Dynamic Optical Coherence Tomography of Cutaneous Blood Vessels in Melasma and Vessel Response to Oral Tranexamic Acid.

BACKGROUND AND OBJECTIVES: Melasma may be related to aberrant blood vessels, but there has been no report on the utility of dynamic optical coherence tomography (D-OCT) in studying vessel characteristics in melasma. We studied the characteristics of cutaneous blood vessels in melasma and the effects of oral tranexamic acid (TXA) with D-OCT. STUDY DESIGN/MATERIALS AND METHODS: Six patients with moderate to severe melasma had a D-OCT scanning of the areas on the face affected by melasma and not affected by it. Three of them had scans within 3 months after starting oral TXA and at a follow-up visit. Blood flow at different depths of the skin and vessel diameter were compared between the melasma and normal skin. For those taking oral TXA, we compared the percent change of blood flow and diameter between the melasma and normal skin. RESULTS: Dermal blood flow and vessel diameter were greater in the melasma skin than in the normal skin. Oral TXA reduced dermal blood flow in both the melasma and normal skin, but the reduction was more dramatic in the lesional melasma skin. CONCLUSIONS: D-OCT findings that (i) dermal blood vessels in melasma are increased in size and flow and (ii) oral TXA reduced the vessel size and flow, providing evidence supporting the relationship between melasma and cutaneous blood vessels. D-OCT may be utilized in measuring response to treatments targeting melasma. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Successful Treatment of Cosmetic Oral Mucosal Tattoos Using QS 694-nm Ruby Laser and 755-nm Alexandrite Picosecond Laser.

BACKGROUND AND OBJECTIVES: Q-switched (QS) and picosecond lasers can effectively and safely remove unwanted tattoo pigments. Cosmetic mucosal tattoos are rare and there are only a handful of cases of successful laser tattoo removal, all with QS 1064-nm neodymium-doped yttrium aluminum garnet (Nd:YAG) laser. STUDY DESIGN/MATERIALS AND METHODS: A 19-year-old Fitzpatrick skin-type II female presented for treatment of a 6-month-old, black tattoo on the mucosal surface of her lower lip. She underwent six treatment sessions with a QS 694-nm ruby laser on months 0, 1, 3, 5, 7, and 12. A 30-year-old Fitzpatrick skin-type IV male presented for treatment of a 10-year-old black tattoo on his left buccal mucosa. He underwent one treatment with 755-nm alexandrite picosecond lasers. RESULTS: One month after last treatment, both patients demonstrated marked improvement to the treatment area without scarring or dyspigmentation. CONCLUSIONS: Given the excellent results seen in the patients presented here, the authors recommend that lasers should be the first-line treatment for the removal of unwanted cosmetic mucosal tattoos, which are typically easier to remove than cutaneous tattoos and can be accomplished with various wavelengths in the picosecond and nanosecond domains. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

Clinical spectrum of cutaneous melanoma morphology.

BACKGROUND: Melanoma can mimic other cutaneous lesions, but the full spectrum and prevalence of these morphologic variants remain largely unknown. OBJECTIVE: To classify nonacral cutaneous melanomas into distinct morphologic clusters and characterize clusters' clinicopathologic features. METHODS: All pathologic melanoma diagnoses (occurring during 2011-2016) were reviewed for routine prebiopsy digital photographs (n = 400). Six dermatologists independently assigned lesions into 1 of 14 diagnostic classes on the basis of morphology. Image consensus clusters were generated by K-means; clinicopathologic features were compared with analysis of variance and χ2. RESULTS: Five morphologic clusters were identified: typical (n = 136), nevus-like (n = 81), amelanotic/nonmelanoma skin cancer (NMSC)-like (n = 70), seborrheic keratosis (SK)-like (n = 68), and lentigo/lentigo maligna (LM)-like (n = 45) melanomas. Nevus-like melanomas were found in younger patients. Nevus-like and lentigo/LM-like melanomas tended to be thinner and more likely identified on routine dermatologic examinations. NMSC-like melanomas were tender, thicker, more mitotically active, and associated with prior NMSC. Typical and SK-like melanomas had similar clinicopathologic features. LIMITATIONS: Cluster subdivision yielded diminished sample sizes. Visual assignment was performed without clinical context. CONCLUSION: When primary cutaneous melanomas were assigned into diagnostic groups and subjected to novel consensus clustering, recurrent morphologic patterns emerged. The spectrum of these morphologies was unexpectedly diverse, which might have implications for visual training and possibly clinical diagnosis.

Dermatology on Instagram: An Analysis of Hashtags.

Forty-two percent of Americans search for health-related information on social media platforms, and forty-five percent of consumers report that social media health information influences their decision to seek care.

Botulinum toxin for treatment of Raynaud phenomenon in CREST syndrome.

Calcinosis, Raynaud phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia (CREST) syndrome is a form of a rare, clinical subtype of systemic sclerosis, known as limited systemic sclerosis. Limited systemic sclerosis, including CREST syndrome, manifests as fibrotic skin changes restricted to the hands and face, with vascular, musculoskeletal, and visceral involvement. We present a case of a 75-year-old woman with a longstanding history of CREST syndrome complicated by a digital ulceration and persistent pain associated with recalcitrant Raynaud phenomenon. After failing a number of first-line pharmacologic therapies such as diltiazem, sildenafil, and topical nitropaste, the patient was started on a trial of botulinum toxin for the left second digit, with 10 unit injections into both webspaces for a total of 20 units. Following injection, the patient reported no further baseline pain in the affected finger and an over fifty-percent improvement in discomfort with manipulation of the digit at a follow-up time of one week. The ulceration started healing within the following three weeks. This result was maintained at a follow-up time of six weeks.

Acquired immune deficiency syndrome-related epidemic Kaposi sarcoma.

Kaposi sarcoma (KS) is a vascular neoplasm that is one of the most common human immunodeficiency virus (HIV)-related malignancies. We present the case of a 42-year-old man with a new diagnosis of HIV and acquired immune deficiency syndrome (AIDS)-related epidemic KS.

An Anatomical Approach to Evaluating and Treating Cellulite.

Cellulite is the common rippling or dimpling of skin of the thighs and buttocks of women, formed from a confluence of skin laxity, tethering fibrous septa, and fat herniation. We describe an anatomical approach to evaluating the cellulite patient and selecting the best treatment from among available non-invasive, minimally invasive, and invasive therapies. It is crucial to consider the anatomy of the patient and the morphology of cellulite while choosing a treatment. Diffuse rippling represents increased adiposity and/or increased skin laxity which may stand to benefit from lipolytic and skin tightening modalities. Dimpling represents tethering by fibrous septa which may stand to improve from subcision by minimally invasive devices such as Cell na. Patients with both morphologies may be treated with a combination of treatments or Cellulaze. Careful evaluation of the patient can help identify the best therapeutic strategy. J Drugs Dermatol. 2017;16(1):58-61..

Papular mucinosis, or localized lichen myxedematosis (LM) (discrete papular type).

Lichen myxedematosus is condition characterized by localized areas of dermal deposition of mucin, presenting with firm papules localized to few areas of the body. The condition needs to be excluded from scleromyxedema, which, in addition to the firm papular eruption, has areas of induration and is usually associated with a monoclonal gammopathyand systemic symptoms. We present a 62-year-old woman with a several-year history of asymptomatic, firm papules over the face and arms with no evidence of thyroid disease or a monoclonal gammopathy,which is consistent with a diagnosis of localized lichen myxedematosus, the discrete papular variant. The patient is being treated with a topical calcineurininhibitor.

How we used a patient visit tracker tool to advance experiential learning in systems-based practice and quality improvement in a medical student clinic.

Poorly designed healthcare systems increase costs and preventable medical errors. To address these issues, systems-based practice (SBP) education provides future physicians with the tools to identify systemic errors and implement quality improvement (QI) initiatives to enhance the delivery of cost-effective, safe and multi-disciplinary care. Although SBP education is being implemented in residency programs and is mandated by the Accreditation Council for Graduate Medical Education (ACGME) as one of its core competencies, it has largely not been integrated into undergraduate medical education. We propose that Medical Student-Faculty Collaborative Clinics (MSFCCs) may be the ideal environment in which to train medical students in SBPs and QI initiatives, as they allow students to play pivotal roles in project development, administration, and management. Here we describe a process of experiential learning that was developed within a newly established MSFCC, which challenged students to identify inefficiencies, implement interventions, and track the results. After identifying bottlenecks in clinic operations, our students designed a patient visit tracker tool to monitor clinic flow and implemented solutions to decrease patient visit times. Our model allowed students to drive their own active learning in a practical clinical setting, providing early and unique training in crucial QI skills.

Darier-White disease.

We present a 58-year-old woman with bipolardisorder and with a longstanding history of yellowbrown,hyperkeratotic papules in a seborrheicdistribution and nail changes. Her father andpaternal grandmother had similar eruptions and alsohad psychiatric disease. Histopathologic examinationshowed acantholysis and dyskeratosis, which wasconsistent with Darier-White disease. Darier-Whitedisease is a rare, hereditary disorder that is inheritedin an autosomal dominant manner and that usuallypresents in adolescence or early adulthood dueto mutations in the SERCA2 calcium pump. Theresultant alterations in calcium homeostasis affectdesmosome assembly and lead to acantholysis andapoptosis, which creates the characteristic eruption.Genetic linkage analysis of affected families showsthat a susceptibility locus for bipolar disorder cosegregateswith genetic markers that are found inthe Darier-White disease region. Treatments, whichinclude topical emollients, mild keratolytics, andtopical or oral retinoids, are aimed at improvingthe appearance of skin, relieving symptoms, andpreventing or treating infectious complications.

Rhabdomyosarcoma arising in a giant congenital melanocytic nevus.

A number of lesions have been documented to arise within congenital melanocytic nevi (CMNs). Although the most frequent malignancy arising within a CMN is melanoma, the association between rhabdomyosarcoma and CMN has rarely been documented. We present a case arising in a 4-month-old girl with a giant CMN. She presented for evaluation of a pedunculated lesion at the superior gluteal crease that had been present since birth and exhibited rapid growth. Biopsy of the lesion revealed two distinct components: an expansile proliferation of pleomorphic cells with varying degrees of cellularity and a proliferation of banal-appearing melanocytic nevic cells. The cells of the expansile proliferation displayed a wide range of morphologic features, including nests of round cells, spindle-shaped cells, and more differentiated rhabdomyoblasts within a myxoid, highly vascularized stroma. Cross-striations, a marker of skeletal muscle differentiation, were present. These tumor cells were strongly immunoreactive with desmin, myo-D1, and myogenin. Fluorescence in situ hybridization analysis with PAX3/7-FKHR probes was negative. A diagnosis of embryonal rhabdomyosarcoma in association with CMN was made. Initial excision revealed tumor at the margins, and the patient underwent reexcision with subsequent chemotherapy with vincristine, actinomycin D, and cyclophosphamide. She was disease-free at the 6-year follow-up. It has been postulated that the combination of melanocytic and rhabdomyoblastic cells within the same lesion may imply derivation from a common pluripotent stem cell or neural crest cell. Clinicians following patients with giant CMN should consider rhabdomyosarcoma in the differential diagnosis of lesions arising within the nevus.

Paired facial treatment with 755nm picosecond laser with diffractive lens array and 1060nm laser lipolysis of the submentum: An open-label prospective trial.

BACKGROUND: Performing multiple cosmetic treatments in a single session to target different aspects of facial rejuvenation is an effective regimen. Picosecond lasers with a fractionated handpiece can target fine lines, which can supplement submental fat reduction procedures. However, limited data exist on the safety and efficacy of single-session treatment strategies. AIMS: To assess the safety and utility of paired facial treatment with 755 nm picosecond laser with diffractive lens array (DLA) and 1060 nm laser lipolysis of the submentum. PATIENTS/METHODS: A prospective clinical study investigated the utility of paired facial treatment with 755 nm picosecond laser with DLA and 1060 nm diode laser lipolysis of the submentum. Subjects received treatments during the same session. Subjects were enrolled to receive up to 3 picosecond laser and 2 lipolysis treatments at 2-8-week intervals. RESULTS: Eleven subjects completed the study. Mean age was 52.1 years, and 81.8% were female. Fitzpatrick skin types II-VI were represented. For investigator global aesthetics improvement scores (GAIS), 63.6%, 81.8%, and 85.7% had improvement from baseline at 30-, 90-, and 180-day follow-up, respectively. At 180-day follow-up, 100% maintained improvement from 90-day follow-up. At 90-day follow-up, calculations for neck laxity showed a significant improvement of 11.7% from baseline (p < 0.001) with a mean amount of lift of 42.7 mm2 , which was above the predetermined threshold (20 mm2 ). No serious or unexpected treatment effects were observed. CONCLUSION: Paired facial treatment with 755 nm picosecond laser with DLA and 1060 nm laser lipolysis of the submentum improved clinical aesthetic outcomes. This treatment regimen was demonstrated to be safe, well-tolerated, and well-liked by subjects.

Laser-assisted delivery of tranexamic acid for melasma: Pilot study using a novel 1927 nm fractional thulium fiber laser.

BACKGROUND: Melasma can be associated with immense psychosocial stress, which can impact quality of life. One theory suggests that ultraviolet light can increase plasmin activity in keratinocytes, which has led to the investigation of tranexamic acid for treating melasma, since it possesses anti-plasmin properties. The use of laser-assisted drug delivery can also increase the uptake of topical medications. AIMS: A prospective pilot study was performed to assess the utility of combination treatment with low-energy, low-density 1927 nm fractional thulium fiber laser and topical tranexamic acid for melasma. PATIENTS/METHODS: A total of 10 subjects were enrolled. Each received 5 treatments to the full face with a low-energy, low-density 1927 nm fractional thulium fiber laser. Immediately following treatment, topical tranexamic acid was applied, and subjects were instructed to apply it twice daily for 7 days. Clinical measures, quality of life, and patient satisfaction were assessed. RESULTS: Mean improvements in Melasma Area and Severity Index (MASI) scores were 1.1 (P = .0899), 3.5 (P = .0395), and 2.5 (P = .2429) at 30-, 90-, and 180-day follow-up, respectively. Maximum improvement occurred at 90-day follow-up. The mean improvement of Melasma Quality of Life Scale (MELASQOL) score was 9.6 (P = .0024) at 30-day follow-up. In addition to changes in pigmentation, subjects also believed their skin felt better, looked more radiant, and had improvements in skin texture and tone. CONCLUSION: Combination of low-energy, low-density 1927 nm fractional thulium fiber laser and topical tranexamic acid improved clinical outcomes and quality of life associated with melasma. This combination treatment was safe, well-tolerated, and well-liked by subjects.

Tripeptide and hexapeptide topical as adjunct to nonablative fractional resurfacing for photodamage: A randomized split-face trial.

BACKGROUND: Topical adjuncts have been investigated to improve clinical outcomes associated with laser resurfacing for photodamage and cutaneous aging. One such product is a tripeptide/hexapeptide serum, which has been shown to increase dermal collagen and elastin as well as improve postprocedural recovery following treatments. AIMS: A randomized, blinded, split-face, comparative trial was performed to assess the utility of a tripeptide/hexapeptide serum as a peri-procedural adjunct to nonablative fractional laser resurfacing. PATIENTS/METHODS: A total of 20 subjects were enrolled. Each hemiface was randomized to either tripeptide/hexapeptide serum or bland moisturizer for twice daily application starting 14 days prior to first laser treatment and continuing until 60 days after. All subjects received 2 treatments to entire face approximately 1 month apart with 1927 nm thulium nonablative fractional laser. Clinical measures and immediate postprocedural recovery were assessed. RESULTS: For each hemiface, scores improved for all measures, including global photodamage, lentigines, pores, radiance, texture, and tone at 30 and 60 days. The tripeptide/hexapeptide serum had greater improvements for all measures at both time points, except for radiance at 60 days, which was equal. In cases where clinical ratings differed between sides, tripeptide/hexapeptide serum more frequently had the superior outcome. Overall, subjects were satisfied with tripeptide/hexapeptide serum. No significant adverse events were observed. CONCLUSION: Addition of tripeptide/hexapeptide serum as a peri-procedural adjunct to nonablative fractional laser resurfacing improved various clinical measures of photodamage and cutaneous aging and the immediate postprocedural recovery. The tripeptide/hexapeptide serum was demonstrated to be safe, well-tolerated, and well-liked by subjects.

Recurrence of herpes simplex encephalitis associated with temozolomide chemoradiation for malignant glioma: a case report and review of the literature.

Although herpes simplex encephalitis is not classically considered an opportunistic infection, reactivation of herpes simplex is being seen increasingly in patients with cancer or immunosuppression. The authors present a patient with malignant glioma and HSV-1 encephalitis whose PCR-proven encephalitis recurred after temozolomide (TMZ) chemoradiation despite acyclovir therapy, and summarize details of four other cases of HSV-1 encephalitis associated with TMZ. The similarity among these cases raises the likely need for longer treatment courses and/or oral suppressive therapy in patients at risk for herpes simplex infections who are receiving TMZ.

Yield of downstream tests after exercise treadmill testing: a prospective cohort study.

OBJECTIVES: The purpose of this study was to estimate the frequency and results of downstream testing after exercise treadmill tests (ETTs). BACKGROUND: The utility of additional diagnostic testing after ETT is not well characterized. METHODS: We followed consecutive individuals without known coronary artery disease referred for clinical ETT at a large medical center. We measured the frequency and results of downstream imaging tests and invasive angiography within 6 months of ETT and the combined endpoint of survival free from cardiovascular death, myocardial infarction, and coronary revascularization. RESULTS: Among 3,656 consecutive subjects who were followed for a mean of 2.5 ± 1.1 years, 332 (9.0%) underwent noninvasive imaging and 84 (2.3%) were referred directly to invasive angiography after ETT. The combined endpoint occurred in 76 (2.2%) patients. The annual incidence of the combined endpoint after negative, inconclusive, and positive ETT was 0.2%, 1.3%, and 12.4%, respectively (p < 0.001). Rapid recovery of electrocardiography (ECG) changes during ETT was associated with negative downstream test results and excellent prognosis, whereas typical angina despite negative ECG was associated with positive downstream tests and adverse prognosis (p < 0.001). Younger age, female sex, higher metabolic equivalents of task achieved, and rapid recovery of ECG changes were predictors of negative downstream tests. CONCLUSIONS: Among patients referred for additional testing after ETT, the lowest yield was observed among individuals with rapid recovery of ECG changes or negative ETT, whereas the highest yield was observed among those with typical angina despite negative ECG or a positive ETT. These findings may be used to identify patients who are most and least likely to benefit from additional testing.