Treatment of Iron-Induced Cutaneous Hyperpigmentation With Energy-Based Devices.

OBJECTIVES: Iatrogenic cutaneous siderosis is a well-recognized dermatologic complication after parenteral iron infusion. The condition manifests as discrete, hyperpigmented patches near the site of injection. Most cases do not resolve spontaneously, leading to significant aesthetic and psychological distress to patients. A recent case of iatrogenic cutaneous siderosis at our institution prompted a systematic review of the efficacy of energy-based devices previously reported in the treatment of this condition. METHODS: PubMed and Cochrane databases were searched for all peer-reviewed articles published using the following search terms: "iron OR heme OR hemosiderosis OR siderosis" and "hyperpigmentation OR staining OR tattoo." Articles reporting on energy-based devices in the treatment of iron-induced hyperpigmentation were included. RESULTS: A total of seven articles and 54 total patients were included in this review. All patients, including the patient treated at our institution, were female, with an average age of 44 years. Hyperpigmentation was most commonly associated with intravenous iron infusion (48/54, 89%), on the arm or forearm (44/54, 81%), and used for the treatment of underlying iron deficiency anemia (54/54, 100%). The application of six different nanosecond or picosecond quality-switched laser systems was reported in the treatment of cutaneous siderosis, with wavelengths ranging from 532 to 1064 nm. Spot sizes varied between 2 and 7 mm, with energy fluences spanning 0.5-40 J/cm2 depending on both the device and spot size. Outcomes were measured after an average of 5.4 laser treatments and 10.4 months, with over half of all reported patients experiencing complete clearance (27/50, 54%). Our patient received treatment in three test areas with picosecond alexandrite 785 nm, nanosecond Nd:YAG 532 nm, and picosecond Nd:YAG 532 nm devices. The nanosecond Nd:YAG 532 nm treated area demonstrated the greatest improvement, and the entire arm was subsequently treated with this device. CONCLUSIONS: Despite the often intractable nature of iatrogenic cutaneous siderosis, laser surgery is a reasonable and safe treatment modality for patients seeking cosmetic improvement of this dyschromia. Dermatologists should be aware of this entity and the efficacy of the energy-based devices currently in our armamentarium. A combination approach may need to be utilized with different wavelengths and pulsed widths to target iron pigment in both dermal and subcutaneous layers.

Hypohidrotic Ectodermal Dysplasia Milia Treatment With Fractional Carbon Dioxide Laser and Laser-Assisted Drug Delivery of Triamcinolone.

Hypohidrotic ectodermal dysplasia (HED) is a genetic disorder characterized by hypohidrosis, hypodontia, and hypotrichosis. Skin manifestations, including dyspigmentation and milia-like papules that coalesce into plaques, are difficult to treat. There is no cure for HED, therefore treatment is focused on managing symptoms and improving quality of life. There is limited evidence in the literature for safe and effective treatments improving HED-related facial skin aesthetics. The facial skin rashes caused by HED demonstrate an unmet clinical need in dermatology. Current therapies are limited to prevention methods such as keeping the skin cool by avoiding heat and applying topical moisturizers to help treat dry, pruritic skin. Herein we present a method for successful treatment of a 34-year-old African American male using fractional carbon dioxide CO2 ablative laser with laser-assisted drug delivery of triamcinolone 0.1% ointment that resulted in decreased milia-like papules, improved dyspigmentation, smoother skin tone, and high patient satisfaction. J Drugs Dermatol. 2023;22(11):1130-1132    doi:10.36849/JDD.7650.

Masculinized Drosophila females adapt their fighting strategies to their opponent.

Many animal species show aggression to gain mating partners and to protect territories and other resources from competitors. Both male and female fruit flies of the species Drosophila melanogaster exhibit aggression in same-sex pairings, but the strategies used are sexually dimorphic. We have begun to explore the biological basis for the differing aggression strategies, and the cues promoting one form of aggression over the other. Here, we describe a line of genetically masculinized females that switch between male and female aggression patterns based on the sexual identity of their opponents. When these masculinized females are paired with more aggressive opponents, they increase the amount of male-like aggression they use, but do not alter the level of female aggression. This suggests that male aggression may be more highly responsive to behavioral cues than female aggression. Although the masculinized females of this line show opponent-dependent changes in aggression and courtship behavior, locomotor activity and sleep are unaffected. Thus, the driver line used may specifically masculinize neurons involved in social behavior. A discussion of possible different roles of male and female aggression in fruit flies is included here. These results can serve as precursors to future experiments aimed at elucidating the circuitry and triggering cues underlying sexually dimorphic aggressive behavior.

Antiandrogen therapy with spironolactone for the treatment of hidradenitis suppurativa.

BACKGROUND: Hormonal therapy is a potential treatment for hidradenitis suppurativa (HS). However, few data exist describing the efficacy of spironolactone in treatment of HS. OBJECTIVE: To assess whether spironolactone treatment improves HS disease severity and patient-reported pain. METHODS: We performed a single-center chart review of female patients with HS who were treated with spironolactone between 2000 and 2017. Primary outcome measurements included the HS Physician's Global Assessment (HS-PGA), Hurley staging, inflammatory lesion count, fistula count, and a numeric rating scale for pain. RESULTS: On average, subjects were exposed to 75 mg of spironolactone daily over a 7.1-month follow-up period. Patients achieved significant disease improvement with regard to pain (Δ-1.5 [P = .01]), inflammatory lesions (Δ-1.3 [P = .02]), and HS-PGA score (Δ-0.6 [P < .001]). As expected, no change was found for Hurley stage (Δ0 [P = .32]) or fistulas (Δ0 [P = .73]). There was no difference in improvement between subjects who received less than 75 mg of spironolactone daily (n = 25; average dose, 45 mg/d) and those who received more than 100 mg daily (n = 21; average dose, 112 mg/d). LIMITATIONS: Retrospective nature, limited sample size, and variations in severity measures documented were limiting factors. CONCLUSIONS: Management of HS with spironolactone reduces lesion count, HS-PGA score, and pain. Lower doses appear to be effective and may be an appropriate option for patients with tolerability concerns.

Examining the prior authorization process, patient outcomes, and the impact of a pharmacy intervention: A single-center review.

BACKGROUND: Dermatology experiences a disproportionately high burden of prior authorizations (PAs). OBJECTIVE: To examine the effect of a centralized pharmacy intervention on the PA process and the impact of PAs on patient outcomes. METHODS: A retrospective review of PAs submitted for medications before and after implementation of pharmacy intervention was conducted. RESULTS: PA was required for 8.1% of all prescriptions. PAs were most frequently submitted for topical steroids, topical antibiotics and antifungals, and topical retinoids. Most common indications included acne, psoriasis, and dermatitis. Biologic agents (55.2%) and brand-name only medications (42.8%) required PA at higher rates. Pharmacy intervention resulted in shorter time to PA submission (4 days vs 1 day, P < .001) and decision (6 days vs 1 day, P < .001) and higher approval rates (63.9% vs 80.6%, P < .001) but did not decrease the total number of PAs. Patients with approved PAs had higher likelihood of disease improvement vs those with denied PAs (71.1% vs 58.0%, P = .013). LIMITATIONS: Data were collected from a single academic institution. Patient medication compliance was not assessed. CONCLUSIONS: The current PA process may result in delays in care and a negative impact on patients. A centralized pharmacy intervention is an effective measure but does not eliminate the overall burden of PAs.

Discordance Between Patient Reported Motivations to Seek Treatment for Psoriasis Compared to Television Advertisements.

INTRODUCTION: Despite a growing arsenal of therapies for psoriasis and, consequently, an increasing number of advertisements for these treatments, many psoriasis patients still remain untreated. While the primary treatment seeking motivations for these patients have been identified, it is unknown if the commercials for the medications designed to encourage patient engagement in treatment are relevant to these concerns. METHODS: Online databases for national television advertisements were searched for psoriasis treatment commercials broadcast between 2000 and 2018. Each advertisement video was viewed 3 times and separately assessed for the content displayed or information conveyed in images, text, and voice-over speech. Additionally, references to known patient motivations for seeking treatment, including concerns about skin symptoms or appearance (embarrassment, scaling/flaking, pain, discomfort, itch, etc.) were recorded. RESULTS: A total of 20 commercials were assessed. Of those, 100% emphasized "clear skin" as the result of the treatment that was being marketed. Bothersome skin symptoms, however, were less frequently displayed; scaling/flaking, pain/discomfort, and itch were present in 15%, 5%, and 0% of commercials, respectively. Similarly, text or images displaying sadness, shame or covering of skin were in 40%, 45% and 30% the advertisements, respectively. None (0%) of the commercials evaluated displayed images of people scratching or verbally addressed skin itching as a bothersome symptom of psoriasis. CONCLUSIONS AND RELEVANCE: While the advertisements assessed in this study did exhibit patient concerns regarding skin appearance, skin symptoms including skin itching, flaking, pain and discomfort were not equally addressed. As these are known factors that motivate psoriasis patients to actively engage in treatment, targeted ads that better demonstrate these concerns may help prompt under-treated patients to seek care. J Drugs Dermatol. 2018;17(8):886-887.

Overview and update on biologic therapy for moderate-to-severe hidradenitis suppurativa.

Hidradenitis suppurativa (HS) is a frequently devastating inflammatory skin disorder. Although many treatments have been tried and tested to date, there is only one Food and Drug Administration-approved treatment option, adalimumab, which is currently indicated for moderateto- severe HS. Our understanding of the management of HS with biologic agents and with nonantibiotic and/ or antimicrobial systemic therapies continues to evolve. In this article, we summarize the existing data on biologics and other small-molecule systemic agents, as well as share our personal experiences with the pharmacological management of HS in the clinical setting. Continued challenges that limit our ability to study and treat this disease effectively include a lack of a universally employed scoring system for disease severity, high variability in clinical presentation, high cost of off-label therapy, and the scarcity of long-term studies on treatment response and medication safety.

Salvage Therapy Options for Local Prostate Cancer Recurrence After Primary Radiotherapy: a Literature Review.

PURPOSE OF REVIEW: While recurrence after primary treatment of prostate cancer (PCa) is not uncommon, there is currently no consensus on the most appropriate management after radiation treatment failure. This article seeks to explore the currently utilized modalities for salvage treatment for radiorecurrent PCa. We focused our review on the oncologic outcomes and reported toxicity rates in the latest studies examining salvage radical prostatectomy (SRP), salvage cryotherapy (SCT), salvage high-intensity focused ultrasound (HIFU) and re-irradiation. RECENT FINDINGS: There does not appear to be any significant difference in overall survival for more invasive salvage radical prostatectomy compared to the minimally invasive salvage approaches. Additionally, there seems to be a trend towards lower morbidity rates associated with minimally invasive and focal salvage treatment. We are encouraged by the results presented in this review and find that there is clearly a role for emerging minimally invasive and focal therapies as durable options for salvage treatment in patients with radiorecurrent PCa.

Economics of a Dermatology Practice.

Understanding the economics behind any medical practice comes down to one basic concept: Profit = Revenue - Expenses. This article aims to demystify the details that underlie this simple formula and to provide the budding dermatologist the information and the tools needed to determine their own profitability in the "real world."

Current guidelines for psoriasis treatment: a work in progress.

Psoriasis is a complex chronic autoimmune skin disease with multiple comorbidities that can have a considerable impact on quality of life (QoL). As therapeutic options evolve, physicians should look to treatment guidelines and consensus statements to keep their practice and management of psoriasis patients current with worldwide standards. This article reviews the most up-to-date general guidelines available for the management of psoriasis.