Nonsurgical correction of drooping mouth corners using monophasic hyaluronic acid and incobotulinumtoxinA.

BACKGROUND: Nonsurgical correction of drooping of the corners of the mouth requires a multimodal approach combining botulinum toxin and soft tissue filler injections. OBJECTIVE: To validate a nonsurgical therapeutic approach for correcting a "saddened" appearance characterized by drooping mouth corners, oral commissures, and/or marionette lines. METHODS: In this prospective, evaluator-blinded study, monophasic hyaluronic acid (MHA) was infiltrated to correct drooping mouth corners in four steps, deep oral commissures in two steps, and/or deep marionette lines in two steps, in that order. Then, incobotulinumtoxinA was injected along the depressor anguli oris and mentalis muscles. RESULTS: The total volumes of MHA used in steps 1-4 were 0.2 mL (interquartile range [IQR]: 0.19-0.3) for the right side of the face and 0.25 mL (IQR: 0.2-0.3) for the left side; total volumes in steps 5-8 were 0.18 mL (IQR: 0-0.4) for the right side and 0.15 mL (IQR: 0-0.33) for the left side. The total mean dose of incobotulinumtoxinA was 26.5 units (IQR: 24-28). The median degrees of drooping of the mouth corners were -4° (IQR: -7° to -2°) at baseline, -1° (IQR: -3° to 1°) at post-treatment 2 weeks, and -1° (IQR: -3° to 0°) at post-treatment 3 months. Median Global Aesthetic Improvement Scale scores were 3 (IQR: 2-3) at post-treatment 2 weeks and 3 (IQR: 2-3.75) at 3 months. CONCLUSION: Our results demonstrated that nonsurgical treatment with MHA and incobotulinumtoxinA provides satisfactory therapeutic outcomes in patients with a saddened appearance by correcting drooping of the mouth corners, deep oral commissures, and/or deep marionette lines.

Clinicopathologic review of 19 patients with systemic candidiasis with skin lesions.

BACKGROUND: A diagnosis of systemic candidiasis is often delayed or missed owing to the absence of sensitive, specific, and timely diagnostic tools. Skin lesions are not common, but they can help to rapidly establish a diagnosis. We report on a 14-year experience of systemic candidiasis with skin lesions in our institution. We report the prevalence, clinical findings, histologic findings, etiologic Candida species, underlying conditions, treatment modalities, and outcomes of the cases and compare them with the previous reports. METHODS: We reviewed the medical records and laboratory data of patients diagnosed with systemic candidiasis from June 1989 to September 2002 at Asan Medical Center, Seoul, Korea. We thoroughly reviewed the data on those patients with characteristic skin lesions. We included the cases in which Candida organisms were either shown or cultured from the skin. We also included the patients who had developed the characteristic rash at the onset of infection if there was no other possible explanation for the rash. RESULTS: Of 53 documented systemic candidiasis cases, 19 (35.8%) had the characteristic skin lesions. Fifteen patients (78.9%) had hematologic problems and were neutropenic. The skin lesions were a maculopapular or nodular rash and plaques. In addition to the trunk and proximal extremities, the rash also involved the face and distal extremities. The rashes were mostly purpuric, not consistently associated with underlying thrombocytopenia but also associated with underlying vascular damage as a result of Candida organisms. The underlying vascular damage also caused intraepidermal necrotic and vesicular change. One case of transepidermal elimination of organisms was newly found. The most common causative species was Candida tropicalis in the 19 patients with skin lesions, in contrast with Candida albicans in a total of 53 patients. The mortality rate was 84.2%. CONCLUSIONS: The prevalence of systemic candidiasis-associated skin lesions may be higher than previously reported. Dermatologists should be familiar with the clinical appearance of skin lesions and suspect this fatal infection when seeing neutropenic patients with a resistant fever and accompanying rash.

Lipodystrophia centrifugalis abdominalis in Korea.

Lipodystrophia centrifugalis abdominalis infantilis is a rare disorder described exclusively in Asians. Thirty Korean patients (4 women, 20 girls, and 6 boys) with a clinical and/or histopathologic diagnosis of this disorder were evaluated. The mean age of onset was 6.2 years. Infantile or congenital onset was seen in only three girls and two boys. In 50% of females, onset was after 5 years of age. All patients had involvement of the lower abdomen and groin both as the site of onset and as the main site. Histopathologic analysis showed loss of fat with or without an infiltrate of lymphocytes and histiocytes in the subcutis. Only one patient responded to treatment, an adult female who received photochemotherapy with softening of the lesions and symptomatic improvement. In previous reports, the age of onset of this disorder was at an age younger than 5 years but older than infants, making the term lipodystrophia centrifugalis abdominalis juvenilis more appropriate. In our series, 50% of females had onset after 5 years of age and 12.5% after 18 years of age. In one woman, the lesion that developed at 4 years of age progressed until adulthood. Our study of affected Korean patients showed a fourfold female predilection and later onset in female patients.