Efficacy of intralesional immunotherapy for the treatment of warts: A review of the literature.

Warts are common epidermal growths caused by human papillomavirus that often cause significant discomfort and embarrassment. Current treatment options include topical therapies, cryotherapy, laser vaporization, and surgical excision. Many of these options are destructive and may result in scarring, while less aggressive approaches can lead to lesion recurrence. Additionally, these local modalities are not practical for patients with a large number of warts. Systemic approaches such as immunotherapy have demonstrated success in treating multiple lesions by combining a targeted approach with upregulation of the host immune system. An extensive literature review was performed to evaluate the various vaccine antigens that have been used intralesionally to treat cutaneous and anogenital warts. The specific intralesional immunotherapies that have been studied include: Candida albicans; measles, mumps, and rubella; Trichophyton; and tuberculin antigens such as purified protein derivative, Mycobacterium w vaccine, and Bacillus Calmette-Guerin. Intralesional vaccine injection represents a safe, effective, and tolerable treatment for warts, including recalcitrant and anogenital warts. This approach has been somewhat overlooked in the past despite substantial evidence of high response rates with a low side effect profile. Large comparative trials are necessary to determine the most effective immunotherapy treatment option as well as the most appropriate dosing parameters.

Utilization of Optical Coherence Tomography in the Evaluation of Cherry Hemangiomas.

Cherry hemangiomas are common vascular proliferative lesions that can be concerning from a cosmetic perspective. Laser therapy is often used to eradicate cherry hemangiomas, but some lesions require multiple treatments or do not resolve at all. The suboptimal response to laser treatment may be due to limitations in penetration depth by vascular lasers such as the pulsed dye laser. Optical coherence tomography is a low-energy, light-based imaging device that can evaluate the depth and extent of vascular lesions such as cherry hemangiomas by allowing visualization of tissue structure and blood vessel architecture, which cannot be appreciated by clinical or dermatoscopic examination alone. We present optical coherence tomography images of a cherry hemangioma to demonstrate the precision and resolution of this imaging modality. Optical coherence tomography provides valuable information that has the potential to predict response to laser therapy without unnecessary attempts. Future prospective studies will determine its value for this purpose.

J Drugs Dermatol. 2016;15(6):713-714.

The picosecond laser for tattoo removal.

The prevalence of tattoos continues to grow as modern society's stigma towards this form of body art shifts towards greater acceptance. Approximately one third of Americans aged 18-25 and 40 % of Americans aged 26-40 are tattooed. As tattoos continue to rise in popularity, so has the demand for an effective method of tattoo removal such as lasers. The various colors of tattoo inks render them ideal targets for specific lasers using the principle of selective photothermolysis. Traditional laser modalities employed for tattoo removal operate on pulse durations in the nanosecond domain. However, this pulse duration range is still too long to effectively break ink into small enough particles. Picosecond (10-12) lasers have emerged at the forefront of laser tattoo removal due to their shorter pulse lengths, leading to quicker heating of the target chromophores, and consequently, more effective tattoo clearance. Recent studies have cited more effective treatment outcomes using picosecond lasers. Future comparative studies between picosecond lasers of various settings are necessary to determine optimal laser parameters for tattoo clearance.

Lasers and nevus of Ota: a comprehensive review.

Nevus of Ota is a benign dermal melanocytic nevus that typically affects Asian children and women. The nevus presents as unilateral blue-gray hyperpigmented macules and patches scattered along the first and second divisions of the trigeminal nerve. Individuals with nevus of Ota experience emotional and psychosocial distress related to cosmetic disfigurement and often look for treatment options. Unfortunately, even when treated early, lesions of nevus of Ota are still difficult to treat. The use of lasers for the treatment of nevus of Ota lesions has become helpful in the management of dermal nevi. Currently, Q-switched (QS) lasers have been the most studied and demonstrated positive results for treatment of nevus of Ota. The purpose of this review article is to summarize the clinical efficacy and side effects associated with QS lasers and the treatment of nevus of Ota lesions.

Laser and light-based treatments of venous lakes: a literature review.

Venous lake is a benign vascular malformation commonly seen in elderly patients, typically arising in sun-exposed areas of the body. Patients often seek treatment to prevent recurrent bleeding or because they find the lesion cosmetically unacceptable. Venous lake may negatively affect quality of life, due to the cosmetic disfigurement it can create and the resulting psychological distress. Traditional treatments, such as surgical excision, cryosurgery, sclerotherapy, and electrocoagulation, result in varying degrees of success and can cause discomfort. Laser- and light-based treatment modalities may offer a safe and effective alternative, as numerous studies have shown their benefit in the treatment of venous lakes, particularly with the long-pulsed 1064-nm neodymium-doped yttrium aluminum garnet (Nd:YAG). Although various types of lasers and lights have been studied, there remains a lack of general consensus as to which one is the superior laser modality. Further studies that establish standardized protocols to compare the results of using different types of laser treatments are warranted.

Erythroplasia of Queyrat treated by laser and light modalities: a systematic review.

Erythroplasia of Queyrat (EOQ) is a squamous cell carcinoma in situ most commonly located on the glans penis or prepuce. EOQ accounts for roughly 10 % of all penile malignancies and may lead to invasive squamous cell carcinoma. Standard therapy includes local excision, partial or total penectomy, cryotherapy, and topical cytotoxic agents. Treatment of EOQ has proven to be challenging due to low response rates and recurrence. In addition, radical procedures can significantly affect sexual function and quality of life. Alternative laser treatments and photodynamic therapy (PDT) offer promising results for treating EOQ. A systemic review of the literature was performed for articles discussing laser and light therapy for EOQ. Among the patients treated with the CO2 laser, 81.4 % of cases had complete remission after one session of treatment. Patients treated with PDT presented with more variable results, where 62.5 % of those treated with methyl aminolevulinate photodynamic therapy (MAL-PDT) achieved complete remission. Aminolevulinic acid (ALA-PDT) treatment showed a similar rate of remission at 58.3 %. One study utilized the Nd:YAG laser, which resulted in a recurrence of the lesion in four of the five patients treated. Of the methods reviewed, the CO2 laser offered the most promising results with a cosmetically excellent prognosis. Further studies with larger power and longer follow-up times are needed to determine the optimal treatment regimen for this penile malignancy.

Proprotein convertase subtilisin/kexin type 9 (PCSK9) affects gene expression pathways beyond cholesterol metabolism in liver cells.

Proprotein convertase subtilisin/kexin type 9 (PCSK9) induces degradation of low-density lipoprotein receptor (LDLR) in the liver. It is being pursued as a therapeutic target for LDL-cholesterol reduction. Earlier genome-wide gene expression studies showed that PCSK9 over-expression in HepG2 cells resulted in up-regulation of genes in cholesterol biosynthesis and down-regulation of genes in stress response pathways; however, it was not known whether these changes were directly regulated by PCSK9 or were secondary to PCSK9-induced changes to the intracellular environment. In order to further understand the biological function of PCSK9 we treated HepG2 cells with purified recombinant wild type (WT) and D374Y gain-of-function PCSK9 proteins for 8, 24, and 48 h, and used microarray analysis to identify genome-wide expression changes and pathways. These results were compared to the changes induced by culturing HepG2 cells in cholesterol-free medium, mimicking the intracellular environment of cholesterol starvation. We determined that PCSK9-induced up-regulation of cholesterol biosynthesis genes resulted from intracellular cholesterol starvation. In addition, we identified novel pathways that are presumably regulated by PCSK9 and are independent of its effects on cholesterol uptake. These pathways included "protein ubiquitination," "xenobiotic metabolism," "cell cycle," and "inflammation and stress response." Our results indicate that PCSK9 affects metabolic pathways beyond cholesterol metabolism in HepG2 cells.

Scalp psoriasis with increased hair density.

Psoriasis is a chronic autoimmune skin disease that commonly affects the scalp. Psoriatic lesions on the scalp typically result in alopecia, possibly due to a higher proportion of hairs in the catagen and telogen stages. Involvement of the scalp in psoriasis can be problematic for the patient's quality of life as well as the clinician treating the condition. Here, we present an unusual case of scalp psoriasis presenting with increased hair density in the involved area that was resistant to topical steroids.

A review of neurologic complications of biologic therapy in plaque psoriasis.

The use of biologic medications has represented a great advancement in the treatment of moderate to severe plaque psoriasis and has improved patients' quality of life. Despite the increasing popularity of biologics, their neurological side effects have been a constant concern. Reports of demyelinating diseases associated with tumor necrosis factor α (TNF-α) inhibitors continue to accumulate. Additionally, efalizumab was withdrawn from the market in 2009 for causing progressive multifocal leukoencephalopathy (PML). These reports highlight the need for dermatologists to inform patients of the risks and promote informed decision-making with patients prior to starting a biologic agent. Dermatologists also need to recognize early manifestations of neurologic side effects. This review provides an overview of the literature on neurologic diseases that have been found to be associated with biologic agents used for plaque psoriasis. Clinical presentations and diagnostic workups of such diseases are given to aid dermatologists in their early diagnosis and referral.

Comparison of guidelines for the use of TNF inhibitors for psoriasis in the United States, Canada, Europe and the United Kingdom: a critical appraisal and comprehensive review.

PURPOSE: To compare and contrast evidence-based CPGs from leading dermatological organizations for the use of tumor necrosis factor inhibitors (TNFi) in psoriasis. MATERIALS AND METHODS: Guidelines from the British National Institute for Health and Care Excellence (NICE), the British Association of Dermatologists (BAD), the American Academy of Dermatology (AAD), the National Psoriasis Foundation (NPF), and the Canadian Dermatology Association (CDA) were reviewed and compared. RESULTS: Various guidelines are similar regarding treatment initiation but have significant differences regarding topics such as continuous versus intermittent therapy, use in erythrodermic and pustular palmoplantar psoriasis and special patient populations. CONCLUSION: TNF inhibitors remain valuable tools in psoriasis therapy, and guidelines for their use may help clinicians use them effectively.

Vascular Features of Nail Psoriasis Using Dynamic Optical Coherence Tomography.

BACKGROUND: Nail psoriasis is a painful and disfiguring nail disease that often leads to invasive biopsies. Dermoscopy of the hyponychium can be useful in the diagnosis showing twisted coiled vessels. Structural features of nail psoriasis have been described with optical coherence tomography (OCT). OBJECTIVES: To investigate vascular features of nail psoriasis using dynamic OCT. METHODS: This was an observational, prospective, controlled study in which psoriasis patients with psoriatic nail changes and healthy control patients underwent OCT imaging of the distal nail plate and proximal nail fold. Vertical and horizontal OCT images were analyzed to describe structural and vascular features and to quantify blood flow at depth. RESULTS: Sixteen psoriatic nails and 16 control nails were included. Psoriatic nails had significantly increased blood flow in the proximal nail fold at depths of 0.72 mm (p = 0.035) and 0.76 mm (p = 0.027). Nail thickness was significantly greater in psoriatic nails compared to control nails (p = 0.0016). Compared to control nails, psoriatic nails had dilated, disorganized blood vessels superficially in the proximal nail fold. LIMITATIONS: The main limitation of our study is the relatively small sample size. CONCLUSIONS: OCT can identify structural and vascular features specific to nail psoriasis.

Medical Malpractice in Dermatology-Part I: Reducing the Risks of a Lawsuit.

Malpractice risk is a common source of concern for the practicing physician. Dermatologists experience fewer lawsuits than most other specialists in medicine, but the risk is not negligible. All physicians should familiarize themselves with areas of potential risk and avoid medico-legal pitfalls. We present Part I of a two-part series addressing medico-legal questions common to most practitioners that cause a great deal of anxiety. Part I will focus upon risk management and prevention of future malpractice lawsuits, and Part II deals with suggestions and guidance once a lawsuit occurs. Herein, we discuss the primary sources of malpractice lawsuits delivered against healthcare practitioners including issues with informed consent, patient noncompliance, medical negligence, and inappropriate documentation, including use of electronic medical records. The overall goal is to effectively avoid these common sources of litigation. The risk management strategies discussed in this paper are relevant to the everyday practitioner and may offer physicians some degree of protection from potential liability.

Medical Malpractice in Dermatology-Part II: What To Do Once You Have Been Served with a Lawsuit.

Facing a malpractice lawsuit can be a daunting and traumatic experience for healthcare practitioners, with most clinicians naïve to the legal landscape. It is crucial for physicians to know and understand the malpractice system and his or her role once challenged with litigation. We present part II of a two-part series addressing the most common medicolegal questions that cause a great deal of anxiety. Part I focused upon risk-management strategies and prevention of malpractice lawsuits, whereas part II provides helpful suggestions and guidance for the physician who has been served with a lawsuit complaint. Herein, we address the best approach concerning what to do and what not to do after receipt of a legal claim, during the deposition, and during the trial phases. We also discuss routine concerns that may arise during the development of the case, including the personal, financial, and career implications of a malpractice lawsuit and how these can be best managed. The defense strategies discussed in this paper are not a guide separate from legal representation to winning a lawsuit, but may help physicians prepare for and cope with a medical malpractice lawsuit. This article is written from a US perspective, and therefore not all of the statements made herein will be applicable in other countries. Within the USA, medical practitioners must be familiar with their own state and local laws and should consult with their own legal counsel to obtain advice about specific questions.

Clinical pearl: the squeeze maneuver.

Plantar warts can be distinguished from calluses using the squeeze maneuver, a quick and easy method to diagnose plantar warts. This technique negates the need for an expensive diagnostic tool.

Local anesthesia injection technique for aesthetic removal of dermal nevi.

Dermatologists should be aware of the surgical techniques that reduce the level of skin distortion following biopsy procedures. (1) a dilution of lidocaine with bacteriostatic 0.9% sodium chloride and (2) injection of the solution directly into the nevus. The nevus balloons in size and shape and becomes tenser resulting in a change in the skin level permitting for easy shave. Good injection technique of anesthesia may represent a simple, but important means to improve postoperative cosmetic outcomes.

Hedgehog Pathway Inhibitor Therapy for Locally Advanced and Metastatic Basal Cell Carcinoma: A Systematic Review and Pooled Analysis of Interventional Studies.

IMPORTANCE: Hedgehog pathway inhibitors (HPIs) were made available by US Food and Drug Administration approval in 2012 for vismodegib and 2015 for sonidegib. Both target the Smoothened molecule and are indicated for locally advanced basal cell carcinoma (laBCC) and metastatic basal cell carcinoma (mBCC). OBJECTIVE: To evaluate clinical experience with HPIs, including efficacy and adverse effects. DATA SOURCES: We conducted a systematic review in concordance with the PRISMA guidelines of PubMed, the Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and EMBASE, using search terms "vismodegib," "sonidegib," "Erivedge," "Odomza," "basal cell carcinoma," and "BCC." STUDY SELECTION: We included clinical trials, retrospective medical record reviews, and prospective case series that used HPIs for the treatment of laBCC or mBCC in human subjects. Individual case reports and limited, retrospective case series were excluded from our review. DATA EXTRACTION AND SYNTHESIS: Data were extracted independently by 2 reviewers on a predesigned, standardized form. MAIN OUTCOMES AND MEASURES: The following data were recorded: number of patients with laBCC or mBCC, dose and frequency of drug administration, median duration of treatment, clearance and recurrence rates, and adverse effects. RESULTS: Eleven vismodegib articles (published between 2009 and 2015) met criteria for inclusion, and 8 articles were able to be pooled for analysis. The 8 pooled articles included 744 total patients with 704 patients clinically evaluable. Sonidegib did not yield enough publications for a formal analysis. Objective response to vismodegib for laBCC had a weighted average of 64.7% (95% CI, 63.7%-65.6%); complete response averaged 31.1% (95% CI, 30.4%-31.8%). Objective response for mBCC was 33.6% (95% CI, 33.1%-34.2%); complete response averaged 3.9% (95% CI, 3.3%-4.4%). Median duration of therapy was 35.8 weeks (95% CI, 35.1-36.5 weeks). CONCLUSIONS AND RELEVANCE: In a systematic review of HPIs for laBCC and mBCC, vismodegib, but not sonidegib, had enough studies to warrant a pooled analysis. Vismodegib was identified to have a significant, consistent effect on the median duration of therapy of laBCC and mBCC. While mBCC responses are superior to any traditional approach, the response rate for laBCC might be considered in the context of other standard treatment options including surgery and radiation therapy.