Treatment of Acne Vulgaris With Salicylic Acid Chemical Peel and Pulsed Dye Laser: A Split Face, Rater-Blinded, Randomized Controlled Trial

Introduction: Pulsed dye laser (PDL) has been used to treat acne lesions and scar erythema by interrupting superficial vasculature. Salicylic acid chemical peels are employed chiefly due to their lipophilic, comedolytic, and anti-inflammatory properties. Although studies have looked at peels and laser therapy independently in acne management, we examined these treatments in combination. Our primary objective was to evaluate the safety and efficacy of concurrent use of salicylic acid peels with PDL versus salicylic acid peels alone in the treatment of moderate to severe acne vulgaris.Methods: Adult patients with moderate to severe acne were included. Subjects received a total of 3 treatments at 3-week intervals. Per randomized split-face treatment, at week 0, one half of the subject’s face was treated with PDL (595 nm) followed by whole face application of a 30% salicylic acid peel. At weeks 3 and 6, the treatments were repeated. At 0 and 9 weeks, patients were assessed with the Global Evaluation Acne (GEA) scale and Dermatology Life Quality Index (DLQI) questionnaire.Results: Nineteen subjects were enrolled, and 18 completed the study. Significant improvement in acne was seen in both the combined (laser and peel) and chemical peel alone treatment arms (P < .0005 and P = .001). Using the GEA scale score, compared to week 0, the mean difference in acne improvement at week 9 was -1.61 in the combination therapy group versus -1.11 in the peel only group. Based on the GEA scale scoring, a statistically significant greater difference in acne improvement was seen, from week 0 to week 9, in the combination treatment group compared with the peel only group (P = .003).Conclusion: While acne subjects had significant benefit from the salicylic acid peel alone, they experienced greater significant benefit from PDL treatment used in conjunction with salicylic acid peels. The adjunctive utilization of PDL to salicylic acid peel therapy can lead to better outcomes in acne management

Perniotic Lupus

A 9-year-old African American female was referred to dermatology for a history of recurring painful, red-purple bumps and blisters on her hands, feet and nose in the winter. She tried topical hydrocortisone 1% cream without improvement, though noted that the previous year she had similar lesions that resolved in the summertime. Family history was notable for lupus and Sjogren’s disease on her maternal side. On the nose and fingertips there were erythematous-to-violaceous papules and plaques. There was fissuring and scaling of the lips and some toes. All toenails and some fingernails were dystrophic with transverse band-like depressions and ragged cuticles. Punch biopsy from a red-purple papule on the right 5th finger revealed perivascular and periadnexal lymphocytic infiltrates within the superficial and deep dermis, papillary dermal edema, and vacuolar lichenoid infiltrate, consistent with perniotic lupus. Perniotic lupus is an erythrocyanotic form of chronic cutaneous lupus erythematosus in which patients have characteristic clinical findings in addition to other features of cutaneous or systemic lupus. The latter differentiates this condition from pernio (i.e. Chillblains). It is important to note that perniotic lupus is also distinct from lupus pernio, which is a form of cutaneous sarcoidosis. Typical lesions of perniotic lupus are edematous red-purple papules, plaques, or nodules that develop in response to cold exposure. They occur most commonly on the dorsal digits however the nose, ears, legs, buttocks, and plantar surfaces can also be affected. Patients often experience pruritus, pain, or a burning sensation and may also develop overlying blisters or ulceration. Perniotic lupus tends to affect young and middle-aged women, however it can also occur in children and men. The pathophysiology is thought to involve an aberrant inflammatory response to cold, triggered by vasoconstriction-induced hypoxemia. Autoantibody-mediated endothelial cell damage and hyperviscosity are also likely contributing factors. The condition is often recurrent with onset in the winter and improvement in the spring and summer months. Treatment therefore primarily focuses on limiting exposure of affected areas to moist, cold environments. Patients should be encouraged to wear well-insulated clothing, gloves, and socks. They may also benefit from medium-to-high potency topical steroids, prednisone, anti-malarials such as Hydroxychloroquine, calcium-channel blockers such as Nifedipine, and Nitroglycerin paste.https://scholarlycommons.henryford.com/merf2019caserpt/1019/thumbnail.jp

Development of sinus tracts within a connective tissue nevus

Background: Connective tissue nevi (CTN) are dermal hamartomas characterized by abnormal proliferation of components of the extracellular dermal matrix, specifically collagen and elastin and/or proteoglycans. CTN present as firm, flesh-colored papules or nodules that coalesce into plaques. They can be sporadic or can be seen in genetic disorders including Buschke-Ollendorff syndrome, Proteus syndrome, tuberous sclerosis, and multiple endocrine neoplasia type 1. We report a case of development of multiple sinus tracts within a connective tissue nevus and our treatment approach. Case report: A 13-year-old Caucasian male with velocardiofacial syndrome presented for evaluation of a lesion on his right posterior neck of approximately 6 years duration. Our patient had a history of cleft palate repair, myringotomy tubes, failure to thrive and reflux but was now in generally good health. On exam, he had a rugated, palm-sized, skin colored to slightly orange plaque on the posterior neck. A punch biopsy demonstrated papillomatosis, mild hyperkeratosis with thickened collagen bundles, and increased numbers of fibroblasts in the dermis. Elastic tissue stain showed decreased staining of lesional skin compared to normal skin, consistent with a diagnosis of CTN. Four months later, several draining pustules and a tender thumb print sized area developed within the CTN. Wound cultures ×2 were negative. The patient remained afebrile throughout and demonstrated no improvement with oral antibiotics and warm soaks. During a subsequent clinic visit, a sterile probe was used to explore the lesion and we determined that several interconnecting sinus tracts had developed within the CTN (see Fig). Treatment consisted of surgical deroofing of the sinus tracts followed by scarification with 100% trichloroacetic acid. Discussion: CTN are considered benign lesions however there are cases in the literature of extensive presentations demonstrating confluence of papules resulting in involvement of an entire limb and ulcerative lesions. To our knowledge there have been no reports of sinus tract development within CTN and this is the first report of sinus tract development within a connective tissue nevus in a patient with velocardiofacial syndrome

Dupilumab Induced Psoriasiform Dermatitis

Atopic dermatitis (AD) is a common inflammatory skin condition that affects up to 20-30% of children and 2-10% of adults. In the past, therapeutic options were limited to emollients, topical glucocorticoids and calcineurin inhibitors, phototherapy, and systemic corticosteroids and anti-inflammatory therapies (e.g., methotrexate, mycophenolate mofetil, azathioprine, cyclosporine). The newly FDA approved biologic dupilumab has demonstrated significant improvement in the signs and symptoms of AD, including pruritus as well as those of anxiety and depression[1]. Dupilumab is a fully human monoclonal IgG4 antibody against interleukin-4 receptor alpha thereby inhibiting signaling of both interleukin-4 and interleukin 13, which are among the principle drivers of a type 2 immune response important in the diathesis of atopic disease [1]. The most frequently reported adverse effects of dupilumab include injection site reactions, nasopharyngitis, upper respiratory infections, and conjunctivitis[1-5]. We report a case of dupilumab-induced psoriasiform dermatitis. To our knowledge, there have been no reports to date of a dupilumab-induced psoriasiform dermatitis. There has been one report of an erythrodermic presentation of psoriasis in a patient treated with dupilumab. As novel immunotherapy treatments are developed and employed in the treatment of common conditions such as AD, it is important to better understand and be aware of the potential side effects and immune-based sequelae that may arise in addition to available treatment options for these adverse reactions.https://scholarlycommons.henryford.com/merf2019caserpt/1016/thumbnail.jp

Drug-induced phototoxicity: A systematic review

BACKGROUND: Phototoxicity has been attributed to numerous oral drugs over the past 60 years. OBJECTIVE: Determine the quality of evidence supporting suspected phototoxicity from oral drugs. METHODS: The MEDLINE and EMBASE databases were searched for all studies that contain original data for drug-induced phototoxicity and were published between May 1959 and December 2016. Study quality was assessed by using a modified Grading of Recommendations, Assessment, Development and Evaluation scale. RESULTS: The review included 240 eligible studies with a total of 2466 subjects. There were 1134 cases of suspected phototoxicity associated with 129 drugs. Most associations were supported by either very low-quality or low-quality evidence (89.1% of the studies). Medications supported by stronger evidence were vemurafenib, nonsteroidal anti-inflammatory drugs, and antibiotics, specifically, fluoroquinolones and tetracyclines. The most frequently reported drugs were vemurafenib, voriconazole, doxycycline, hydrochlorothiazide, amiodarone, and chlorpromazine. Photobiologic evaluation was performed in only 56 studies (23.3%), whereas challenge-rechallenge was done in 10% of cases. LIMITATIONS: Only English-language publications were reviewed. Cases of phototoxicity that had been incorrectly categorized as photoallergy would not have been included. CONCLUSIONS: Most purported associations between oral drugs and phototoxicity are not supported by high-quality evidence. Despite the variable quality of data, clinicians should be aware of the possible consequences of long-term use of culprit drugs

Treatment of lateral canthal rhytides with a medium depth chemical peel with or without pretreatment with onabotulinum toxin type A: a randomized control trial

Background: Combination therapies used to treat the photoaged skin have become more popular as studies demonstrate greater efficacy and improved clinical outcomes compared to single treatment modalities. Objectives: To evaluate the safety and effectiveness of treating the lateral canthal rhytide complex with a Jessner’s and 35% TCA peel with and without pretreatment with BTX-A. Methods: Twenty-six subjects with Fitzpatrick skin types I -III were randomized to receive treatment of their lateral canthal rhytide complex with a Jessner’s and 35% TCA peel with or without pretreatment with BTX-A. A single blinded dermatologist assigned a lateral canthal wrinkle score of subjects’ at baseline and week 8-10. Results: Comparison between the two treatment groups demonstrated that the group receiving combination treatment had significantly greater improvement in wrinkle reduction as compared to the group only receiving the chemical peel (P =0.002). In addition, there was no significant association between skin type and treatment groups (P = 0.11). Conclusions: These findings suggest that treating the lateral canthal rhytide complex with a combination of BTX-A followed by Jessner’s and 35% TCA peel is more effective than chemical peel alone. These results are independent of skin type and demonstrate an additional treatment strategy for lateral canthal rhytides