Vein imaging laser reduces bruising in bruise-prone botulinum toxin injected patients.

BACKGROUND: Injection-related bruising is a common complication of many injectable treatments including facial injections of botulinum toxin (BTX) for aesthetic use. OBJECTIVE: We have investigated the use of a vein imaging laser (VIL) to observe otherwise non-visible subcutaneous blood vessels in 40 patients who had a history of bruising with past BTX injections to the face during the previous 12 months. METHODS: Over a 4-month period 40 patients, who previously had developed bruising after injectable BTX to the face, were treated with further BTX to the same areas as previously, but using a VIL during the injections. Patients were evaluated for their severity of bruising. RESULTS: 40 patients out of 2400 patients had experienced bruising with a severity score total of 92 (mean per patient 2.3) with BTX injections before VIL use. On injection using the VIL 6 of the 40 patients had bruising with severity score total of 7 (mean 1.16). CONCLUSION: The use of a VIL significantly reduced the frequency and severity of bruising associated with BTX injections.

CTLA4Ig-mediated blockade of T-cell costimulation in patients with psoriasis vulgaris.

Engagement of the B7 family of molecules on antigen-presenting cells with their T cell-associated ligands, CD28 and CD152 (cytotoxic T lymphocyte-associated antigen-4 [CTLA-4]), provides a pivotal costimulatory signal in T-cell activation. We investigated the role of the CD28/CD152 pathway in psoriasis in a 26-week, phase I, open-label dose-escalation study. The importance of this pathway in the generation of humoral immune responses to T cell-dependent neoantigens, bacteriophage phiX174 and keyhole limpet hemocyanin, was also evaluated. Forty-three patients with stable psoriasis vulgaris received 4 infusions of the soluble chimeric protein CTLA4Ig (BMS-188667). Forty-six percent of all study patients achieved a 50% or greater sustained improvement in clinical disease activity, with progressively greater effects observed in the highest-dosing cohorts. Improvement in these patients was associated with quantitative reduction in epidermal hyperplasia, which correlated with quantitative reduction in skin-infiltrating T cells. No markedly increased rate of intralesional T-cell apoptosis was identified, suggesting that the decreased number of lesional T cells was probably likely attributable to an inhibition of T-cell proliferation, T-cell recruitment, and/or apoptosis of antigen-specific T cells at extralesional sites. Altered antibody responses to T cell-dependent neoantigens were observed, but immunologic tolerance to these antigens was not demonstrated. This study illustrates the importance of the CD28/CD152 pathway in the pathogenesis of psoriasis and suggests a potential therapeutic use for this novel immunomodulatory approach in an array of T cell-mediated diseases.

An overview of ultraviolet radiation, sunscreens, and photo-induced dermatoses.

The incidence of sunlight-induced skin aging and skin cancers, particularly melanoma skin cancer, has been increasing in many parts of the world. Authorities are recommending primary prevention programs to reduce cutaneous photodamage and skin carcinogenesis. An integral component of these programs is the use of protective clothing and effective sunscreens. Most modern sunscreens have highly efficient absorption or reflecting capabilities throughout ultraviolet B, partly ultraviolet A, and in some instances infrared wavelengths. Over the last several years, more efficient sunscreening ingredients have been developed for improved skin protection. More recently, direct evidence has demonstrated the effectiveness of sunscreens in their ability to reduce the incidence of solar keratoses. This article reviews the protectiveness of sunscreens and assays that predict their levels of protection.

Induction of ornithine decarboxylase activity and DNA synthesis in hairless mouse epidermis by retinoids.

The ability of all-trans-retinoic acid (RA) and other retinoid derivatives to enhance DNA synthesis and to induce ornithine decarboxylase [L-ornithine carboxylyase; EC 4.1.1.17 (ODC)] activity has been investigated in normal and tape-stripped hairless mouse epidermis. Initial studies showed that the retinoids could inhibit the induction of epidermal ODC activity found 4.5 hr after tape stripping. Ten nmol RA, 13-cis-retinoic acid (13-cis-RA), ethyl-all-trans-9-(4-methoxy-2,3,6-trimethylphenyl)-3,7-dimethyl-2,4,6, 8-nonatetraenoate (aromatic retinoid), or ethyl-p-[(E)-2-(5,6,7,8-tetrahydro-5,5,8, 8,-tetramethyl-2-naphthyl)-1-propenyl]benzoate (arotinoid ethyl ester) applied topically to the skin at 1 hr before tape stripping inhibited the induction of ODC activity. Induction of epidermal ODC activity was inhibited by arotinoid ethyl ester but not by RA, 13-cis-RA, or aromatic retinoid when they were applied to the skin at 24 hr prior to tape stripping. RA applied topically to normal hairless mouse skin induced a dose-dependent increase in epidermal ODC activity, detectable 24 hr or more after treatment. RA induced epidermal ODC activity to levels only 15- to 30-fold less than found after treatment with the potent tumor promoter tetradecanoylphorbol-13-acetate. Epidermal ODC activity was also induced by topical 13-cis-RA, aromatic retinoid, and arotinoid ethyl ester at this time, although in lower amounts than after RA treatment. The induction of ODC activity by RA was itself inhibited by topical arotinoid ethyl ester treatment. RA, 13-cis-RA, and aromatic retinoid induced ODC activity at doses below those required to enhance epidermal DNA synthesis. In summary, we have shown that, in common with other proliferative stimuli, retinoids can induce ODC activity in hairless mouse epidermis per se. Our results suggest that, because of their ability to also inhibit the expression of ODC activity, the induced ODC activity is found only after the retinoids have been depleted. The ability both to inhibit and to induce ODC activity may be related to the action of RA as a weak tumor promoter under certain conditions and as an inhibitor of promotion under others.

Inhibition of ultraviolet-B epidermal ornithine decarboxylase induction and skin carcinogenesis in hairless mice by topical indomethacin and triamcinolone acetonide.

Modulation of ultraviolet-B (UVB) skin carcinogenesis by topical treatment with two antiinflammatory drugs expected to have different mechanisms of action has been studied in the hairless mouse. Indomethacin is a nonsteroidal antiinflammatory agent which may act by inhibiting prostaglandin biosynthesis. Triamcinolone acetonide is a steroidal antiinflammatory agent. Both of these drugs inhibited the induction of epidermal ornithine decarboxylase by UVB when applied topically in a acetone vehicle. A UVB skin tumor study was designed. Groups of mice were irradiated daily with UVB for 20 days, each mouse receiving a total of 17.1 kJ UVB per sq m. Group 1 was treated with acetone immediately after each irradiation; Group 2 received 700 nmol indomethacin in acetone immediately after each irradiation; Group 3 received 14.4 nmol triamcinolone acetonide in acetone immediately after each irradiation. Mice were killed after 52 weeks, and the tumors were excised and examined histologically. Both topical indomethacin and topical triamcinolone acetonide were effective in reducing the incidence and size of the skin tumors induced by UVB. This evidence supports the hypothesis that the induction of ornithine decarboxylase may be a critical component of UVB skin carcinogenesis and that inhibition of ornithine decarboxylase induction can be used as a screen for agents which will inhibit UVB skin carcinogenesis.

Inhibition of ultraviolet-B skin carcinogenesis by all-trans-retinoic acid regimens that inhibit ornithine decarboxylase induction.

There is a correlation between the ability to induce the polyamine-biosynthetic enzyme ornithine decarboxylase (ODC) and the tumor-promoting ability of various carcinogens in mouse epidermis. Some agents which inhibit skin carcinogenesis also inhibit ODC induction. In this study, all-trans-retinoic acid (RA) regimens that inhibited the induction of epidermal ODC by ultraviolet-B (UVB) were tested for their ability to inhibit UVB skin carcinogenesis. Hairless mice were irradiated once daily with UVB for 20 days, receiving a total dose of UVB (17.1 kJ/sq m). Topical RA was applied immediately (RA, one dose) or applied 0, 1, 2, 3, and 4 hr (RA, five doses) after each irradiance. The mice were maintained for 52 weeks and then sacrificed. Groups treated with RA tended to have fewer mice with tumors, fewer tumors per mouse, smaller tumor diameters, and slower growing tumors than did appropriate irradiated control groups. RA given five times was more effective than was RA given one time at inhibiting UVB skin carcinogenesis. These results show that RA treatments that inhibit epidermal ODC induction may be effective in reducing the carcinogenicity of UVB.

Ultraviolet light and epidermal polyamines.

Numerous studies have indicated that the activities of the polyamine biosynthetic enzymes, ornithine decarboxylase (ODC) and S-adenosyl methionine decarboxylase (SAM.D) are increased in hyperplastic and neoplastic growth. The levels of the polyamines themselves, putrescine, spermidine, and spermine are also often altered in these situations. Epidermal ODC activity is greatly elevated in response to tumor promoting chemicals and also in response to irradiation with short-wave length and mid-wave length ultraviolet. In addition, the levels of the epidermal polyamines change after mid-wavelength ultraviolet irradiation, leading to elevation of putrescine and spermidine, but depression of the spermine level. The spermidine to spermine ratio was significantly elevated after chronic ultraviolet irradiation. Preliminary studies on human skin also shows that mid-wavelength ultraviolet light is capable of inducing ODC. Different pharmacological agents have been found to significantly inhibit the ultraviolet induction of epidermal ODC. Topical corticosteroids and indomethacin significantly inhibit ultraviolet induced opidermal ODC. In addition, retinoic acid inhibited the ultraviolet induction of this enzyme in some experimental situations. Long-wave length ultraviolet alone produced no significant induction of ODC, however, certain phototoxic drugs (8-methoxypsoralen and anthracene) in combination with long-wave length ultraviolet did induce epidermal ODC. It is possible that further studies of changing epidermal polyamine metabolism in response to ultraviolet and tumor promoting agents, may lead to a greater understanding of cutaneous carcinogenesis.

Epidermal pyridoxal 5'-phosphate depletion, inhibition of DNA synthesis, and inhibition of the expression of ornithine decarboxylase activity by the vitamin B-6 antagonist 4'-deoxypyridoxine.

The induction of ornithine decarboxylase (ODC) activity may be an essential component of skin tumor promotion. ODC requires pyridoxal 5'-phosphate (PLP) as a cofactor. We have measured the epidermal PLP concentration and investigated its relationship to DNA synthesis and ODC activity in the hairless mouse. The epidermal PLP concentration was approximately 1.0 microgram/g. When tape-stripping was used to induce ODC activity in the epidermis the concentration of PLP was significantly elevated 4.5 h later at the time of peak ODC activity and when DNA synthesis was reduced. Systemic treatment with the vitamin B-6 antagonist 4'-deoxypyridoxine (4-DOP) significantly reduced the epidermal PLP concentration and DNA synthesis. The ODC activity induced in the epidermis 4.5 after tape-stripping in 4-DOP-treated mice was only 17% of that induced in untreated tape-stripped controls. In in vitro experiments it was shown that while 4-DOP does not inhibit ODC activity, a major metabolite of 4-DOP-phosphate (Ki .06 mM), does. In mixing experiments it was shown that the epidermal extracts from 4-DOP-treated mice did not contain significant amounts of ODC inhibitors. 4-DOP may inhibit ODC induction in the epidermis by depleting the PLP content.

Antiinflammatory drug effects on ultraviolet light-induced epidermal ornithine decarboxylase and DNA synthesis.

Ornithine decarboxylase which forms putrescine by the decarboxyalation of ornithine, is the first and probably the rate-limiting enzyme in the biosynthesis of the other polyamines, spermidine and spermine. Epidermal ornithine decarboxylase activity is greatly elevated in response to tumor promoting agents and ultraviolet light. The purpose of this paper is to report modification of ultraviolet-induced epidermal ornithine decarboxylase activity by antiinflammatory agents. Topical triamcinolone acetonide and indomethacin were found to significantly inhibit the UV-B induction of epidermal ornithine decarboxylase in hairless mice when applied following ultraviolet light irradiation. The corticosteroid also showed inhibition of ultraviolet light increased epidermal DNA synthesis. Indomethacin failed to show any inhibition of DNA synthesis. It is suggested that these assays may be used to study drugs that may modulate some ultraviolet light effects on the epidermis.

Linoleic acid effects on epidermal DNA synthesis and cutaneous prostaglandin levels in essential fatty acid deficiency.

An essential fatty acid (EFA) deficient state has been induced in hairless mice. The epidermal changes included hyperkeratosis, hypergranulosis and acanthosis. Epidermal DNA synthesis was increased 3-fold compared with normal diet mice. Prostaglandin E (PGE) and prostaglandin F (PGF) levels, measured by radioimmunoassay, were much reduced in the EFA deficient mice skin. 10% Linoleic acid applied topically for 2 weeks corrected the gross and histological skin abnormalities and reduced epidermal DNA synthesis to normal values. The levels of PGE and PGF were only partially corrected. Linoleic acid applied to normal diet mice increased skin levels of PGE and PGF compared with the control vehicle treated normal diet mice. These results provide further evidence for the importance of essential fatty acids in the control of epidermal proliferation and differentiation. The importance of PGE and PGF in controlling epidermal DNA synthesis in EFA deficiency is less clear.

Retinoic acid modulation of ultraviolet light-induced epidermal ornithine decarboxylase activity.

Irradiation of skin with ultraviolet light of sunburn range (UVB) leads to a large and rapid induction of the polyamine biosynthetic enzyme ornithine decarboxylase in the epidermis. Induction of epidermal ornithine decarboxylase also occurs following application of the tumor promoting agent 12-0-tetradecanoylphorbol-13 acetate and topical retinoic acid is able to block both this ornithine decarboxylase induction and skin tumor promotion. In the studies described below, topical application of retinoic acid to hairless mouse skin leads to a significant inhibition of UVB-induced epidermal ornithine decarboxylase activity. The degree of this inhibition was dependent on the dose, timing, and frequency of the application of retinoic acid. To show significant inhibition of UVB-induced ornithine decarboxylase the retinoic acid had to be applied within 5 hr of UVB irradiation. If retinoic acid treatment was delayed beyond 7 hr following UVB, then no inhibition of UVB-induced ornithine decarboxylase was observed. The quantities of retinoic acid used (1.7 nmol and 3.4 nmol) have been shown effective at inhibiting 12-0-tetradecanoyl phorbol-13 acetate induced ornithine decarboxylase. The results show that these concentrations of topical retinoic acid applied either before or immediately following UVB irradiation reduces the UVB induction of epidermal ornithine decarboxylase. The effect of retinoic acid in these regimens on UVB-induced skin carcinogenesis is currently under study.

Evaluation of sunscreen protection by measurement of epidermal DNA synthesis.

Different sunscreens were tested to determine their protection of epidermis from ultraviolet light effects. Ultraviolet light-induced changes in hairless mouse epidermal DNA synthesis were used for measurement of sunscreen protection. Visual assessment of erythema and edema was also performed. This initial study has evaluated sunscreens containing para-aminobenzoic acid (PABA) as the principle sunscreen chemical. These experiments were conducted using fluorescent sunlamp tubes and hydroxylapatite extraction of epidermal DNA. The ultraviolet light exposure was measured using a recording radiometer. The results showed that the sunscreens tested were able to partially prevent ultraviolet light induced changes in epidermal DNA synthesis. It may be possible to use this assay as one of the initial evaluations of potential ultraviolet light protectants.

Effects of topical prostaglandin E analogue on normal hairless mouse epidermal DNA synthesis.

The in vivo topical effects of a synthetic analogue of prostaglandin E2 (15(S)-15-methyl PGE2 methyl ester [PGE2 analogue]), have been studied on the epidermis of hairless mice. One microgram of the PGE2 analogue increased DNA synthesis significantly by 5 hr, a maximum increase of 390% was reached by 12 hr, and DNA synthesis returned to control levels by 24 hr. Twenty micrograms of the PGE2 analogue reduced epidermal DNA synthesis for 12 hr after application, DNA synthesis was increased at 24 hr, returning to control levels by 48 hr. One hundred micrograms of topical PGE2 had no significant effect on epidermal DNA synthesis over 48 hr, but 1 mug of intradermal PGE2 increased DNA synthesis by 160% at 24 hr. These results suggest that topical 15(S)-15-methyl PGE2 methyl ester is biologically active compared with PGE2.

Histologic changes in the skin of the rhino mouse (hrrhhrrh) induced by retinoids.

The effects of four retinoids, all-trans-retinoic acid (RA), 13-cis-retinoic acid (13-cis-RA), aromatic retinoid, and arotinoid ethyl ester ( arotinoid ) were examined on the skin of the rhino mouse. Rhino mouse skin is characterized by the presence of keratin-containing utricles attached to the epidermis, and subcutaneous cysts, both of which are derived from hair follicles. The utricles were examined in horizontal sheets of epidermis, and in vertical histologic sections. After applications of 0.1 ml of 0.1% RA, 0.1% 13-cis-RA, 0.1% aromatic retinoid, or 0.001% arotinoid in acetone to the dorsal skin for 5 days a week for 2 weeks, there was a reduction of utricle diameter to 45%, 52%, 30%, and 31% of acetone-treated controls, respectively. Histologic examination of the epidermis revealed that a dose-dependent hyperplasia and thickening of the epidermis and the stratum granulosum was induced by the retinoids when given at subtoxic doses, being most marked after arotinoid or RA. The thickness of the walls of the utricles also increased with increasing dose of retinoid, paralleling the changes in the epidermis. After doses of 0.1% RA and 0.001% arotinoid , the utricles resembled the hair follicles of hairless mice. Hyperplasia of the epidermis appears to be a primary effect of retinoids or rhino mouse skin. Hyperproliferation of the utricle wall is accompanied by a reduction in the size of the utricle lumen, preceding eventual differentiation of the utricles to normal-looking pilar units.

Pharmacokinetics of topically applied radiolabeled retinoids in hairless mouse epidermis and dermis after single applications.

The retention of tritium-labeled all-trans-retinoic acid (RA), 13-cis-retinoic acid (13-cis-RA), aromatic retinoid, and arotinoid ethyl ester in the epidermis and dermis of hairless mice was measured up to 24 h following a single topical application in an acetone vehicle. The radioactivity in the tissues was extractable with chloroform:methanol, and the identities of the radioactive species extracted were confirmed as retinoids using thin-layer chromatography. All the retinoids were absorbed into the skin rapidly. After an initial period of distribution and penetration (lasting for about 1 h) the amount of the applied retinoid remaining in the epidermis and dermis decreased more slowly, obeying first order (exponential) decay kinetics. Both the arotinoid and the aromatic retinoid persisted for longer in the epidermis than equivalent doses of RA or 13-cis-RA. The half-lives of the retinoids in the dermis tended to be longer than in the epidermis, except for the arotinoid. Aromatic retinoid persisted for longest in the dermis with a half-life of 11 h.

Psoriasiform dermatosis in a rhesus monkey.

We describe a dermatosis in a rhesus monkey (Macaca mulatta) that has the characteristic features of the human skin disease, psoriasis vulgaris. The monkey was affected by chronic erythematous, scaling plaques that occurred on the scalp, face, dorsal back, the extensor aspects of the limbs and the palms and soles. Subungual hyperkeratosis was present. Skin biopsies of the affected skin showed a regular acanthosis with reduction of granular cell layer, parakeratosis and supra papillary thinning of the epidermis. Foci of inflammatory cells were seen in the upper epidermis. The dermal changes were tortuous capillary loops and benign inflammatory infiltrate, particularly in the papillary dermis, all of which are features of the human skin disease psoriasis vulgaris. The presence of a nutritional deficiency syndrome was excluded and there was no evidence of any systemic disease.

Mutagenicity of urine from psoriatic patients undergoing treatment with coal tar and ultraviolet light.

The possible percutaneous absorption of the mutagens from patients receiving crude coal tar (CCT) and ultraviolet light was investigated. Urine samples were collected from nonsmoking volunteers, smoking, and nonsmoking psoriatic patients. Patients were treated with 1% CCT U.S.P. or 1 to 10% CCT in petrolatum in the evening. The following morning, patients received coal tar baths and then ultraviolet light (mainly 290-320 nm, UVB). Nonpolar organics in urine samples were extracted by adsorption onto XAD-2 resin and the extracted organics assayed in the Ames Salmonella/Microsome test. TA98 was the most sensitive bacterial strain to detect mutagenicity. Except for smoking psoriatic patients, the addition of liver homogenate was necessary to see mutagenicity. No increase in the number of revertants was observed when B-glucuronidase was added to the assay. Of 14 patients studied 12 had at least one mutagenic urine sample. Typical values for nonsmoking psoriatics treated with CCT ranged from 42 to 496 his +/20 ml of urine after the subtraction of spontaneous his + counts (26 +/- 6). Two nonsmoking normal volunteers were found to excrete mutagenic urines. Smoking psoriatic patients ranged from 213 to 1,100 his +/20 ml urine. This study demonstrates the percutaneous absorption of mutagens from CCT and indicates that its effects may not be limited to the skin.

Differential rates of percutaneous absorption through the eczematous and normal skin of a monkey.

A monkey (Macaca fascicularis), diagnosed as having eczematous dermatitis on the basis of histopathology of a skin biopsy, was used to study the percutaneous absorption of 2 anti-inflammatory steroids. Absorption was measured through involved and uninvolved skin by using in vitro diffusion cell techniques. Hydrocortisone (0.5%) and triamcinolone acetonide (0.1%) were applied to the skin in a petrolatum vehicle. After application for 24 h, the permeation of hydrocortisone was approximately doubled (from 2.6 to 5.5% of the applied dose) when diseased skin was used. The absorption of triamcinolone acetonide was enhanced through the eczematous skin during the initial 12 h. At 24 h, however, no significant difference in total absorption was obtained.

Effects of 13-cis retinoic acid therapy on human antibody responses to defined protein antigens.

We have evaluated the in vivo effects of 13-cis retinoic acid (13-cis RA) on human antibody responses to immunization with tetanus toxoid (TT) and keyhole limpet hemocyanin (KLH). Subjects with severe cystic acne were immunized with suboptimal doses (10 micrograms) of KLH 7 d and 3 months after starting retinoid therapy (13-cis RA, 1 mg/kg/day for 4 mo). A standard booster immunization with TT was given along with the initial KLH sensitization. A control group of acne patients received identical immunization regimens, but no 13-cis RA. Plasma retinoid levels were evaluated by reverse-phase HPLC and confirmed that blood-level concentrations of 13-cis RA and metabolites in these acne patients reached values previously demonstrated to be immunomodulatory in vitro. The retinoid had no effect on responses to TT as reflected by the characteristics of increased anti-TT IgG levels or the isotype distribution of the antibody. In contrast, the anti-KLH response was significantly enhanced in the 13-cis-RA-treated group. Whereas anti-KLH antibody was detected in only 4 of 13 control subjects after the secondary immunization, 10 of 13 retinoid-treated subjects had measurable levels of anti-KLH IgG (p less than 0.05). Among the responders, no differences were noted in the isotype distribution of anti-KLH antibody. These results showing enhanced anti-KLH responses induced by 13-cis RA therapy represent the first demonstration in humans that in vivo administration of a retinoid can modulate antigen-specific immune responses.