Routine Dermatological Practice Research Articles

Patrones de microscopia confocal para el cáncer cutáneo no melanoma y aplicaciones clínicas

Reflectance confocal microscopy is currently the most promising noninvasive diagnostic tool for studying cutaneous structures between the stratum corneum and the superficial reticular dermis. This tool gives real-time images parallel to the skin surface; the microscopic resolution is similar to that of conventional histology. Numerous studies have identified the main confocal features of various inflammatory skin diseases and tumors, demonstrating the good correlation of these features with certain dermatoscopic patterns and histologic findings. Confocal patterns and diagnostic algorithms have been shown to have high sensitivity and specificity in melanoma and nonmelanoma skin cancer. Possible present and future applications of this noninvasive technology are wide ranging and reach beyond its use in noninvasive diagnosis. This tool can also be used, for example, to evaluate dynamic skin processes that occur after UV exposure or to assess tumor response to noninvasive treatments such as photodynamic therapy. We explain the characteristic confocal features found in the main nonmelanoma skin tumors and discuss possible applications for this novel diagnostic technique in routine dermatology practice.

Survival rate of antitumour necrosis factor-α treatments for psoriasis in routine dermatological practice: a multicentre observational study

Adherence is an overall marker of treatment success, and it depends on multiple factors including efficacy and safety. Despite the wide use of tumour necrosis factor (TNF)-α blockers in the treatment of plaque-type psoriasis, few data regarding treatment adherence in routine clinical practice are available. To estimate the long-term survival rate of anti-TNF-α therapy in a cohort of patients with psoriasis in routine clinical practice; to evaluate the reasons for and predictors of treatment discontinuation. The Outcome and Survival rate Concerning Anti-TNF Routine treatment (OSCAR) study was based on a retrospective analysis to estimate the long-term survival rate of the first anti-TNF-α treatment in patients with psoriasis, from three Italian academic referral centres. Adult patients (n = 650) with plaque psoriasis treated with a first course of adalimumab, etanercept or infliximab for ≥ 3 months were included. Global adherence to anti-TNF-α treatments after 28·9 ± 15·4 months (867 ± 462 days) of observation was 72·6%. Etanercept showed a longer survival (mean 51·4 months, 1565 days; P < 0·001) compared with infliximab (36·8 months, 1120 days) and adalimumab (34·7 months, 1056 days). Treatment discontinuation due to primary and secondary inefficacy was observed in 5·2% and 14·5% of patients, respectively, whereas discontinuation due to adverse events was reported in 29 subjects (4·5%). Independent predictors of treatment withdrawal were female gender [hazards ratio (HR) 1·3], treatment with adalimumab or infliximab compared with etanercept (HR 2·7 and 1·7, respectively), and the concomitant use of traditional systemic treatment, as a rescue therapy, compared with monotherapy (HR 1·9). Overall survival of anti-TNF-α agents in psoriasis is elevated, with drug discontinuation mostly due to inefficacy. Etanercept showed a longer adherence compared with adalimumab and infliximab.

Treatment of facial lesions of multicentric reticulohistiocytosis by carbon dioxide laser

The carbon dioxide (CO2) laser is a versatile tool that has applications in ablative lasing and caters to the needs of routine dermatological practice as well as the esthetic, cosmetic, and rejuvenation segments. We report a case of multicentric reticulohistiocytosis with cosmetically disfiguring confluent papules over the scalp, forehead, nasolabial folds, chin, and retroauricular region. We used CO2 laser in superpulse mode for ablating the lesions in three sittings. The lesions regressed completely and no recurrence was observed over a regular follow-up of 8 months.

La formulación magistral en la terapéutica dermatológica actual

Compounding continues to play a key role in the treatment of skin conditions, despite the abundance of products made by the pharmaceutical industry. Right from the earliest days of dermatology, compounding proved very useful in the treatment of diseases for which no specific drugs were available. However, as new products came onto the market, this usefulness was called into question, and doubts over safety, stability, and effectiveness were raised. Today, compounding is regaining the place it once held in routine dermatological practice. We review the advantages and disadvantages of compounding, the most common indications, current legislation in our setting, and the latest developments in active ingredients and vehicles.

Health-Related Quality-of-Life Assessment in Dermatologic Practice: Relevance and Application

Health-related quality of life (HRQoL) is gradually becoming a standard outcome in clinical research and health care management. Nevertheless, application in dermatologic practice is not customary and many practical and attitudinal barriers need to be overcome. To contribute to the discussion on and the implementation of HRQoL assessment in routine dermatologic practice, this article describes (1) why HRQoL assessment is relevant for dermatologic practice, (2) which patients would benefit most from routine HRQoL assessment, and (3) how HRQoL assessment can be applied in clinical practice.

Carbon dioxide laser guidelines

The carbon dioxide (CO2) laser is a versatile tool that has applications in ablative lasing and caters to the needs of routine dermatological practice as well as the aesthetic, cosmetic and rejuvenation segments. This article details the basics of the laser physics as applicable to the CO2 laser and offers guidelines for use in many of the above indications.

Dermojet delivery of bleomycin for the treatment of recalcitrant plantar warts

Background: Plantar warts may cause significant morbidity. Intralesional bleomycin is effective. When bleomycin is injected with a needle and syringe, it is difficult to prevent the bleomycin from infiltrating the dermis adjacent to the wart, producing unnecessary acute pain, persistent pain, and potential sloughing of normal adjacent skin. Efficacy of delivery by dermojet is not yet established. Objectives: To assess the response of recalcitrant plantar warts to bleomycin delivered by dermojet. Methods: A total of 47 patients with 138 plantar warts present for more than 2 years and resistant to 10 cycles of cryosurgery, were recruited. Bleomycin (1 U/ml) was delivered intralesionally by dermojet at 5‐week intervals for 25 weeks. Results: Out of 138, 124 (89.9%) plantar warts showed complete or partial clearance after one to five sets of bleomycin injections. The recurrence rate was 6/138 (4.4%), and 8/138 (5.8%) warts failed to clear. The reduction in mean surface area of the plantar warts after each set of bleomycin injections compared to baseline surface area was statistically significant. Local side effects were similar to other methods of delivery. No systemic side effects were reported. Conclusions: This study assesses therapeutic efficacy of bleomycin delivered by dermojet in solely recalcitrant plantar warts. It provides preliminary evidence that this method of delivery may benefit a group of patients with particularly recalcitrant plantar warts and is safe and easy to use in routine dermatology practice.

A new and effective delivery system of bleomycin for the treatment of recalcitrant warts

The effectiveness of intralesional bleomycin in the treatment of viral warts is well established. Various methods of delivering bleomycin into plantar warts have been decribed with success rates ranging from 60-90%. Its general acceptance in routine dermatological practice remains low, as needle methods are limited by local pain and potential risks to both the patients and operator. We describe a new delivery system for intralesional belomycin using a needle-less high velocity airjet. Its efficacy, safety and acceptance in patients with recalcitrant plantar warts were assessed in this study. Twenty three patients (11 males, 12 females) with 59 plantar warts have been treated to date. The warts have been present for at least 2 years and failed to respond to intensive conventional treatments including cryosurgery. Mean surface area pre-treatment was 1.3 sq cm. We use a high velocity jet with a plastic safety guard to administer an aqueous solution of bleomycin (0.1 ml of 1 mg/ml bleomycin intralesionally for each 0.25 sq cm of plantar wart).

Erfolgreiche Reduktion des SCORAD‐Scores bei Kindern mit atopischem Ekzem im 6‐Wochen‐Vergleich durch Kurzschulung mit einem vereinfachten Hautmodell

Zusammenfassung Hintergund: Zur langfristigen Stabilisierung des Hautbefundes bei Patienten mit atopischem Ekzem ist die konsequente Durchführung einer Hautpflege essentiell. Im Rahmen der ambulanten dermatologischen Sprechstunde bleibt häufig zu wenig Zeit für eine intensive Aufklärung der Patienten. Zur Evaluation der Effektivität einer kurzen, aber eindrucksvollen praktischen Hautpflegeschulung mit dem „Hautmodell nach Kardorff, Schnelle‐Parker” während der normalen Sprechstunde führten wir eine randomisierte prospektive Vergleichsstudie durch. Patienten und Methodik: 30 konsekutiv in unserer Praxis als Patienten vorstellig gewordene Kinder zwischen 3 und 6 Jahren mit mittelschwerem atopischem Ekzem wurden eingeschlossen. Die Hälfte der Patienten erhielt an den Tagen 0 und 14 eine aktive Kurzzeitschulung von 10 Minuten mit dem Hautmodell, die Kontrollgruppe erhielt in der selben Zeit intensive verbale Erklärungen wie bei einer dermatologischen Routinebehandlung. Der SCORAD‐Score wurde an den Tagen 0, 14 und 42 blind ermittelt. Ergebnisse: Nach 42 Tagen hatte die mit dem „Hautmodell nach Kardorff, Schnelle‐Parker” geschulte Gruppe einen signifikant geringeren SCORAD‐Score als die Kontrollgruppe (p &lt; 0,006). Schlußfolgerungen: Durch die auch für Vorschulkinder einleuchtende, den Tastsinn einbeziehende Schulung mit dem Hautmodell wird eine bessere Compliance in Bezug auf regelmäßige Hautpflege erzielt. Hierdurch werden positive Effekte für das langfristige Erkrankungsmanagement des atopischen Ekzems erwartet.

Photodynamic therapy in dermatology

Editorial commentTherapies that selectively target diseased cells while sparing normal tissue remain the goal of modern medicine. Photodynamic therapy (PDT) achieves double selectivity both by the degree that preferential accumulation of the photosensitizer occurs in the targeted cells and the extent to which the illumination is spatially localized to the target. Dr. GI Stables has reviewed the burgeoning literature on this oxygen-requiring technique by discussing its essential components (photosensitizers, light sources) and its many applications including benign, premalignant, and malignant disease. Most studied has been the use of 5 -aminolaevulinic acid PDT for psoriasis, actinic keratoses and non-melanoma skin cancer. While residents and trainees have reason to be excited about these developments, all readers should be cautioned that PDT's role in routine dermatological practice awaits comparison to carefully controlled trials involving comparison to more standardized techniques.

Accuracy of epiluminescence microscopy among practical dermatologists: a study from the Emilia-Romagna region of Italy.

The accuracy of epiluminescence microscopy (ELM) for pigmented skin lesions (PSLs) is still unclear. The large scale utilization of the technique is generally discouraged. The present study was aimed at comparing the accuracy of ELM with that of clinical examination alone in a group of 20 practical dermatologists. Thirty digital clinical images of benign and malignant PSLs and their digital ELM counterparts were used. A set of cumulative accuracy measures reported in the combined clinical/ELM diagnosis was compared with that reported in the clinical diagnosis alone. The proportion of nonmelanocytic lesions (NMLs), melanocytic nevi, and melanomas correctly identified, the predictive value of such diagnoses, and the proportion of melanomas detected by referral for biopsy (irrespective of the diagnosis reported) increased significantly. The cases referred for biopsy despite a "benign" impression decreased significantly among NMLs. The observed tendency towards a greater accuracy suggests that even in the routine dermatology practice ELM has the potential to improve the clinical examination of PSLs.

The importance of cytology technic for the dermatologist in office practice.

Although Tzanck reported his cyto-diagnostic studies around 1947, this technic was not used widely in this country until the work of Harvey Blank and his collaborators in 1951. 1 Since that time, this procedure has been shown to be of value. Many dermatologists believe that the cytological examination is of academic interest primarily, and concerned chiefly with investigative studies. It is, however, an excellent diagnostic tool in routine dermatologic office practice. Our studies are based on a four-year period of experience with this procedure. The technical phases of this examination are of importance; adherence to these details will spell the difference between success and failure. Here again, as with many laboratory reports, the negative test is often, but not always, of questionable value. One must be trained in the interpretation of the smears, otherwise one can miss important details. The technical phases of the procedure begin with the selection of