles/pustules, neither dermcidin nor hCAP-18/LL-37 were overexpressed by neighboring keratinocytes. These findings suggest that the acrosyringium may be involved as the main site of the vesicle formation in the pathomechanism of PPP.

Increased serine protease activity and cathelicidin promotes skin inflammation in rosacea.

Acne rosacea is an inflammatory skin disease that affects 3% of the US population over 30 years of age and is characterized by erythema, papulopustules and telangiectasia. The etiology of this disorder is unknown, although symptoms are exacerbated by factors that trigger innate immune responses, such as the release of cathelicidin antimicrobial peptides. Here we show that individuals with rosacea express abnormally high levels of cathelicidin in their facial skin and that the proteolytically processed forms of cathelicidin peptides found in rosacea are different from those present in normal individuals. These cathelicidin peptides are a result of a post-translational processing abnormality associated with an increase in stratum corneum tryptic enzyme (SCTE) in the epidermis. In mice, injection of the cathelicidin peptides found in rosacea, addition of SCTE, and increasing protease activity by targeted deletion of the serine protease inhibitor gene Spink5 each increases inflammation in mouse skin. The role of cathelicidin in enabling SCTE-mediated inflammation is verified in mice with a targeted deletion of Camp, the gene encoding cathelicidin. These findings confirm the role of cathelicidin in skin inflammatory responses and suggest an explanation for the pathogenesis of rosacea by demonstrating that an exacerbated innate immune response can reproduce elements of this disease.

Bilateral comparison of the efficacy and tolerability of 3% diclofenac sodium gel and 5% 5-fluorouracil cream in the treatment of actinic keratoses of the face and scalp.

Actinic keratoses (AKs) are a common precancerous condition and are said to account for 14% of visits to dermatologists in the US each year. Along with cryotherapy, topical treatments are a mainstay of therapy for these lesions. One of the potential benefits of topical therapy is less pain and irritation as compared to cryotherapy. Additionally, topical therapies have a perceived benefit of treating subclinical lesions along with clinically evident keratoses. We conducted a bilateral comparison study of the efficacy and tolerability of diclofenac 3% gel used for 90 days and 5% fluorouracil cream used for 28 days in thirty patients with AK of the face and scalp. The diclofenac gel and 5-fluorouracil cream each demonstrated substantial efficacy in the number of lesions cleared and the proportion of patients with significant lesion clearing. In most patients, diclofenac induced only mild signs of inflammation compared to 5-fluoruracil, despite a longer treatment period. A greater number of patients expressed significant satisfaction with diclofenac gel compared to the 5-fluorouracil cream.

The characteristics and utility of solid phase porous microspheres: a review.

Topical drugs use a variety of ingredients to control the properties of the final product. Solid phase porous microspheres (SPPM, Microsponge) have been incorporated into several topical prescription products in an effort to improve performance or tolerability. SPPMs provide a reservoir effect allowing more prolonged skin exposure to the active ingredient. They are used in products for acne vulgaris, actinic keratoses, and pigmentary changes. The differences in clinical performance between existing formulations of these common active ingredients and the formulations using SPPMs are compared and contrasted.

Dermatan sulfate proteoglycan and glycosaminoglycan synthesis is induced in fibroblasts by transfer to a three-dimensional extracellular environment.

Composition and architecture of the extracellular matrix dictate cell behavior. Proteoglycans bind multiple components of the extracellular matrix by serving as important regulators of cell behavior. Given the influence of culture architecture on cell function, we investigated whether switching NIH3T3 fibroblasts from growth on type 1 collagen in monolayer to a collagen gel might influence dermatan sulfate expression. Immunofluorescent staining, immunoblot, and Western blot demonstrated an induction in decorin expression in cells switched to collagen gels. This induction was associated with a 40-fold increase in decorin transcript expression determined by quantitative real time PCR. Disaccharide analysis of extracted glycosaminoglycans from collagen gels showed an increase in total glycosaminoglycan and in the ratio of chondroitin sulfate to heparan sulfate compared with monolayer culture. The ratio of chondroitin sulfate to heparan sulfate likewise increased on syndecan-1 from gel culture. Digestion with chondroitinase B showed that this induced chondroitin sulfate was dermatan sulfate. Syndecan-1 extracted from wounded mouse skin also displayed an increase in dermatan sulfate synthesis compared with unwounded skin. Furthermore, glycosaminoglycans from collagen gel culture activated keratinocyte growth factor, whereas glycosaminoglycans from monolayer culture lacked this ability. These findings suggest that regulation of dermatan sulfate and dermatan sulfate proteoglycan is dependent on extracellular matrix architecture. The ability of collagen gel culture to mimic better the in vivo dermal environment may be due in part to this influence on dermatan sulfate and dermatan sulfate proteoglycan synthesis.

Use of RT-PCR and DNA microarrays to characterize RNA recovered by non-invasive tape harvesting of normal and inflamed skin.

We describe a non-invasive approach for recovering RNA from the surface of skin via a simple tape stripping procedure that permits a direct quantitative and qualitative assessment of pathologic and physiologic biomarkers. Using semi-quantitative RT-PCR we show that tape-harvested RNA is comparable in quality and utility to RNA recovered by biopsy. It is likely that tape-harvested RNA is derived from epidermal cells residing close to the surface and includes adnexal structures and present data showing that tape and biopsy likely recover different cell populations. We report the successful amplification of tape-harvested RNA for hybridization to DNA microarrays. These experiments showed no significant gene expression level differences between replicate sites on a subject and minimal differences between a male and female subject. We also compared the array generated RNA profiles between normal and 24 h 1% SLS-occluded skin and observed that SLS treatment resulted in statistically significant changes in the expression levels of more than 1,700 genes. These data establish the utility of tape harvesting as a non-invasive method for capturing RNA from human skin and support the hypothesis that tape harvesting is an efficient method for sampling the epidermis and identifying select differentially regulated epidermal biomarkers.

Migration studies and histology of injectable microspheres of different sizes in mice.

Injectable dermal filler materials consist of either fluids, biological fragments, or suspensions of particles or microspheres. Particles and microspheres are said to "migrate," but migration can occur only when they are injected into blood vessels. To evaluate biocompatibility and transport, five nonresorbable polymethylmethacrylate microspheres of various sizes, suspended in different carriers, as well as resorbable polylactic acid and dextran microspheres were injected subcutaneously into mice. The five implantation sites were the right cheek, right axilla, right groin, urethra, and the right quadriceps muscle of the thigh. These sites were excised along with the local lymph nodes, lungs, liver, and spleen at 1, 3, 6, and 9 months after injection. Polymethylmethacrylate microspheres of 4 microm and 8 microm were phagocytosed but not transported to lymph nodes or distant organs. Larger microspheres of 20, 40, and 100 microm were encapsulated by connective tissue, macrophages, and giant cells. Polylactic acid microspheres caused a mild inflammatory response and had disappeared at 6 months. Dextran microspheres caused a pronounced foreign-body reaction and were phagocytosed at 9 months. The extremely large carbon-coated spheres of 200 to 500 microm in diameter "migrated" up to 1 cm from the implantation site. With the exception of an erroneous intravenous injection, no migration or transportation of any of the injected microspheres to lymph nodes or filter organs was seen. Obviously, the collagen glue released no microspheres. After subdermal injection, the collagen carrier substance kept the microspheres apart as a scaffold for tissue ingrowth, whereas all other carrier substances, such as gelatin, hyaluronic acid, or alginate, separated soon after injection, thereby causing agglomeration of the microspheres.

Human histology and persistence of various injectable filler substances for soft tissue augmentation.

An increasing number of soft tissue filler substances have been introduced to the beauty market outside the U.S. which lack experimental and clinical data in support of their claim. Ten commercially available filler substances were examined for biocompatibility and durability: 0.1 cc of each substance was injected deep intradermally into the volar forearm of one of the authors and observed for clinical reaction and permanence. At 1, 3, 6, and 9 months the test sites were excised, histologically examined, and graded according to foreign body reactions classification. Collagen (Zyplast) was phagocytosed at 6 months and hyaluronic acid (Restylane) at 9 months. PMMA microspheres (Artecoll) had encapsulated with connective tissue, macrophages, and sporadic giant cells. Silicone oil (PMS 350) was clinically inconspicuous but dissipated into the tissue, causing a chronic foreign body reaction. Polylactic acid microspheres (New-Fill) induced a mild inflammatory response and had disappeared clinically at 4 months. Dextran microspheres (Reviderm intra) induced a pronounced foreign body reaction and had disappeared at 6 months. Polymethylacrylate particles (Dermalive) induced the lowest cellular reaction but had disappeared clinically at 6 months. Polyacrylamide (Aquamid) was well tolerated and remained palpable to a lessening degree over the entire testing period. Histologically, it dissipated more slowly and was kept in place through fine fibrous capsules. Polyvinylhydroxide microspheres suspended in acrylamide (Evolution) were well tolerated, slowly diminishing over 9 months. Calcium hydroxylapatite microspheres (Radiance FN) induced almost no foreign body reaction but were absorbed by the skin at 12 months. Host defense mechanisms react differently to the various filler materials, but all substances-resorbable or nonresorbable-appeared to be clinically and histologically safe, although all exhibit undesirable side effects. Since the mechanism of late inflammation or granuloma formation is still unknown, early histological findings are not useful in predicting possible late reactions to filler substances.

Short incubation PDT versus 5-FU in treating actinic keratoses.

The efficacy of photodynamic therapy (PDT) using broad area treatment with 5-aminolevulinic acid (ALA) has not been compared to topical 5-fluorouracil (5-FU) in the treatment of actinic keratoses (AK). The purpose of this study was to compare the efficacy and tolerability of PDT using short incubation time, broad area treatment with ALA plus activation with either blue light or laser light to topical 5-FU in the treatment of AK of the face and scalp. Thirty-six subjects with AK of either the face or scalp were randomized to receive either application of ALA for 1 hour followed by activation with blue light or pulsed dye laser or topical 5-FU. Efficacy was evaluated by grading AK lesions and photoaging signs. Tolerability was assessed by scoring crusting/erosions, erythema and stinging/burning. Treatment with PDT using ALA plus blue light was as effective as topical 5-FU in clearing AK. PDT using ALA plus laser light was the least effective treatment. All treatments made improvements in the signs of photoaging. Both PDT treatments were better tolerated than 5-FU. In conclusion, broad area PDT treatment with ALA plus activation with blue light appears to be as effective as 5-FU in the treatment of AK. ALA plus laser light is somewhat less effective than the above therapies. Efficacy could likely be improved with further study of laser parameters and incubation times.