Anatomic Location Influences Duration of Local Lidocaine Anesthesia in Dermatologic Surgery.

BACKGROUND: Although the onset and duration of local anesthetics are well-defined, how the anatomic site influences the duration of local anesthetics has not been well characterized in dermatology. OBJECTIVE: To define the duration of local anesthesia by anatomic site. MATERIALS AND METHODS: This was a prospective study. Adult healthy volunteers and patients undergoing Mohs micrographic surgery were invited to participate. The nose and the shin were chosen to represent highly and poorly vascularized anatomic sites, respectively. A total of 0.5 mL of buffered 1% lidocaine hydrochloride with 1:100,000 epinephrine was injected subcutaneously into each anatomic site of each participant. A pinprick test was used to assess adequate anesthesia until return of baseline sensation or visit completion. RESULTS: This study enrolled 25 participants. Time to return of sensation was significantly shorter on the nose compared with the shin ( p < .0001). On the nose, there was an association between male sex and shorter time to return of sensation. CONCLUSION: Time to return of sensation is significantly shorter on the nasal ala compared with the shin, suggesting that patients may regain sensation sooner on highly vascularized sites. Defining the duration of local anesthetics based on anatomic regions is important for treatment planning in dermatologic procedures.

Field Therapy for Actinic Keratosis: A Structured Review of the Literature on Efficacy, Cost, and Adherence.

BACKGROUND: Although there are evidence-based guidelines for actinic keratosis management, selecting a cost-effective field therapy is challenging because of limited studies comparing cost, efficacy, and adherence among treatments. OBJECTIVE: To review the literature on field-directed therapies for actinic keratosis, comparing efficacy, cost, and adherence data for topical and in-office treatments. MATERIALS AND METHODS: PubMed, Embase, Web of Science, and Google Scholar databases were searched from October 2020 to March 2021 for articles on field therapy for actinic keratosis. Total cost per regimen was estimated using wholesale acquisition cost package prices and Medicare coverage rates for May 2021. Effective cost was approximated by dividing total cost by complete response rate. RESULTS: Efficacy data for various field therapies range widely, and long-term follow-up is limited. Cross-study comparisons are challenging because of heterogeneity of studies. Field-directed therapy with topical 5-fluorouracil and photodynamic therapy have similar effective cost. Adherence may significantly affect real-world efficacy and long-term clearance; this would favor shorter duration topical regimens or in-office procedures. CONCLUSION: Standardization of future studies examining efficacy of field treatments for actinic keratosis will allow comparison across treatments. In-office treatments such as photodynamic therapy represent a cost-effective alternative to topical therapies with comparable efficacy.

Durable Clearance Rate of Photodynamic Therapy for Bowen Disease and Cutaneous Squamous Cell Carcinoma: A Systematic Review and Meta-Analysis.

BACKGROUND: Although surgery is the treatment of choice for Bowen disease (BD) and cutaneous squamous cell carcinoma (cSCC), nonsurgical treatments such as photodynamic therapy (PDT) may be preferred for select tumors. Previous meta-analysis have failed to gather strong evidence to recommend PDT. OBJECTIVE: This study evaluates the effectiveness of PDT in the treatment of cSCC and BD for clearance rate (CR) after 1 year. METHODS: A literature search of studies of biopsy-proven BD and cSCC treated with PDT was performed. Pooled CRs were estimated. Subgroup analyses were performed based on follow-up, treatment regimen, lesion size, and site. RESULTS: Forty-three studies were included, enrolling 1943 BD lesions and 282 SCC lesions. Pooled CRs for BD and SCC were 76% (95% CI: 71%-80%; I2 = 78.9%) and 51% (95% CI: 35%-66%; I2 = 85.7%), respectively. CONCLUSION: Our findings support the selective use of PDT for BD; however, patients should be advised of potential for recurrence. Although PDT can be used for certain cases of cSCC, the high rate of treatment failure necessitates close surveillance for residual or recurrent disease. Further studies are needed to justify the usage of PDT in the treatment of BD and cSCC.

Cutaneous Reactions to Continuous Glucose Monitoring and Continuous Subcutaneous Insulin Infusion Devices in Type 1 Diabetes Mellitus.

BACKGROUND: Continuous glucose monitoring (CGM) and continuous subcutaneous insulin infusion (CSII) are the standard of care for type 1 diabetes in children. There is little reported on device-related skin complications and treatment options. This study documents cutaneous reactions to CGM and CSII devices in children and young adults with type 1 diabetes. METHODS: One hundred and twenty-one subjects (3-25 years) with type 1 diabetes and CGM and/or CSII use were recruited over a three-month period from the Naomi Berrie Diabetes Center at Columbia University Irving Medical Center. A five-question survey was completed for each subject detailing demographic data, diabetes management, and device-related skin complications. RESULTS: Sixty percent of subjects reported skin complications related to CGM and/or CSII use. Terms most frequently used to describe cutaneous reactions were "red," "itchy," "painful," and "rash." Subjects who used both CGM and CSII were more likely to report skin problems than those who used only CSII (odds ratio 2.9, [95% confidence interval: 1.2-6.7]; P = .015). There were no associations between skin complications and sex or race/ethnicity. Twenty-two percent of subjects with adverse skin event(s) discontinued use of a device due to their skin problem. Seven percent were evaluated by a dermatologist. Eighty-one percent used a range of products to treat their symptoms, with variable perceived clinical outcomes. CONCLUSIONS: Skin complications related to CSII or CGM devices are commonly reported in pediatric patients with type 1 diabetes and may lead to interruption or discontinuation of device use. Future studies are needed to elucidate the causes of these reactions and determine the best methods for prevention.

Integrative analysis of rare copy number variants and gene expression data in alopecia areata implicates an aetiological role for autophagy.

Alopecia areata (AA) is a highly prevalent autoimmune disease that attacks the hair follicle and leads to hair loss that can range from small patches to complete loss of scalp and body hair. Our previous linkage and genome-wide association studies (GWAS) generated strong evidence for aetiological contributions from inherited genetic variants at different population frequencies, including both rare mutations and common polymorphisms. Additionally, we conducted gene expression (GE) studies on scalp biopsies of 96 patients and controls to establish signatures of active disease. In this study, we performed an integrative analysis on these two datasets to test the hypothesis that rare CNVs in patients with AA could be leveraged to identify drivers of disease in our AA GE signatures. We analysed copy number variants (CNVs) in a case-control cohort of 673 patients with AA and 16 311 controls independent of the case-control cohort of 96 research participants used in our GE study. Using an integrative computational analysis, we identified 14 genes whose expression levels were altered by CNVs in a consistent direction of effect, corresponding to gene expression changes in lesional skin of patients. Four of these genes were affected by CNVs in three or more unrelated patients with AA, including ATG4B and SMARCA2, which are involved in autophagy and chromatin remodelling, respectively. Our findings identified new classes of genes with potential contributions to AA pathogenesis.