Current status of surgery in dermatology.

An article titled "Current issues in dermatologic office-based surgery" was published in the JAAD in October 1999 (volume 41, issue 4, pp. 624-634). The article was developed by the Joint American Academy of Dermatology/American Society for Dermatologic Surgery Liaison Committee. A number of subjects were addressed in the article including surgical training program requirements for dermatology residents and selected advances in dermatologic surgery that had been pioneered by dermatologists. The article concluded with sections on credentialing, privileging, and accreditation of office-based surgical facilities. Much has changed since 1999, including more stringent requirements for surgical training during dermatology residency, and the establishment of 57 accredited Procedural Dermatology Fellowship Training Programs. All of these changes have been overseen and approved by the Residency Review Committee for Dermatology and the Accreditation Committee for Graduate Medical Education. The fertile academic environment of academic training programs with interaction between established dermatologic surgeons and fellows, as well as the inquisitive nature of many of our colleagues, has led to the numerous major advances in dermatologic surgery, which are described herein.

A decade of experience with injectable poly-L-lactic acid: a focus on safety.

BACKGROUND: Injectable poly-L-lactic acid (PLLA) is a biodegradable synthetic polymer device that stimulates collagen production, leading to gradual volume restoration. It has been used worldwide for more than a decade to treat the lines and wrinkles of the aging face and in individuals with the human immunodeficiency virus for treatment of facial lipoatrophy. OBJECTIVE: To provide an overview of the experience with injectable PLLA in Europe and the United States and the practices that have improved product use. MATERIALS AND METHODS: A review of the literature was conducted, and the authors' clinical experience was included detailing the evolution of the use of injectable PLLA for facial restoration. RESULTS: Although relatively high rates of nodule and papule formation were reported during early use of injectable PLLA, updated methods have led to better safety and efficacy, including patient selection, preparation, and instruction; product preparation; timing of injections and avoidance of overcorrection; an updated understanding of the anatomy of the aging face; and site-specific injection techniques. CONCLUSION: Important lessons have been learned that have enhanced the safety and efficacy of injectable PLLA and have made it a desirable product for restoring facial volume.

Cutaneous Manifestations of Nutritional Deficiencies in the Context of Food Deserts of United States.

Food deserts exist due to a multitude of factors ranging from socioeconomic status, racial disparities, geography, cost, and healthful food access. Given the vast biological function of vitamins and minerals, the clinical presentation for nutritional deficiencies ranges from benign to life-threatening. Often, the first indicators of underlying nutritional deficiencies are cutaneous manifestations. The first patient case is a 36-year-old female at 25 weeks gestation with a pruritic and painful rash that began in the genital region and spread centrifugally to her legs. The second patient case is a 42-year-old male with a pruritic rash that began at his abdomen and progressed to his thighs. The third patient case is a 48-year-old female with scattered lower extremity ecchymoses in different healing stages and scattered perifollicular erythema with corkscrew hairs. All three patients were found to have nutritional deficiencies and lived in identified food deserts. Deficiencies of zinc, vitamin A, thiamine, pyridoxine, and vitamin C and their subsequent cutaneous manifestations have scarce documentation within food deserts. These cases provide further insight into nutritional deficiencies and offer an opportunity for providers to identify patients at risk. To promote wellness, patients suffering from food insecurity must be identified efficiently and connected with essential resources.

The tower technique: a novel technique for the injection of hyaluronic acid fillers.

A number of injection techniques have been described for the placement of hyaluronic acid fillers. Such techniques include, but are not limited to, linear threading, depot, fanning, and layering. The tower technique for hyaluronic acid filler injection is a novel variation of the depot and layering techniques. With this technique, the hyaluronic acid is deposited via a perpendicular approach to the deep tissue plane with a gradual tapering of product deposition as the needle is withdrawn. A series of towers or struts are thus created. These towers serve as support structures for the overlying soft tissue, thereby restoring the face to a more youthful appearance. The anatomic areas most amenable to this technique include the lateral brow, the nasolabial folds, the marionette lines, the prejowl sulcus, and the mental region. A detailed description of the tower technique for facial volume restoration with hyaluronic acid fillers is provided. Further prospective studies are needed to compare the efficacy, safety, and longevity of this technique to other commonly used techniques for the injection of hyaluronic acid fillers.

Hodgkin lymphoma presenting as generalized pruritus in an adolescent.

Pruritus is a common manifestation of Hodgkin lymphoma (HL), and given its high frequency, inclusion of itching as a B symptom of HL has been proposed. We present a 16-year-old adolescent boy with treatment-refractory eczema of 2 years' duration. Physical examination revealed a thin adolescent boy with widespread excoriations, but no eczematous or primary cutaneous lesions were identifiable. Lymph node examination revealed palpably enlarged nodes in the cervical and supraclavicular regions. Laboratory studies revealed leukocytosis and an elevated lactate dehydrogenase level. Diffuse lymphadenopathy was detected on a chest radiograph, and excisional lymph node biopsy revealed HL (nodular sclerosing subtype). The patient was classified as HL stage IIIB (Ann Arbor staging classification) after further evaluation. Chemotherapy was initiated followed by radiation therapy. The patient's pruritus markedly improved within 2 cycles of chemotherapy; however, his HL relapsed and additional salvage combination chemotherapy followed by high-dose chemotherapy and autologous stem cell transplant were required. This case underscores the need for a complete history as well as a careful skin and systemic evaluation in patients presenting with long-term pruritus, including children and adolescents.

Metabotropic glutamate receptor 2 and 3 gene expression in the human prefrontal cortex and mesencephalon in schizophrenia.

Group II metabotropic glutamate receptors (mGluR2 and mGluR3) are implicated in schizophrenia. We characterized mGluR2 and 3 mRNA in the human prefrontal cortex (PFC) and mesencephalon, and then compared cases with schizophrenia to matched controls. In the human brain, both receptors were expressed in the PFC and, unlike the rodent, in dopaminergic (DA) cell groups. In schizophrenia, we found significantly higher levels of mGluR2 mRNA in the PFC white matter. The expression of mGluR2, 3 in DA cells provide a mechanism for glutamate to modulate dopamine release in the human brain and this species-specific difference may be critical to understanding rodent models in schizophrenia.

Advertising in dermatology journals: journals' and journal editors' policies, practices, and attitudes.

BACKGROUND: Problems in some advertisements in medical journals, including dermatology journals, have been identified in various studies. Examples have included poorly supported claims, failure to balance claims of efficacy with potential adverse effects of a drug, and slogans that recommend prescribing a drug for groups of patients different from those assessed in a referenced study. OBJECTIVE: We sought to assess dermatology journals' and dermatology journal editors' policies, practices, and attitudes toward prescription-medicine advertising in dermatology journals. METHODS: We searched dermatology journals' paper copies and World Wide Web sites for statements of advertising policy and sent surveys to dermatology journal editors. RESULTS: Of 22 journals, 8 (36.4%) had an advertising policy published in a paper copy or a World Wide Web site. Of 17 editors (70.8%) from 17 journals (77.3%) who responded to the survey, 3 reported having an advertising policy; these policies were also identified in searches of paper copies or World Wide Web sites. Two editors whose journals each had a published policy reported not having one. In all, 7 editors (41.2%) reported that they or other physician members of the editorial board reviewed advertisements before publication in the previous year. A total of 8 editors (47.1%) agreed somewhat or strongly that advertisements in medical journals, including dermatology journals, generally present information that is accurate, and 12 (70.6%) agreed somewhat or strongly with the same statement regarding advertisements appearing in their own journal. In all, 12 editors (70.6%) agreed somewhat or strongly that advertisements should be reviewed for accuracy by the editorial staff before publication, and 3 (17.6%) agreed somewhat or strongly that advertisements should be reviewed for accuracy before publication in a peer-review process similar to that used for submitted manuscripts. LIMITATIONS: This study did not assess processes by which editors or other members of editorial or publishing staffs review advertisements before publication. CONCLUSIONS: Policies, practices, and attitudes toward advertising vary among dermatology journals and dermatology journal editors. Journals, especially those without a policy, should consider establishing policies to separate and, therefore, minimize conflicts of interest between editorial and business aspects of publication.

Merkel cell carcinoma: a review.

Merkel cell carcinoma (MCC) is a rare neuroendocrine tumor of unknown origin that usually presents in the elderly population. A novel polyomavirus has been associated with a large percentage of tumors. Immune response plays an important role in pathogenesis of MCC. This article reviews the history, pathogenesis, presentation, and treatment of MCC. Future treatments also are discussed briefly.

Downstream coding region determinants of bacterio-opsin, muscarinic acetylcholine receptor and adrenergic receptor expression in Halobacterium salinarum.

The aim of this work is to develop a prokaryotic system capable of expressing membrane-bound receptors in quantities suitable for biochemical and biophysical studies. Our strategy exploits the endogenous high-level expression of the membrane protein bacteriorhodopsin (BR) in the Archaeon Halobacterium salinarum. We attempted to express the human muscarinic acetylcholine (M(1)) and adrenergic (a2b) receptors by fusing the coding region of the m1 and a2b genes to nucleotide sequences known to direct bacterio-opsin (bop) gene transcription. The fusions included downstream modifications to produce non-native carboxyl-terminal amino acids useful for protein identification and purification. bop mRNA and BR accumulation were found to be tightly coupled and the carboxyl-terminal coding region modifications perturbed both. m1 and a2b mRNA levels were low, and accumulation was sensitive to both the extent of the bop gene fusion and the specific carboxyl-terminal coding sequence modifications included. Functional a2b adrenergic receptor expression was observed to be dependent on the downstream coding region. This work demonstrates that a critical determinant of expression resides in the downstream coding region of the wild-type bop gene and manipulation of the downstream coding region of heterologous genes may affect their potential for expression in H. salinarum.

Recessive dystrophic epidermolysis bullosa: a review of disease pathogenesis and update on future therapies.

OBJECTIVE: Review the pathogenesis of recessive dystrophic epidermolysis bullosa and provide an update on research currently underway that is aimed at treating and potentially curing this severe skin disorder. DESIGN: Review article. SETTING: Private practice and large teaching hospital. PARTICIPANTS: None. MEASUREMENTS: N/A. RESULTS: Currently, patients with recessive dystrophic epidermolysis bullosa are managed with only supportive care. However, there are several promising new treatment avenues that may help patients in the future. These include gene therapy, cell therapy, and protein-based therapy. Each approach offers distinct advantages and disadvantages. CONCLUSIONS: The advances in understanding the molecular basis for epidermolysis bullosa over the last few decades has led to significant progress in devising new treatment options. Though many of these approaches remain several years away from regular implementation, it is an exciting time for research in the field.

It is better to flush than to break under pressure.

In this issue Fromy et al. describe alterations in pressure-induced vasodilation in the populations most prone to development of pressure ulcers of the skin. Advancing our understanding regarding the basic pathophysiological mechanisms mediating the development of pressure ulcers will allow for better delineation of populations at risk. This study provides novel insights into this important and poorly understood entity, using tools that are potentially deployable into clinical practice.

Effectiveness of recombinant human platelet-derived growth factor for the treatment of diabetic neuropathic foot ulcers.

The goal of this study was to estimate the effectiveness in actual clinical practice of recombinant human platelet-derived growth factor (rhPDGF) for the treatment of diabetic neuropathic foot ulcer (DNFU). Previously published pivotal trials have shown that by the 20th week of care 35 percent more ulcers healed in the group randomized to receive rhPDGF than those who did not receive rhPDGF (i.e., a relative risk [RR] of about 1.35). This represents an estimate of the efficacy of rhPDGF under the tightly controlled conditions of randomized clinical trials. Treatment effectiveness under standard clinical practice was estimated in a retrospective cohort study, controlling for treatment selection bias using propensity scores. We noted 24,898 individuals with a DNFU, of whom 9.6 percent received rhPDGF. We successfully created a propensity score model that evenly balanced many wound characteristics between those who received rhPDGF and those who did not. We created five groups, which varied from those least likely to receive rhPDGF to those most likely to receive rhPDGF. The RR, controlling for the propensity, to receive rhPDGF for a healed wound after treatment with rhPDGF as compared with standard care was 1.32 (1.22, 1.38). With respect to amputation, the RR for undergoing amputation after receiving rhPDGF was 0.65 (0.54, 0.78) as compared with those who did not receive rhPDGF. Within the limitations of our study, rhPDGF is more effective than standard therapy in both helping a wound to heal and preventing amputation, and its effect is similar to the efficacy estimates from previously published randomized controlled trials.

Reducing the incidence of foot ulceration and amputation in diabetes.

Diabetes is a common disease that is associated with numerous complications, including foot ulceration and amputation. In diabetic patients, the incidence of foot ulcers ranges from 1.0% to 4.1%, and the incidence of lower-extremity amputations ranges from 2.1 to 13.7 per 1000. Risk factors for developing foot ulcers and subsequent amputation include neuropathy, peripheral vascular disease, and trauma. To reduce these complications, several preventive strategies have been devised, from reducing risk factors to improving treatment and management.