Evidence for accelerated skin wrinkling among developmentally delayed individuals with Down's syndrome.

Down's Syndrome (DS) is a genetic disorder involving mental retardation which is reported to be a condition of accelerated aging. However, few studies exist which examine age-dependent changes in DS and these studies fail to include a control group. In the present study a non-invasive, painless, and easily obtainable measure reflecting age-dependent topographical changes of the skin (skin wrinkling) was obtained in 15 DS subjects, 14 developmentally disabled (DD) (mentally retarded) controls (DD controls) and 16 healthy controls of similar ages ranging from 22 to 51 years. The healthy control group failed to show correlations of skin measures with age, as predicted for the age-range of these subjects, based on results of previous studies. However, the DS group showed significant correlations of all skin measures from relatively non-sun-exposed and sun-exposed skin sites, with age. The DD control also showed significant correlations with age of several but not all skin sites and the correlation coefficients tended to be less than that of the DS; at least, when contrasted with the healthy controls the DS showed greater values of several skin measures suggestive of accelerated skin wrinkling. These results provide evidence for accelerated aging of the skin, and possibly greater effects of sun-exposure on skin wrinkling, in DS and possibly (DD) individuals in contrast to healthy individuals without a genetic disorder and without mental retardation.

Promoting sun awareness: evaluation of an educational children's book.

OBJECTIVE: To assess the value of early childhood education as a means of increasing awareness and knowledge about the sun and related skin disease(s). METHODS: A children's book promoting sun awareness and protection was developed. The next was incorporated into the health education curriculum of two third-grade classrooms (n = 82). The students completed a questionnaire before, immediately after, and 6 weeks after reading the text. Student sun awareness knowledge was compared using descriptive statistics and paired T-tests. RESULTS: Behaviors and attitudes that resulted in over-exposure to the sun's ultraviolet light were common among third-graders. Primary test areas included the sun's effect on skin, effective sunscreens, skin type, and skin cancer. Test scores showed a marked improvement (40% compared with baseline) in knowledge of sun protection at both posttests. Parents represented the greatest source of information for children (28 of 82) before this study, while doctors and teachers each accounted for only 1 of 82. CONCLUSIONS: Preventive measures in childhood have the potential to significantly reduce the incidence of sunrelated skin diseases; however, education to date has been directed primarily at presents. This study demonstrated that an educational book for elementary school students can be an effective tool to increase sun awareness and knowledge. The multifaceted approach to prevention recommended here is similar to that of the highly successful dental care campaign, consisting of direct education of children by physicians, teachers, parents, and the media.

Mometasone furoate 0.1%-salicylic acid 5% ointment versus mometasone furoate 0.1% ointment in the treatment of moderate-to-severe psoriasis: a multicenter study.

Topical corticosteroids and keratolytics are both used widely in the management of patients with psoriasis. A combination of the two types of agents may provide enhanced relief. The purpose of this study was to compare the efficacy and safety of the combination ointment mometasone furoate 0.1% plus salicylic acid 5% with that of mometasone furoate 0.1% ointment in the treatment of moderate-to-severe psoriasis vulgaris. A total of 408 patients were enrolled in this controlled, randomized, double-masked, parallel-group, multicenter comparison. Patients applied either mometasone furoate-salicylic acid ointment or mometasone furoate ointment alone to target lesions twice daily for 21 days. Severity of erythema, induration, and scaling were scored at baseline and at days 4, 8, 15, and 22. An evaluation of overall change in disease status of all treated lesions was performed at each follow-up visit. Adverse events were also monitored and scored, including signs of skin atrophy. Beginning on day 8, the combination of mometasone furoate-salicylic acid was significantly more effective than mometasone furoate alone, as indicated by the mean percentage of improvement in total disease scores, mean total disease sign scores, and the individual score for scaling. Similarly, the combination was more effective beginning on day 15, as indicated by the global evaluation of overall clinical response and individual scores for erythema and induration. Both treatments were well tolerated. Mometasone furoate-salicylic acid ointment provides more effective treatment of moderate-to-severe psoriasis than does mometasone furoate ointment alone and is safe and well tolerated.

Reliability of counting actinic keratoses before and after brief consensus discussion: the VA topical tretinoin chemoprevention (VATTC) trial.

OBJECTIVE: To assess the reliability of counts of actinic keratoses (AKs) and the effect of a brief joint discussion of discrepancies on that reliability. DESIGN AND INTERVENTION: Seven dermatologists independently counted AKs on the face and ears before and after a brief joint discussion of discrepancies. SETTING AND PATIENTS: A volunteer sample of 9 patients from the ongoing VA (Department of Veterans Affairs) Topical Tretinoin Chemoprevention (VATTC) Trial. All participating individuals are veterans and have had 2 or more keratinocyte carcinomas (basal or squamous cell carcinoma) in the 5 years before enrollment in the study. MAIN OUTCOME MEASURE: Standard deviation of estimates of the Poisson regression parameter for the dermatologists. RESULTS: Substantial variation was found among the dermatologists in their AK counts. The SD of the parameter estimates for the dermatologists decreased from 0.45 to 0.24 after the brief joint discussion, a 47% decrease (P =.076). The variation attributable to the dermatologists also decreased substantially (chi(2)(6) decrease, 94 to 12). CONCLUSIONS: Actinic keratoses are common, and there is a continuous spectrum of lesions that ranges from sun-damaged skin to squamous cell carcinoma in situ. Clinical distinguishing features may be difficult to delineate precisely. Counts of AK are commonly performed, but appear to be unreliable, even when performed by experienced dermatologists. Joint discussion of discrepancies may enhance the reliability of these counts, although substantial variation remains. Research that relied on these counts must be reevaluated in light of the marked variation among expert observers. Future studies should consider measures to assess and enhance reliability.

Topical corticosteroids in clinical practice: focus on fluticasone propionate.

Topical corticosteroids are the most widely used agents for the treatment of inflammatory skin disease, particularly atopic dermatitis and psoriasis. In selecting the most appropriate steroid preparation to use-among the vast array currently available-the clinician must consider the severity and localization of the disease, the risk of drug-induced adverse reactions, the age of the patient, and the potency of the various agents. Due to differences in bioavailability, the vehicle and application technique of corticosteroids must also be evaluated. Numerous clinical trials have demonstrated that fluticasone propionate-a fluorinated corticosteroid-is effective, safe, well tolerated, and offers the advantage of a low potential for systemic and local side effects.

A systematic review of the safety of topical therapies for atopic dermatitis.

BACKGROUND: The safety of topical therapies for atopic dermatitis (AD), a common and morbid disease, has recently been the focus of increased scrutiny, adding confusion as how best to manage these patients. OBJECTIVES: The objective of these systematic reviews was to determine the safety of topical therapies for AD. METHODS: Databases searched included: OVID Medline, Medline In-Process and Other Non-Indexed Citations, Embase, and the Cochrane Central Register of Controlled Trials. In addition to the articles identified by this search, investigators were also referred to a list of links (most recently updated 25 September 2005) to recent Food and Drug Administration (FDA) studies, reports and meetings regarding the topical calcineurin inhibitors for further potential references. Only fully published papers available in English and data obtained from FDA sites were included. Furthermore, the criteria for inclusion and exclusion for each systematic review were further evaluated at a meeting of all of the content and evidence-based medicine experts participating in this process and alteration of the inclusion criteria was done at that time when it was felt necessary to avoid inclusion of lower-quality data in the review. Qualitative review of the abstracted data was performed and reviewed at a meeting of all of the content and evidence-based medicine experts. RESULTS: While systemic exposure to these topical agents does occur, physiological changes appear to be uncommon and systemic complications rare and have only been found with use of topical corticosteroids. CONCLUSIONS: Based on the data that are available the overall safety of AD therapies appears to be good with the only documented systemic side-effects of therapy those occasionally seen with use of topical corticosteroids.

Current concerns with collagen for soft tissue augmentation.

The Scientific Board of the California Medical Association presents the following inventory of items of progress in dermatology. Each item, in the judgment of a panel of knowledgeable physicians, has recently become reasonably firmly established, both as to scientific fact and important clinical significance. The items are presented in simple epitome, and an authoritative reference, both to the item itself and to the subject as a whole, is generally given for those who may be unfamiliar with a particular item. The purpose is to assist busy practitioners, students, researchers, or scholars to stay abreast of these items of progress in dermatology that have recently achieved a substantial degree of authoritative acceptance, whether in their own field of special interest or another. The items of progress listed below were selected by the Advisory Panel to the Section on Dermatology of the California Medical Association, and the summaries were prepared under its direction.

Alginates. A "new" dressing alternative.

BACKGROUND: Currently, a wide variety of bio-occlusive dressing materials are available. In general, these dressing materials provide a moist wound healing environment that has been shown to promote healing in both human and animal studies. To effectively use these dressings the clinician must have a full understanding of the properties of the materials as well as the pathophysiology of the particular wound. Most recently, a "new" biosynthetic dressing material, the alginates, has become available. OBJECTIVE: To highlight proper use of alginate dressings for the management of acute and chronic wounds. METHODS: Case study and literature review. RESULTS: Alginates were shown to be effective in a wide variety of acute and chronic wounds. CONCLUSION: Alginates possess several unique properties that should prove useful to the dermatologic surgeon as well as the dermatologist. Proper patient selection and use of this "new" dressing material, as well as a review of the literature is presented.

Evaluation of hylan b gel as a soft-tissue augmentation implant material.

BACKGROUND: The ideal soft tissue augmentation material should be an inert, safe, volume-filling material that is easy to use and remains in place over time. Hylan b gel, a cross-linked hyaluronic acid, may have many of these characteristics. OBJECTIVE: We assessed the potential value of hylan b gel as a soft tissue augmentation material. METHODS: A 12-month guinea pig model was used to investigate the tissue effects of hylan b gel versus "collagen" controls. RESULTS: Hylan b gel was found to be biologically compatible and stable in dermal tissues. At 1 year, only hylan b gel implants were evident (12 of 16 test sites). CONCLUSION: In this model hylan b gel performed favorably when compared with the most commonly used soft-tissue augmentation products. The material possesses many desirable implant material characteristics.

Short contact 70% glycolic acid peels as a treatment for photodamaged skin. A pilot study.

BACKGROUND: Glycolic acid has been one of the more commonly used alpha hydroxy acids for the treatment of photodamaged skin. Its value as a quick "skin refreshing" peeling agent has been widely touted. This type of peel differs from a conventional therapeutic peel (eg, phenol, trichloroacetic acid, or a longer time exposure alpha hydroxy acid peel) in that there is little skin reaction and patients can go about their daily routine without concern. OBJECTIVE: To assess the potential value of glycolic acid-based refresher peels as a cosmetic procedure. METHODS: Twelve healthy subjects with at least a moderate degree of photodamage were treated with monthly serial 70% glycolic acid peels over a period of 4 months. In addition to the "peels," six subjects were randomized to a 10% glycolic acid-based moisturizer twice daily. Patients were evaluated monthly and graded on a clinical scale using objective measures. RESULTS: No conclusive differences were noted on histologic evaluation. Ninety percent (9/10) of patients felt that overall they noticed significant improvement, however, there was no distinction between the two treatment options. The improvement in fine wrinkling and pigmentation was primarily seen in the patients who additionally received 10% glycolic emollient twice daily. CONCLUSION: In this limited pilot study, no specific benefit could be assigned to the concomitant use of monthly glycolic acid refresher "peels" in the treatment of photodamaged skin.

Super potent topical corticosteroid use associated with adrenal suppression: clinical considerations.

The potential for a variety of local and systemic side effects from the use of potent topical corticosteroids has long been recognized. However, adrenal suppression has only rarely been documented. We describe two patients with profound hypothalamic-pituitary-adrenal axis suppression resulting from the unregulated use of super potent topical corticosteroids.

Histiocytoid hemangioma: a disease spectrum. Report of a case with simultaneous cutaneous and bone involvement limited to one extremity.

The collective term histiocytoid hemangioma encompasses a spectrum of diseases that share a histologic features characterized by distinctive histiocytoid endothelial cells. Several incompletely defined cutaneous and extracutaneous vascular tumors, including atypical pyogenic granuloma, pseudopyogenic granuloma, papular angioplasia, angiolymphoid hyperplasia with eosinophilia, Kimura's disease, and inflammatory arteriovenous hemangioma, have been included in this group. We describe a 31-year-old Mexican-American man with multiple histiocytoid hemangiomas involving skin, subcutaneous tissue, and bone limited to the left arm and hand. Examination of skin and bone lesion biopsy specimens showed a proliferation of histiocytoid endothelial cells with intracytoplasmic vacuoles and associated vascular lumen formation. Ultrastructural and immunoperoxidase studies supported endothelial cell differentiation. Radiation therapy resulted in significant clinical improvement. Current concepts regarding the clinical and pathologic features of this disease spectrum also are discussed.

Gastric outlet obstruction and epidermolysis bullosa.

We describe a case of pyloric atresia coexisting with epidermolysis bullosa, almost certainly of the junctional type. The coexistence of pyloric atresia and junctional epidermolysis bullosa (PA-JEB syndrome) has been repeatedly observed. This syndrome has several clinical features that distinguish it from Herlitz junctional epidermolysis bullosa (JEB). These include a lack of prominent granulation tissue formation and increased frequencies of genitourinary tract involvement and ear anomalies. Aplasia cutis congenita is sometimes present; esophageal atresia is uncommonly present. In all 12 patients examined to date, normal basement membrane zone expression of laminin-5 biochemically distinguishes PA-JEB syndrome from Herlitz JEB. Mutations in the beta 4 integrin gene have been observed in one patient with PA-JEB syndrome. Thus there are both clinical and biochemical reasons to separate the PA-JEB syndrome from Herlitz JEB. This is the second known case of papillary hyperplasia of the amnion to be seen in any setting. The other was a case of JEB without pyloric atresia.

Oral 2-chlorodeoxyadenosine in psoriatic arthritis. A preliminary report.

OBJECTIVE: To determine if weekly oral 2-chlorodeoxyadenosine (2-CdA) can induce selective lymphocytopenia, and reduce inflammation, in patients with refractory psoriatic arthritis. METHODS: Seven patients with psoriatic arthritis were treated with oral 2-CdA at weekly dosages of 0.3 mg/kg to 0.45 mg/kg for 12 weeks, followed by monthly maintenance therapy. The patients were evaluated after 6 months. RESULTS: The drug treatment produced selective lymphocytopenia, and reduced lymphocyte infiltration into involved skin. One patient did not complete 12 weeks of therapy because of perceived lack of efficacy. Four of the 6 remaining patients had improved joint disease, and 5 of 6 had improved psoriasis. CONCLUSION: Weekly oral 2-CdA appears to be a well-tolerated regimen for the inducement of peripheral lymphocytopenia in patients with psoriatic arthritis. Larger-scale, controlled trials may be warranted.