Topical Human Epidermal Growth Factor in the Treatment of Senile Purpura and the Prevention of Dermatoporosis.

BACKGROUND: Senile purpura presents itself as a largely unexplored challenge as it has been long thought of as a benign condition without long-term health sequelae. It is becoming increasingly accepted that skin aging not only results in cosmetic disturbances, but as a functional ones. With modern increases in lifespan, skin atrophy associated with solar damage is presenting as a clinically significant inability to mechanically protect patients. This chronic cutaneous insufficiency/fragility syndrome was recently termed dermatoporosis and senile purpura appears to be a visible marker of early stage dysfunction. OBJECTIVE: To examine the effects of topically human epidermal growth factor on the clinical presence of senile purpura and its effect on skin thickness as measured via cutaneous ultrasound. METHODS: Six subjects applied human epidermal growth factor morning and night for six weeks. Clinical outcomes were evaluated by comparing initial clinical photos to 6-week photos and performing a blinded investigator's global assessment (IGA). Skin thickness was evaluated via cutaneous ultrasound measurement. RESULTS: Ultrasound measurements indicated a mean skin thickening of 195.2 ± 35.7 um (SEM) over 6 weeks. The average number of purpuric lesions decreased from 15 ± 4.6 (SEM) to 2.3 ± 0.7 (SEM) over that same period. CONCLUSION: Senile purpura presents itself as a cosmetic disturbance posing significant psychological distress and serves as a marker of the severity of skin thinning. In this study, we demonstrate that topical h-EGF diminishes the appearance of senile purpura by thickening skin and may help prevent the development of late stage dermatoporosis.

Effect of Carbon Dioxide Facial Therapy on Skin Oxygenation.

BACKGROUND: Recently popularized in the field of cosmetic dermatology, subcutaneous carbon dioxide (CO2) injections have been shown to improve the skin's appearance by augmenting oxygen delivery and thereby aiding cellular metabolism and neocollagenesis. However, they carry several risks and cannot be used on the entire face, leaving them best suited for the treatment of localized skin concerns. To combat these issues, a less invasive CO2 facial suited for full-face treatment has been developed, though its efficacy in oxygenating the skin has not been thoroughly investigated. OBJECTIVE: The aim of this study was to evaluate the ability of the CO2 facial to oxygenate the skin. METHODS AND MATERIALS: Twelve patients were enrolled in this split-face study. They were treated one week apart with a CO2 facial on one side of the face and particle-free microdermabrasion on the other. Measurements of transcutaneous oxygen tension (tcPO2) were recorded at baseline and after each treatment. Statistical significance was assessed by comparing the average tcPO2 difference in mmHg following microdermabrasion and after a carbon dioxide facial using a 1-tailed paired t-test (α = 0.05).
RESULTS: The average increase in tcPO2 after CO2 facial treatment was statistically significantly greater (p = .0252) than after microdermabrasion. CONCLUSION: Carbon dioxide facials improve skin oxygenation immediately following treatment, attributable to the generation of an artificial Bohr effect.

Improvement in Atrophic Acne Scars Using Topical Synthetic Epidermal Growth Factor (EGF) Serum: A Pilot Study.

BACKGROUND: Atrophic acne scars are a common and psychologically devastating sequela of acne vulgaris that are refractory to the vast majority of topical treatments. OBJECTIVE: We evaluated the efficacy of a topically applied synthetic epidermal growth factor (EGF) serum in reducing the appearance of atrophic acne scars. METHODS: A single-center clinical trial was performed on nine self-selected male and female patients with Goodman & Baron grade II-IV atrophic acne scars. Subjects followed a standardized treatment regimen, including twice-daily application of EGF serum to scarred areas over 12 weeks. Subject progress was evaluated at baseline and 4-week intervals by clinical photography, Investigator Global Assessment (IGA), Goodman grade and patient self-assessment. Final patient perceptions were shared by written self-assessment at the end of the study. Before and after photographs were also evaluated by a blind investigator. RESULTS: Eight subjects completed the trial. Compared to baseline, there was an improvement in mean IGA score from 2.875 (SEM= .327) to 2.38 (SEM = .375). Mean Goodman grade was reduced from 3.00 (SEM = .309) to 2.75 (SEM = .25). Of the eight pairs of before and after photographs given to a blind investigator, five were correctly chosen as the post-treatment image. Two were assessed as "excellent" (76-100%) improvement and three were assessed as "good" (50-75%) improvement. A one-tailed paired student t-test (α = .05) using blind investigator ratings of scar severity for each before and after photograph yielded a P-value of .0019, confirming the difference as statistically significant. On final self-assessment, all but one patient reported "good" to "excellent" improvement in their scars compared to baseline. 75% of patients who received alternative treatments in prior years reported EGF serum to be more efficacious. CONCLUSION: These results suggest that topical EGF may improve the appearance of atrophic acne scars, though further study and more objective evaluation measures are required for definitive conclusions to be drawn.

Pemphigoid Gestationis: A Case Report and Review of Management.

BACKGROUND: Pemphigoid gestationis (PG) is a rare pruritic autoimmune dermatosis associated with several adverse fetal outcomes. An appropriate pharmacotherapy regimen reduces these risks while also providing symptomatic relief. CASE: A woman in her second trimester presented with an intensely pruritic vesiculobullous rash diagnosed as PG. She was started on prednisone and gradually tapered to an appropriate maintenance dose until her uncomplicated delivery of a full-term healthy newborn. CONCLUSION: Proper management of PG requires a suitable pharmacotherapy regimen, close observation, and collaboration with a multi-disciplinary treatment team. These steps are crucial to reduce maternal morbidity, lessen fetal risk, and adequately prepare for the possibility of unfavorable obstetric outcomes.

Reduced appearance of under-eye bags with twice-daily application of epidermal growth factor (EGF) serum: a pilot study.

BACKGROUND: Under-eye bags are a common manifestation of age and a frequent complaint among patients who no longer feel youthful. Non-invasive topical agents are largely ineffective at reducing their appearance. OBJECTIVE: We studied the ability of a topical serum containing epidermal growth factor (EGF) to minimize the appearance of under-eye bags. METHODS: A single-center clinical trial was performed on eighteen volunteer male and female patients with under-eye bags. Subjects applied EGF serum to the infraorbital area twice daily for 12 weeks. At each visit, subjects were evaluated using clinical photography and written self-assessment. A grade on the Merz Infraorbital Hollowness Scale was also given and two independent, blind investigators assigned an Investigator's Global Assessment (IGA) score. At the trial's end, patients shared their final evaluation and perception of results with a questionnaire. RESULTS: Sixteen subjects completed the trial. The final average Merz grade was 1.63 (SEM = .273), statistically significantly lower than the mean baseline average of 2.06 (SEM = .232) (P = .0019). A reduction in average IGA score was also significant (P< .0001). Average initial IGA was 2.75 (SEM = .270) and average final IGA was 2.00 (SEM = .310). All but two subjects reported improvement at the final visit. Improvement was quantified as 76-100% by two subjects, 50-75% by three subjects, and 25-49% by nine subjects. Eleven subjects classified their under-eye bags as milder at the end of the trial compared to the first visit. Seven subjects reported greater satisfaction with their overall facial appearance. Of the subjects who had used other topical treatments in the past, two reported the serum to be "significantly better" and four said it was "better" in treating their under-eye bags. CONCLUSION: Our results offer evidence that topical EGF can reduce the appearance of under-eye bags.

DNA repair enzymes: an important role in skin cancer prevention and reversal of photodamage--a review of the literature.

The incidence of skin cancer continues to increase annually despite preventative measures. Non-melanoma skin cancer affects more than 1,000,000 people in the United States every year.1 The current preventative measures, such as sunscreens and topical antioxidants, have not shown to be effective in blocking the effects of UV radiation based on these statistics. The level of antioxidants contained in the majority of skin creams is not sufficient to majorly impact free radical damage. Sunscreens absorb only a portion of UV radiation and often are not photostable. In this review article, we present the novel use of exogenous DNA repair enzymes and describe their role in combating photocarcinogenesis and photoaging. Topical application of these enzymes serves to supplement intrinsic DNA repair mechanisms. The direct repair of DNA damage by endogenous repair enzymes lessens rates of mutagenesis and strengthens the immune response to tumor cells. However, these innate mechanisms are not 100% efficient. The use of exogenous DNA repair enzymes presents a novel way to supplement intrinsic mechanisms and improve their efficacy. Several DNA repair enzymes critical to the prevention of cutaneous malignancies have been isolated and added to topical preparations designed for skin cancer prevention. These DNA repair enzymes maximize the rate of DNA repair and provide a more efficient response to carcinogenesis.

Through knee amputation: technique modifications and surgical outcomes.

BACKGROUND: Knee disarticulations (KD) are most commonly employed following trauma or tumor resection but represent less than 2% of all lower extremity amputations performed in the United States annually. KDs provide enhanced proprioception, a long lever arm, preservation of adductor muscle insertion, decreased metabolic cost of ambulation, and an end weight-bearing stump. The role for KDs in the setting of arterial insufficiency or overwhelming infection is less clear. The purpose of this study is to describe technique modifications and report surgical outcomes following KDs at a high-volume Limb Salvage Center. METHODS: A retrospective study of medical records for all patients who underwent a through-knee amputation performed by the senior author (C.E.A.) between 2004 and 2012 was completed. Medical records were reviewed to collect demographic, operative, and postoperative information for each of the patients identified. RESULTS: Between 2004 and 2012, 46 through-knee amputations for 41 patients were performed. The mean patient age was 68 and indications for surgery included infection (56%), arterial thrombosis (35%), and trauma (9%). Postoperative complications included superficial cellulitis (13%), soft tissue infection (4%), and flap ischemia (4%) necessitating one case of surgical debridement (4%) and four trans-femoral amputations (9%). 9 (22%) patients went on to ambulate. Postoperative ambulation was greatest in the traumatic cohort and for patients less than 50 years of age, P<0.05. Alternatively, diabetes mellitus and infection reduced the likelihood of postoperative ambulation, P<0.01. CONCLUSIONS: Knee disarticulations are a safe and effective alternative to other lower extremity amputations when clinically feasible. For patient unlikely to ambulate, a through-knee amputation maximizes ease of transfers, promotes mobility by providing a counterbalance, and eliminates the potential for knee flexion contracture with subsequent skin breakdown.

Anna, leaving home--an adolescent girl's journey.

The author presents an in-depth exploration of psychoanalytic process from her work with Anna, a young woman in treatment from age 15 through her 18th birthday, when she left for college. Anna came to treatment with attachment problems and bulimic symptoms embedded in her character structure, the deformation of which had impaired relationships and disrupted developmental processes. A noteworthy aspect of Anna's analysis is a treatment resistance that repeated early issues of abandonment and loss, and that allowed the analyst to experience the centrality of Anna's sadomasochistic relatedness. As this material is analyzed, an erotized transference emerges in which Anna both longs for and fears a special intimacy with her analyst. Talented at working and playing in the transference, Anna is able to use the transference to remember her early life, to learn to experience and tolerate a range of affects, and to explore old and new kinds of attachments. Psychoanalysis helps to put developmental processes back on track and results in significant intrapsychic and interpersonal change, allowing Anna to separate and to leave home.