Faculty Bibliography

BACKGROUND AND OBJECTIVES/OBJECTIVE: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/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.

BACKGROUND AND OBJECTIVES/OBJECTIVE:) laser has well-demonstrated safety and efficacy in resurfacing treatment of scars in the adult population and in the treatment of pediatric burn scars. However, there is a paucity of literature regarding laser resurfacing of traumatic and surgical scars for cosmetic benefit in the pediatric population, and in majority of cases previously reported, this was done under general anesthesia. STUDY DESIGN/MATERIALS AND METHODS/METHODS:laser resurfacing (FALR) of traumatic or surgical scars at a single center between 2018 and 2019, inclusive. Primary endpoints included safety and tolerance. RESULTS:A total of 31 FALR treatments were performed in 10 patients with traumatic and surgical scars located on the face (age 4-14 years, Fitzpatrick skin type [FST] I-IV, 60% female). Settings ranged from total energy per session 0.02-0.33 kJ, with a 7-mm tip and 30-50% coverage. Nine patients had two or more treatments (average 3, maximum 8) spaced at least 4 weeks apart. All resurfacing treatments were well-tolerated with local infiltration of 1% lidocaine with epinephrine (1:100,000). Six (67%) patients were treated with additional measures including pulsed dye laser, 1927-nm fractional non-ablative low-energy, low-density laser, or intralesional agents (5-fluorouracil, triamcinolone, botulinum toxin). At follow-up (of varied intervals), short-term erythema, as expected, was seen in six patients, and hyperpigmentation in one case (FST IV), both treated with aforementioned alternate devices. Although gradual, improvement in scar appearance and texture was seen with FALR treatments. No additional scarring, infection, or hypopigmentation was seen. CONCLUSIONS:Treatment with fractional ablative laser resurfacing is safe and well-tolerated in the pediatric population in an outpatient setting with local anesthesia. Traumatic scars may cause significant distress to children and parents alike. Multimodal therapy may lead to optimal cosmesis. Given the excellent tolerability, the authors recommend consideration of laser resurfacing in pediatric patients with traumatic or surgical scars when bothersome, either cosmetically or psychologically. Lasers Surg. Med. © 2020 Wiley Periodicals LLC.

Background/Purpose: Patients with systemic sclerosis (SSc) may be at increased risk for severe outcomes with COVID-19, given the high rate of immunosuppressive medication use, underlying lung pathologies, and accompanying co-morbid conditions. Limited data are available on outcomes of COVID-19 infection in these patients.1,2 The American College of Rheumatology (ACR) and the European League Against Rheumatism (EULAR) are collecting provider-entered COVID-19 cases in a registry of patients with rheumatic diseases.3,4 We report number and outcomes of COVID-19 cases in regularly monitored diffuse cutaneous(dc) SSc patients followed in 2 open-label extension (OLE) studies of lenabasum, an orally-administered, non-immunosuppressive, selective cannabinoid receptor type 2 (CB2) agonist.
Method(s): This cohort included participants satisfying ACR/EULAR criteria for SSc who were receiving lenabasum 20 mg BID in the OLE studies in a Phase 2 (NCT02465437) or Phase 3 trial (NCT03398837). Background therapy with immunosuppressive medications was allowed. COVID-19 infection rate was discerned by review of adverse events (AEs) and required a positive COVID-19 test. Outcome of COVID-19 was provided by treating physicians.
Result(s): Four/385 (0.11%) participants suffered a COVID-19 adverse event (AEs), including one serious AE (SAE). Mean age was 52 years (40-77), with 2 females, and all participants were white. Two had interstitial lung disease (ILD) and were being treated with mycophenolate mofetil (Table 1). One with ILD was asymptomatic and tested for Covid-19 because of contact with known COVID-19 positive individuals. This individual was treated with 5 days of hydroxychloroquine. During COVID-19 infection, 3 continued and 1 temporarily stopped lenabasum treatment due to hospitalization (SAE). This participant with ILD was hospitalized for 3 days and discharged home after 2 doses of experimental remdesivir, with full recovery 4 weeks after symptoms began. One received oxygen therapy in the emergency room (ER), then discharged home with oxygen for a week with subsequent full recovery. One symptomatic had an ER visit without requiring oxygen therapy and another asymptomatic did not have an ER visit; both did not require hospitalization and were self-quarantined.
Conclusion(s): The rate of confirmed COVID-19 infections (0.11%) in this cohort of dcSSc patients is about the same as the rate estimated from CDC data of June 5, 2020, adjusted for age (~0.1%). This suggests the diffuse cutaneous SSc subjects in this cohort are not more vulnerable to COVID-19 infection than the general population. All 4 trial participants despite 2 with confirmed ILD had acceptable outcomes, in the context of continued or resumed lenabasum treatments

BACKGROUND:Photodynamic therapy (PDT) is an FDA approved treatment for actinic keratoses (AK's) although multiple off-label indi- cations are reported. Despite frequent use for AK's, no clear consensus exists regarding protocols for overall treatment parameters. METHODS:Retrospective chart review of 1,491 subjects who underwent PDT between 2007 and 2011 at a high volume laser surgery center. Demographic information, clinical history, treatment data, and subsequent diagnosis of skin cancers were recorded. An ex- ploratory subgroup analysis was performed for patients treated for AK and/or squamous cell carcinoma (SCC) that developed SCC or remained SCC-free one year after treatment. RESULTS:The most common indications for PDT were actinic keratoses (n=1404, 94.9%) then NMSC (n=45, 3.0%) The most common treatment site was the head and neck (n=1274, 86.1%). Blue light activation (405-420nm) was used more frequently than red light and visible light. (73.8% vs. 22.8% vs. 6.8%). The most commonly used photosensitizer was aminolevulinic acid (ALA) (98.6%, n=1456). Topical application (97.7% n=1437) of photosensitizer was used more frequently than intralesional administration (2.0%, n=29). 580 patients met subgroup analysis criteria. 66 developed SCC at treatment site (11%). Factors associated with developing SCC were older age, SCC history, Fitzpatrick skin-type 1, and sixty-minute or less incubation times (P less than 0.05 for all factors). The SCC subgroup had a unique distribution of treatment sites (P less than.001). No statistically significant differences were observed for gender or wavelength. CONCLUSION/CONCLUSIONS:There are differences in protocols based on indication and location of lesion. Blue light is preferable for superFIcial lesions and red light for deeper lesions. Intralesional delivery is used more commonly for NMSC. Extremities require longer incubation times. PDT may be more effective with younger patients and longer than sixty-minute incubation times. PDT chemoprevention is independent of light source used. <em>J Drugs Dermatol. 2016;15(11):1420-1426.</em>.

Aesthetics continues to be a rapidly growing field within dermatology. In 2014, Americans spent 5 billion dollars on an estimated 9 million minimally invasive cosmetic procedures. Between 1997 and 2014, the number of aesthetic procedures performed on men increased by 273%. The approach to male aesthetics differs from that of females. Men have a squarer face, a more angled and larger jaw, and equally balanced upper and lower facial proportions. Facial muscle mass, subcutaneous tissue, and blood vessel density are also increased in men relative to women. While many of the same cosmetic procedures are performed in males and females, the approach, assessment, and treatment parameters are often different. Improper technique in a male patient can result in feminizing facial features and patient dissatisfaction. With an increasing number of men seeking aesthetic procedures, it behooves dermatologists to familiarize themselves with male facial anatomy and the practice of cosmetic dermatology in this population.

BACKGROUND: Facial erythema is a frequent and often distressing complaint of patients with rosacea. Treatment of facial erythema with botulinum toxin has previously been proposed and reported. However, the current literature has mixed results. OBJECTIVE: The primary objective of this study was to evaluate the safety and efficacy of intradermal abobotulinumtoxinA on facial erythema of rosacea. MATERIALS AND METHODS: Twenty-five subjects aged 35 to 70 years with Fitzpatrick skin Types I to IV and facial erythema of erythematotelangiectatic rosacea were enrolled in the trial. Subjects received 15 to 45 units of intradermal injections of abobotulinumtoxinA to the nasal tip, nasal bridge, and nasal alae. A nontreating investigator assessed the facial erythema of rosacea using a standardized grading system (0 = absent, 1 = mild erythema, 2 = moderate erythema, and 3 = severe erythema) to evaluate digital photographs at baseline, 1, 2, and 3 months after treatment. Statistical analysis of erythema grade included one-way repeated-measures analysis of variance and pairwise comparisons using SPSS (IBM Corporation) software. RESULTS: Fifteen of the 25 enrolled subjects completed all the appropriate follow-up visits. Only the 15 subjects with complete data were included in analysis. The subjects were of Fitzpatrick skin Types I to III, a mean age of 54 years, and 80% women. The mean baseline erythema grade was 1.80 (+/-0.56), and the mean erythema grade at 3 months after treatment was 1.00 (+/-0.38). The treatment resulted in statistically significant improvement in erythema grade at 1, 2, and 3 months after treatment when compared with baseline (p < .05, p < .001, and p < .05, respectively). Pairwise comparison to baseline showed a mean erythema grade improvement of 0.80 (p < .001) at 3-month follow-up. CONCLUSION: Intradermal injection of botulinum toxin for the treatment of facial erythema of rosacea seems both effective and safe. Larger, randomized, blinded, placebo-controlled studies are warranted. Additionally, further investigation is needed to elucidate the mechanism of action by which botulinum toxin improves facial flushing of rosacea.

A 68-year-old woman presented for evaluation of a large, red-brown plaque on her left buttock with irregular borders and prominent overlying verrucous changes. The plaque had been present since childhood but over a three-year period had been enlarging with increasing nodularity and easy bleeding with trauma. Histopathologic examination demonstrated an enlarged papillated and polypoid heterogeneous lesion. In part of the specimen, there are bulbous aggregates of small squamous cells with foci of eccrine ductal differentiation. There are other areas with horn pseudocysts, hypergranulosis, and compact orthokeratosis with parakeratosis. There are scattered enlarged heavily pigmented melanocytes, some of which have long and thick dendrites. This collision tumor consisted of an eccrine poroma, a seborrheic keratosis, and a viral wart. The clinical and histopathologic features of collision tumors and poromas are reviewed.

This is a very exciting time in cutaneous laser surgery with an ever-expanding therapeutic armamentarium and an increased sophistication of available technology. These recent trends have allowed for both a rapid development of interest and exploration of laser-assisted drug delivery and its potential applications. We review the current literature on anatomy, technology, and therapeutics as it relates to laser-assisted drug delivery. The focus of our review is on two areas of interest that have received much attention to date - photodynamic therapy in the treatment of actinic keratoses and nonmelanoma skin cancers as well as the treatment of scarring. We will also discuss potential complications of existing modalities used independently and in laser-assisted drug delivery and conclude with future indications for this burgeoning therapeutic methodology.