Dermatologist Use of Intralesional Triamcinolone in the Treatment of Acne.

OBJECTIVE: Despite common administration of intralesional triamcinolone to acne lesions, there is little published data or consensus on best practices. This study aimed to evaluate specific characteristics of intralesional triamcinolone for acne among various dermatology healthcare professionals. DESIGN: One hundred participants (82 attending physicians, 9 physician assistants, 8 other healthcare professionals, and 1 unidentified) from private practices and academic centers completed a 10-question survey to assess specific characteristics of intralesional triamcinolone injections, including frequency, indication, depth of injection, concentration, volume, as development of adverse events. RESULTS: The most common reported concentration of intralesional triamcinolone was 2.5mg/mL (52.5%). The most frequently used volume injected was 0.05mL (42.3%). In total, 61.6 percent of those surveyed answered that they inject into the center of the lesion. Additionally, 50.5 percent of respondents counsel patients on potential adverse effects of hypopigmentation and atrophy before every injection. The majority of respondents (88.8%) reported that less than one percent of their patients returned for adverse events resulting from triamcinolone usage, and 48.4 percent reported that atrophy lasted over six months (48.4%). CONCLUSION: The data collected from this study can offer guidance on best practices in administering intralesional kenalog to patients. While consistency exists for the concentration of triamcinolone used, there was significant discordance in the volumes and depth of triamcinolone injection. Observed skin atrophy rates are extremely low, but they are long lasting when it occurred. We can use these data to refine our treatment techniques as well as improve treatment outcomes and patient satisfaction.

A randomized placebo-controlled single-center pilot study of the safety and efficacy of apremilast in subjects with moderate-to-severe alopecia areata.

Alopecia areata (AA) is a common autoimmune disease that results in non-scarring hair loss. AA pathogenesis is thought to involve multiple inflammatory cytokines. Apremilast is a phosphodiesterase 4 (PDE4) inhibitor that reduces pro-inflammatory cytokine production. Recent studies demonstrate upregulation of PDE4 in human scalp lesions of AA patients and hair regrowth in a humanized AA mouse model upon apremilast treatment, suggesting a possible potential of apremilast in AA. To assess the efficacy and safety of apremilast in AA, we conducted a double-blind, placebo-controlled single-center pilot study in 30 moderate-to-severe AA patients (≥ 50% scalp involvement) that were randomized 2:1 to receive apremilast (n = 20) or placebo (n = 10) orally for 24 weeks. The primary endpoint was the percentage of patients achieving 50% reduction in severity of alopecia tool (SALT) score (SALT50) at 24 weeks compared to baseline, and the secondary endpoints included the percent change in SALT score at weeks 24 and 48. Eight patients in the apremilast arm withdrew prior to week 24 along with two patients in the placebo group, mostly due to lack of efficacy and adverse events. At 24 weeks, only 1 of 12 apremilast-treated subjects achieved SALT50, and similarly 1 of 8 placebo-treated subjects achieved SALT50. The difference between the mean percent improvement in SALT score at week 24 compared to baseline of the two study arms was not statistically significant (p = 0.38). The lack of treatment response in most of our patients argues against a pathogenic role for PDE4 specifically in moderate-to-severe AA, but targeting this pathway may still be of value in patients with mild AA as there is less of an inflammatory burden in this population. However, future larger studies may be needed to conclude apremilast's lack of efficacy in moderate-to-severe AA.

Efficacy and safety of secukinumab treatment in adults with extensive alopecia areata.

Alopecia areata (AA) is a common form of non-scarring hair loss. The pathogenesis of AA is believed to involve multiple inflammatory cytokines, including possibly IL-17A. To assess the efficacy and safety of the IL-17A antagonist secukinumab in AA, we conducted a double-blinded, randomized prospective pilot study in which 11 subjects were treated with either secukinumab (n = 7) or placebo (n = 4) subcutaneously at weeks 0, 1, 2, 3, 4 and every 4 weeks thereafter until (inclusive of) week 20. The primary endpoint for the study was the percentage of patients achieving SALT50 at 24 weeks. A total of three subjects out of 11 completed the study through the primary endpoint, and therefore, we used the last observation carried forward method to analyze the missing data. At the primary endpoint or last completed observation, 0% (0/7) of the secukinumab-treated subjects achieved a 50% reduction in SALT score (SALT50), and likewise, 0% (0/4) of the placebo-treated subjects achieved SALT50. In the secukinumab group, one (14.3%) subject had some hair regrowth, one (14.3%) subject had worsening hair loss, and five (71.4%) subjects had no change in response to treatment. No adverse events attributable to the study drug were observed. The lack of a treatment response to most of our treated patients suggests that the TH17/IL-17 axis likely has no pathogenic role in AA and an alternative therapeutic approach should be considered for this disease. However, due to the low statistical power of this study, future studies may be required to corroborate these findings.

Ideals of facial beauty.

Facial aesthetic procedures are central to cosmetic dermatology. Success depends not only on improving individual structures but also on establishing facial harmony. Several canons of aesthetic dimensions have been described, and these concepts can provide a useful basis for procedural planning. Here, we review aesthetic facial measurements and proportions as well as the variations that may occur in different ethnic groups and the changes that develop with age.

Local anesthetics in cosmetic dermatology.

Local anesthetics play an important role in cosmetic dermatology. Techniques using topical and regional anesthesia provide numerous pain management options for laser and injection treatments. In this article, we review strategies to maximize patient comfort during cosmetic interventions.