Dermatologic Procedures Research Articles

European Guidelines (S1) on the use of high-dose intravenous immunoglobulin in dermatology

Treatment of severe dermatological autoimmune diseases and toxic epidermal necrolysis (TEN) with high-dose intravenous immunoglobulin (IVIg) is awell-established procedure in dermatology. As treatment with IVIg is usually considered for rare clinical entities or severe cases, the use of immunoglobulin is not generally based on data from randomized controlled trials usually required for evidence-based medicine. Since the indications for the use of IVIg are rare, it is unlikely that such studies will be available in the foreseeable future. Because first-line use is limited by the high costs of IVIg, the first clinical guidelines on the use of IVIg in dermatological conditions were established in 2008 and renewed in 2011. The European guidelines presented here were prepared by apanel of experts nominated by the European Dermatology Forum (EDF) and European Academy of Dermatology and Venereology (EADV). The guidelines were developed to update the indications for treatment currently considered effective and to summarize the evidence for the use of IVIg in dermatological autoimmune diseases and TEN. The current guidelines represent consensual expert opinions and definitions on the use of IVIg reflecting current published evidence and are intended to serve as adecision-making tool for the use of IVIg in dermatological diseases.

Laser Treatment in Hirsutism: An Update.

Unwanted hair growth, which is a common aesthetic problem, has traditionally been treated using various techniques such as shaving, waxing, and epilation, but most of these provide only a temporary solution. Laser and light-based technology for hair removal has become one of the fastest growing procedures in modern cosmetic dermatology in the last decade. Clinical experience suggests that in the ideal subject with fair skin and dark hair, laser treatment can reduce hair growth significantly. This article reviews the various laser and light-based devices used for hair removal along with the various laser and patient parameters that affect the outcome of laser treatment for hair removal. Photoepilation, when properly used, offers clear advantages when compared with older, traditional techniques.

Resposta terapêutica da cisteamina no tratamento do melasma

O objetivo deste estudo foi avaliar de que forma o uso da cisteamina no tratamento do melasma vem sendo trabalhado na literatura. Trata-se de uma pesquisa qualitativa do tipo revisão integrativa para identificação de produções sobre temas associados ao tratamento tópico do melasma com a cisteamina. A busca dos artigos foi através das bases de dados Scopus, Science Direct e Pubmed com a utilização dos termos: “melasma” e “cysteamine” e termos correspondentes no português. A pesquisa obedeceu aos critérios de inclusão: a) artigos b) estar disponível em texto completo c) recorte temporal de 01/01/2010 à 31/03/2020 d) estudos disponíveis nos idiomas português, inglês ou espanhol. Como critérios de exclusão, foram desconsiderados os textos que não tinham relação com a temática ou apresentaram duplicatas. Do montante de 11 artigos apresentados, 6 foram selecionados por afinidade à temática de busca, sendo 5 artigos excluídos pelos critérios supracitados. A resposta terapêutica da cisteamina para o tratamento do melasma é positiva, reduzindo as lesões hiperpigmentadas e com efeitos adversos controláveis com a duração do tratamento. Não foram encontradas evidências do uso da cisteamina associada a outros ativos ou procedimentos dermatológicos.

Efficacy of lidocaine 7 %, tetracaine 7 % self-occlusive cream in reducing MAL-cPDT-associated pain in subjects with actinic keratosis: A randomized, single-blind, vehicle-controlled trial (The "3P-Trial").

Conventional photodynamic therapy (cPDT) is considered a very effective treatment of actinic keratosis (AK) lesions. However, its use is limited by the fact that this procedure could be very painful. The use of topical anesthetics such as tetracaine or lignocaine/prilocaine has shown disappointing results in term of pain reduction. A self-occlusive topical 7% lidocaine/7% tetracaine anesthetic cream (LT-C) approved by the FDA to provide local topical anesthesia in adults undergoing superficial dermatological procedures is available. There are no data regarding its pain reducing effect during cPDT. We perform a prospective, randomized, single-blind, two-center trial (The 3P-Trial) to assess the pain reduction effect of LT-C versus vehicle in subjects with AK undergoing cPDT. Fifty AK subjects (74 ± 10 years, 32 men, 18 women) with on average 17 lesions were enrolled after their written informed consent. Eight subjects presented also a total of 16 basal cell carcinoma lesions. Twenty-five were randomized to LT-cream, applied 1 h before the Methyl amino levulinate (MAL)-cPDT session and 25 to cream vehicle. The main outcome was the patient-assessed evaluation of pain score during and just after the conclusion of cPDT session (mean of the two values) using a 10-point visual analog scale (VAS). The cPDT session (LED Red light 630 nm) was performed with a duration of 6 ± 2 min with a standard fluence of 37 J/cm2. All treated lesions were prepared by gentle superficial curettage. All the randomized subjects concluded the trial. The mean ± SD of VAS score in vehicle group was 6.2 ± 2.7 (95 % CI of the mean: 5.0-7.5). In the group treated with LT-cream the VAS score was 3.3 ± 1.9 (95 % CI of the mean: 2.5-4.1). The active cream reduced the VAS score by 47 %. Median values of pain VAS score in the active group was reduced by 60 % in comparison with vehicle group (3.0 vs 7.5). The difference between the two groups was statistically significant (p = 0.0009; Mann-Whitney test). The 3P-trial has demonstrated that the preventive application of the self-occlusive lidocaine 7%-tetracaine 7% cream is very effective in reducing the procedure-associated pain during MAL-cPDT for the treatment of AK lesions.

Pain-less injection: principles and pearls.

There has been an exponential growth in the number of dermatologic procedures performed over the past two decades. This surge in procedural volumes is accompanied by increasing utilization of local anesthetics. A proper technique in administering local anesthesia is necessary to minimize pain and promote comfort, as it is often regarded as the most painful part of cutaneous procedures. Pain is a psychophysiological phenomenon that involves attention, cognitive appraisal, and emotion. Sensory feedback and anxiety are two important aspects of pain perception. This article aims to introduce a novel way that minimizes pain and discomfort associated with local anesthetics. It is the authors' experience that painless injection is achievable by keeping syringes/needles out of sight, proceeding with injection without pre-procedure warning, and engaging patients in a conversation or simple tasks.

The Language of Electricity

ABSTRACT Electrical devices are commonly used within the field of dermatologic surgery. With the growing role of nursing providers in the dermatologic setting, it is essential to provide education and training regarding electrical devices and concepts within the nursing community. This installment introduces electricity principles and reviews terminology associated with the electrical devices used in dermatologic procedures.

Video education to improve clinical skills in the prevention of and response to vasovagal syncopal episodes.

BackgroundVasovagal syncope is a common clinical occurrence during routine outpatient dermatology procedures, such as injections and biopsies. Despite its prevalence, many medical students and health care professionals do not know how to respond appropriately to a syncopal episode.ObjectiveThe aim of this study was to determine the efficacy of a health education video in teaching medical students and health care professionals the appropriate management steps for vasovagal syncope and its prodromal symptoms in a clinical setting.MethodsWith input from dermatologists and an anesthesiologist, an instructional video was developed to demonstrate basic management for a presyncopal and syncopal patient. A pre- and post-video quiz was used to assess comprehension. A total of 124 medical students and health care professionals were enrolled in this study.ResultsAfter viewing the video, the proportion of respondents who were able to correctly identify how long to monitor a patient after a syncopal episode increased from pre- to post-intervention (44% vs. 71%; p < .001). Participants expressed higher levels of agreement with the statement “I am aware of the appropriate steps in managing a patient during an episode of vasovagal syncope” after the intervention (p < .001). Respondents reported increased confidence in managing a patient during a syncopal episode after this intervention (p < .001).ConclusionThese results suggest that this health education video is a useful tool for educating medical students and nursing professionals about the management of vasovagal syncope in a clinical setting. We propose the use of video education as an efficient means of increasing recognition and standardizing therapeutic response to the prodromal symptoms of syncope and syncopal episodes.

Variability in Wound Care Recommendations Following Dermatologic Procedures.

Dermatologists routinely perform office-based surgical procedures that result in cutaneous wounds. Wound care instructions are an important resource for postoperative patients. As there is no consensus on the ideal wound care regimen after dermatologic procedures, recommendations may vary. To evaluate the current recommendations for wound care following dermatologic procedures. The authors conducted a cross-sectional assessment of dermatology wound care handouts available online. The handouts were evaluated based on predefined parameters: topical agent recommendations for wound healing, caution against topical antibiotic use, and discussion of scarring, infection, bleeding, analgesia, and lifestyle considerations. A total of 169 handouts were evaluated. The majority (84%) recommended the application of petrolatum-based products, specifically Vaseline (75%) and Aquaphor (43%). Nearly half (43%) recommended the use of topical antibiotics, whereas 24% advised patients to avoid antibiotic ointments. Handouts variably addressed scarring (36%), infection (72%), bleeding (69%), pain (66%), and lifestyle modifications (64%). The instructions provided in dermatology patient handouts are highly variable, with various topical agents being recommended for wound healing. Topical antibiotics are not indicated for prophylaxis in clean dermatologic procedures but are still widely used. Greater efforts should be made to ensure that patients receive consistent and evidence-based wound care guidance.

Update and Review of Bleeding Considerations in Dermatologic Surgery: Hemostatic Techniques and Treatment Strategies for Bleeding Complications.

There are many intraoperative and postoperative techniques to aid hemostasis in dermatologic procedures. An updated understanding is critical for the surgeon. To provide an updated review of methods for hemostasis and therapies for postprocedural purpura and ecchymosis applicable to dermatology. A review of Ovid MEDLINE was performed to review the English-language medical literature of hemostatic options and their use in cutaneous surgery. All available publication years were included from 1946 to present. A comprehensive and current list of hemostatic options used in the intraoperative and postoperative period is provided along with traditional and emerging therapies for postprocedural purpura and ecchymosis. A myriad of options exist for minimizing and treating bleeding complications. The appropriate use and updated knowledge of hemostatic options is provided.

Comfort positioning during procedures in pediatric dermatology.

Procedures performed in pediatric dermatology can often be painful or distressing for patients and their families. Comfort positioning, which involves sitting the child upright, immobilized and held by a caretaker, is one strategy that may be employed in this setting; this measure has been shown to reduce patient distress, improve cooperation and give caretakers a more active role in the procedure. We demonstrate several positions of comfort for dermatologic procedures involving the arm, cheek, back and leg of a young child.

Local Anesthetics Allergies in Children

Background: Local anesthetics are used to provide effective analgesia for many dental, surgical, and dermatologic procedures. Local anesthetics constitute the most commonly used drug group in dentistry. Objectives: The aim of this study was to evaluate the results of skin tests with local anesthetics and to investigate the factors associated with these results in patients in the Faculty of Dentistry who were referred to allergy specialists due to a history of allergy. We aimed to evaluate the results of the test with local anesthetics in patients with a history of atopy. Methods: The results of prick and intradermal tests with local anesthetics of patients in whom surgery could not be performed due to their or their relatives’ allergic disease and who were sent to allergy outpatient clinic for testing with the local anesthetics that were planned for use in the Faculty of Dentistry between December 2017 and December 2018 were analyzed. Results: Eighty-two patients were tested with local anesthetics. In 71 (86.5%) of these patients, no allergy was detected as a result of prick test and subsequent intradermal test. In the study group, prick test was positive in 1 patient (intradermal test was also found positive in this patient), and the intradermal test was found positive with 1:100 concentrations in 11 (13.4%) patients. Conclusions: Test positivity with local anesthetics was not significant in patients with history of drug allergy, and history of allergy with local anesthetics. Intradermal test positivity was found to be statistically significant in asthma patients. Treatment should be initiated before dental intervention in atopic patients after having the necessary consultations, and treatment should be initiated with local anesthetic agents associated with fewer reactions in emergency situations in risky patients.

New optical examination procedures for the diagnosis of skin diseases

Since the establishment of dermoscopy as aroutine examination procedure in dermatology, the spectrum of noninvasive, optical devices has further expanded. In difficult-to-diagnose clinical cases, these systems may support dermatologists to arrive at acorrect diagnosis without the need for asurgical biopsy. To give an overview about technical background, indications and diagnostic performance regarding four new optical procedures: reflectance confocal microscopy, in vivo multiphoton tomography, dermatofluoroscopy, and systems based on image analysis by artificial intelligence (AI). This article is based on aselective review of the literature, as well as the authors' personal experience from clinical studies relevant for market approval of the devices. In contrast to standard histopathological slides with vertical cross sections, reflectance confocal microscopy and in vivo multiphoton tomography allow for "optical biopsies" with horizontal cross sections. Dermatofluoroscopy and AI-based image analyzers provide anumerical score, which helps to correctly classify askin lesion. The presented new optical procedures may be applied for the diagnosis of skin cancer as well as inflammatory skin diseases. The presented optical procedures provide valuable additional information that supports dermatologists in making the correct diagnosis. However, asurgical biopsy followed by dermatohistopathological examination remains the diagnostic gold standard in dermatology.

National survey of UK Dermatologists demonstrates significant variation in how to obtain consent for dermatological procedures.

Consent must be undertaken prior to any dermatological procedure; however, in doing this, the clinician needs to ensure consent is valid and satisfies the principles of determining material risk. We aimed to assess variations in obtaining consent in the UK andunderstanding of material risk through a nationally distributed survey to members of the British Society for Dermatological Surgery and British Association of Dermatologists. Of 165 responses, we found that written consent was being obtained for all procedures in 73.9% of cases and typically at the time of procedurein the operating room/theatre (78.8%). Fifty-seven per cent of respondents were not familiar with the term 'material risk' and almost one-third were not aware of the Montgomery vs. Lanarkshire ruling, which replaced the Bolam test in 2015. We would encourage readers to be aware of these changes to consent law in the UK and how it might affect their approach toobtainingconsent.

Topical stabilized hypochlorous acid: The future gold standard for wound care and scar management in dermatologic and plastic surgery procedures.

Hypochlorous acid (HOCl), a naturally occurring molecule produced by the immune system, is highly active against bacterial, viral, and fungal microorganisms. Moreover, HOCl is active against biofilm and increases oxygenation of the wound site to improve healing. Natural HOCl is unstable; through technology, it can be stabilized into an effective topical antiseptic agent. This paper focuses on the use of topical stabilized HOCl in wound and scar management for pre-, peri-, and postprocedures-including its ability to reduce the occurrence hypertrophic scars and keloids. The role of the product in other skin conditions is beyond the scope of this article. A panel comprising clinicians with experience in cosmetic and surgical procedures met late 2018 to discuss literature search results and their own current clinical experience regarding topical stabilized HOCl. The panel of key opinion leaders in dermatology and plastic surgery defined key insights and consensus statements on the direction of use for the product. Topical stabilized HOCl provides an optimal wound healing environment and, when combined with silicone, may be ideal for reducing scarring. Additionally, in contrast to chlorhexidine, HOCl, used as an antiseptic skin preparation, raises no concerns of ocular- or ototoxicity. For wound care and scar management, topical stabilized HOCl conveys powerful microbicidal and antibiofilm properties, in addition to potency as a topical wound healing agent. It may offer physicians an alternative to other less desirable wound care measures.

Review of Innovative Physical Therapy Methods: Introduction to the Principles of Cold Physical Plasma.

The principles of physics and precision engineering have allowed many technologies to enter standard treatment regimens for a range of diseases. Recently, a new type of technology has been accredited as safe and efficient routine procedure in dermatology in Europe: cold physical plasma. Several accredited devices successfully restrain the powerful energy of plasmas to make them available for therapeutic purposes. Herein, we introduce an introduction to the concept of cold physical plasmas and highlight some fields of their medical applications.

Hypopigmented macules following quality-switched 1064 nm laser hair removal: A retrospective study

Introduction: Laser hair removal (LHR) is a common procedure in dermatology. LHR using quality-switched (QS) 1064-nm neodymium-doped yttrium aluminum garnet (Nd:YAG) is very popular in our community despite lack of sufficient evidence on its efficacy and safety. Purpose: We report the characteristics of nine patients who developed hypopigmented macules after being treated with QS 1064 nm laser for hair removal. Methods: This was a retrospective study at a laser center in Saudi Arabia conducted between June 2014 and September 2018. Patients who developed white macules following treatment with QS 1064 nm Nd:YAG laser for removal of unwanted hair were included in the study. Results: All patients were Saudi females with a mean age of 28.8 years (range: 25–37 years). Well-defined hypopigmented to depigmented 1–3 mm macules developed after being treated with QS 1064 nm Nd:YAG laser for hair removal. The most commonly affected area was the face. Majority of patients had skin phototype IV. Hypopigmented macules developed after an average of 22 laser sessions (range: 4–48 sessions). None of the patients had either personal or family history of vitiligo. Lesions seem to be difficult to treat, with only two patients responding to topical tacrolimus and excimer laser. Conclusion: Hypopigmented macules might develop after QS 1064 nm LHR. Those macules appear to be resistant to treatment. Further prospective controlled studies needed to elaborate more on the safety profile of this procedure.

The use of lidocaine/prilocaine anesthetic cream for laser procedures in dermatology and cosmetology

The use of lidocaine/prilocaine anesthetic cream for laser procedures in dermatology and cosmetology

Modification in 26-gauge Needle.

Needles are the most widely used medical device. A 26-gauge hypodermic needle is a simple hollow instrument; however, its use in dermatologic procedures are numerous. Needle can be used as a cutting instrument and can be used as an extractor. Here, I present a simple innovation that makes the grip of fingers firm over the needle and thus extraction of lesions becomes easy and faster. Insert the tip of the needle in the front portion of the lead pencil and one can hold the needle like a pen which makes the removal of lesions easy. The front portion of a pen is made up of metal and thus it can be sterilized in an autoclave. A video demonstration of this innovation is attached.

Comparative study of three different modalities of topical anesthesia in various dermatological procedures

Background: Infiltrative anesthetics are frequently chosen because of their proven safety record, low cost, ease of storage, widespread availability, and rapid onset of action; a good topical anesthetic agent can eliminate the use of painful injections prior to procedures. Aims: The present study was carried out to compare the eutectic mixture of local anesthetic (EMLA), cryogel, lignocaine spray, and controls for pain caused during common dermatological procedures. Methods: This study included 120 patients who were divided into four groups with 30 patients each for needle extraction for molluscum contagiosum and milia; intralesional injection for keloids and alopecia areata; radiofrequency ablation for warts, acrochordons, and intradermal nevus; and dermabrasion for surgical treatment of vitiligo. Topical anesthetics such as EMLA, cryogel, and lignocaine spray were applied and pain was assessed using visual analog scale (VAS) score. Data were analyzed using Microsoft Excel. P

TREATMENT OF VERRUCA VULGARIS IN TRADITIONAL MEDICINE.

SUMMARYCommon warts (verrucae vulgares) are the most common complaint in routine dermatological practice. Warts can be painful on pressure and are often an aesthetic problem, but they are not a major threat to the person’s general health. Treatment options are symptomatic and do not eradicate the causative agent. Dermatological surgery procedures such as cryotherapy, electrocauterization and excochleation can be painful, with common recurrences. These are the most important reasons for revival of the treatment procedures and remedies based on traditional medicine. Traditional medicine is still commonly practiced as a form of self-healing. This paper presents the most commonly used wart remedies of plant, animal and mineral origin, along with various magic practices. We emphasize that this paper is written from the viewpoint of physicians, practitioners of dermatology, not as a study in the history or culture. The main objective of the study was to explore various substances and methods people use as home remedies for warts. We performed a case study survey among the general population by interviewing 147 adult participants using a simple preliminary questionnaire inquiring about preferred treatment and knowledge about common warts.