Acne Scarring Management: Systematic Review and Evaluation of the Evidence

BACKGROUND

Modalities for atrophic acne scarring can be classified depending upon the needs they satisfy; that is, resurfacing, lifting/volumization, tightening, or surgical removal/movement of tissue that is required for correction. A plethora of treatment options have resulted from the need to treat various acne scar types, variability of responses noted in various skin types, and increasing popularity of minimally invasive modalities. Still, there is a lack of consensus guidelines on treatment or combination therapies for various clinical scenarios.

OBJECTIVE

This systematic review includes a critical evaluation of the evidence relevant to these modalities and various multimodality therapies.

METHODS

We performed a systematic literature search in Medline and EMBASE databases for studies on acne scar management. Also, we checked the reference lists of included studies and review articles for further studies. A total of 89 studies were included in our quality of evidence evaluation.

RESULTS

The efficacy of lasers and radiofrequency in atrophic acne scarring is confirmed by many comparative and observational studies. Other modalities can be used as an adjunct, the choice of which depends on the type, severity, and number of atrophic scars. Minimally invasive procedures, such as fractional radiofrequency and needling, provide good outcomes with negligible risks in patients with dark or sensitive skin types.

CONCLUSIONS

There is a lack of high-quality data. Fractional lasers and radiofrequency offer significant improvement in most types of atrophic acne scars with minimal risks and can be combined with all other treatment options. Combination therapies typically provide superior outcomes than solo treatments.

Complications of fillers in the lips and perioral area: Prevention, assessment, and management focusing on ultrasound guidance

An ever-increasing interest in perioral rejuvenation with dermal fillers reflects the esthetic importance of this region. However, filler injections in the lips and perioral area have been associated with various complications. Such complications are classified according to severity (mild, moderate, severe) or by the time of onset: immediate (within 24 h after injection), early (24 h to 4 weeks post-procedure), and late or delayed (>4 weeks after injection). While most complications are mild and manageable, vascular compromise, infections, and the development of delayed-onset nodules may significantly undermine the ultimate esthetic outcome and cause substantial morbidity. These more serious complications often require more invasive treatment modalities. This article details the prevention and management of such adverse events and discusses safe filler injection principles, including safety recommendations for the lips. Lastly, we highlight the use of ultrasound guidance in complication prevention (vascular mapping, filler identification, location, and extent), assessment (identification of intravascular embolus or external vascular compression by the filler implant), and management (real-time imaging of hyaluronidase or other drug injection in the affected area). Esthetic practitioners should be versed in injection anatomy, and the prevention, recognition, and management of filler complications in the perioral area.

Impact of COVID-19 pandemic on dermatology practices: Results of a web-based, global survey

The spectrum and magnitude of changes in dermatology practice induced by the COVID-19 pandemic have not been adequately studied.

OBJECTIVE

This study aimed to assess the immediate and long-term effects of the pandemic on dermatology practice on a large scale, including the clinical activity of participants, frequency and types of procedures used, and teledermatology (TD) use.

METHODS

This web-based, global survey included 733 dermatologists. The primary outcomes are percentages of respondents providing in-person consultations, hospital service, and TD and performing procedures. Factors in logistic regression models that may influence the odds ratio (OR) for TD use during pandemic and for future use also were analyzed.

RESULTS

The percentages of respondents providing in-person consultations (46.6% vs. 100% before the pandemic) and hospital service (27% vs. 52.8% before the pandemic) as well as performing procedures (25.6% vs. 100% before the pandemic) decreased, whereas practicing TD increased three-fold (75.2% vs. 26.1% before the pandemic) during the pandemic (p < .001 for each). Practice location was associated with TD use during the pandemic and with its expected use in the future (p < .001 for both), with North American respondents indicating the highest use. TD use during the pandemic showed a positive correlation with TD use before the pandemic, performing procedures and, more specifically, with biopsies of suspicious pigmented lesions during the pandemic (p < .001 for each). TD use before the pandemic was the most powerful predictor of TD use during the pandemic (OR: 16.47; 95% confidence interval, 7.12-38.06). More than two third of participants (68.6%) expect to use TD in the future. The factor with the largest increase in OR on the expectation of future TD use was >1000 COVID-19 cases in the country (OR: 3.80; 95% confidence interval, 2.33-6.21).

CONCLUSION

This survey indicates a profound immediate effect of the pandemic on dermatology practice. The pandemic appears to have substantially contributed to an increased use of TD in the long run.

Cutaneous Complications of mRNA and AZD1222 COVID-19 Vaccines: A Worldwide Review

Because of the increasing emergence of cutaneous reactions from COVID-19 vaccines worldwide, we investigated the published reports of these complications. We searched the PubMed, Google Scholar, and Scopus databases and the preprint server bioRxiv for articles on cutaneous complications linked to mRNA-1273 (Moderna), BNT162b2 (Pfizer-BioNTech), and AZD1222 (AstraZeneca-Oxford University) vaccines published until 30 September 2021. Eighty studies describing a total of 1415 reactions were included. Cutaneous reactions were more prevalent in females (81.6%). Delayed large local reactions were the most common complication (40.4%), followed by local injection site reactions (16.5%), zoster (9.5%), and urticarial eruptions (9.0%). Injection site and delayed large local reactions were predominantly caused by the mRNA-1273 vaccine (79.5% and 72.0%, respectively). BNT162b2 vaccination was more closely linked to distant reactions (50.1%) than mRNA-1273 (30.0%). Zoster was the most common distant reaction. Of reactions with adequate information for both vaccine doses, 58.3% occurred after the first dose only, 26.9% after the second dose only, and 14.8% after both doses. Overall, a large spectrum of cutaneous reaction patterns occurred following the COVID-19 vaccination. Most were mild and without long-term health implications. Therefore, the occurrence of such dermatologic complications does not contraindicate subsequent vaccination.

Combination therapy using subcision, needling, and platelet-rich plasma in the management of grade 4 atrophic acne scars: A pilot study

BACKGROUND

Multimodality therapies including minimally invasive modalities are increasingly used in atrophic scarring.

OBJECTIVE

To evaluate the role of platelet-rich plasma (PRP) as adjunctive therapy to a combined subcision and needling treatment in severe (grade 4) atrophic acne scarring.

METHODS

A total of 30 patients with grade 4 acne scars were randomly divided into two groups, 15 patients each: Group A underwent three sequential treatments of subcision and needling while Group B, three sequential treatments of subcision, needling, and topical application of PRP that were performed at 3-week intervals. Scar grading was assessed 3 months following the final session. Participant's assessment of treatment response was registered.

RESULTS

Scar improvement ≥50% was reported significantly more often by Group B than Group A patients (P = 0.025). Regarding physician-based assessment of scar grading post-therapy (number of patients with two grades improvement vs one grade or no improvement), there was a trend toward more improvement in Group B (P = 0.195). Physician's evaluation of acne scar improvement correlated with the patient's assessment of improvement: 60% of Group A and 66.6% of Group B patients appreciated an improvement of 25%-49% and 50%-74%, respectively. Mean duration of postprocedure erythema/edema was shorter among Group B than Group A patients (16.1 vs 32.9 hours, respectively). Overall, substantial improvement was noticed in rolling and boxcar scars with only a mild change in icepick scars.

CONCLUSION

Platelet-rich plasma appears to add to the improvement of grade 4 atrophic acne scars when combined with needling and subcision. These findings require further evaluation by future studies.

Mental distress in dermatologists during COVID-19 pandemic: Assessment and risk factors in a global, cross-sectional study

There is a sparsity of data regarding the mental health status of dermatologists during COVID-19 pandemic. Evaluate the effects of pandemic on mental health of dermatologists on a large scale and identify risk factors for mental distress. 733 dermatologists were included in this cross-sectional, web-based survey. Mental distress was reported by 77.2% of responders. Considerable percentages of participants experienced stress (73.9%), irritation (33.7%), insomnia (30%), or depression (27.6%), and 78.6% were overwhelmed with the amount of pandemic information they were receiving. Mental distress was significantly associated with practice years, volume of patients seen per week before pandemic, personal protective equipment availability at hospital (P = .001 for each), practice location (continent; P < .001), and participant's assessment that the healthcare system was not equipped for the pandemic (P = .003). Stress was associated with hospital service (P = .003), and depression with being overwhelmed with the amount of pandemic information received (P = .004). In a logistic model, teledermatology use was the most powerful predictor of mental distress (OR, 1.57 [95% CI, 1.07-2.32]). Mental distress was common among dermatologists during this pandemic. Teledermatology use was the most powerful predictor of mental distress. Preventative strategies and psychosocial interventions should be implemented.

Global impact on dermatology practice due to the COVID-19 pandemic

This contribution focuses on the effects of coronavirus disease 2019 (COVID-19) on dermatology practice. We discuss the impact on practice volume and procedures and on the considerable increase in teledermatology use. We also describe the important roles that dermatologists have played in enhancing infection prevention and on the frontline. During the crisis, dermatologists have faced the challenge of a shortage of resources, such as personal protective equipment, in the health care system. In addition, they have been involved in managing cutaneous manifestations related to COVID-19 and occupational disease caused by personal protective equipment. Dermatologists have made a diligent effort to identify melanoma and to ensure the treatment of high-risk skin cancers. Safety guidelines have been suggested to minimize the potential risks associated with the systemic use of immunosuppressant agents and immunomodulators in patients with severe inflammatory skin disease during the pandemic. Finally, social distancing necessitated that dermatology conferences take place virtually and teaching via e-learning increased.

Virtual conferences and e-learning in dermatology during COVID-19 pandemic: Results of a web-based, global survey

During the pandemic, virtual conferences became the norm. We conducted a cross-sectional global study to assess dermatologists' responses to virtual conference and e-learning program attendance, as well as to discuss the status of such events during the pandemic. This web-based, global survey included 733 dermatologists. Primary outcomes are percentages of responders answering questions. Assessment of the relationship between two categorical variables was performed with the chi-square test. A substantial percentage of responders were willing to attend a virtual meeting (70.6%) or webinar (80.2%), or to conduct a webinar (47.3%). Among participants who provided resident or fellow training before the pandemic, 38% responded that they did not have any teaching systems in place during the pandemic. Virtual conference attendance was significantly associated with video conference attendance before the pandemic, webinar attendance, teledermatology (TD) use during the pandemic, future TD use, having training systems in place for residents or fellows (P < .001 for each), and North American location of participant (P = .001). Webinar attendance was associated with North American location, conducting webinars (P < .001 for each), and future TD use (P = .024). This pandemic has had a profound effect on dermatology conferences and e-learning programs. Attending video conferences and webinars or other online training was associated with TD use and future use, which indicates that these technologies are all here to stay.

Impact of COVID-19 Pandemic on Dermatology Practice in India

BACKGROUND

COVID-19 pandemic has disrupted healthcare systems throughout the globe. It has affected dermatology practice to a great extent. Since most of the consultations (except emergencies) in dermatology are deferred as a precautionary measure, dermatologists have taken the route of virtual appointments in order to continue treating patients in the present lockdown state. However, the concept of telemedicine is quite new for doctors as well as for patients in India.

MATERIAL AND METHODS

An online questionnaire was circulated among Indian dermatologists which included participant demographics, changes in their practice and teaching during COVID-19, use of virtual or e-health technologies, and attitudes/opinions on their experiences. We also wanted to understand doctor perspectives on their own roles, wellness, and hospital responses to the pandemic.

RESULTS

A total of 260 responses from qualified dermatologists of different parts of India were received between 1st and 8th April 2020 and were analyzed. Two-thirds of the respondents were within 10 years of starting practice. Virtual consultations have increased by almost three-fold during the pandemic, which is a major change noticed in the practice when we compare before and during the pandemic. Earlier the focus of teledermatology (TD) was mainly for follow-up care (85%), whereas during the pandemic, both new and follow-up patients were provided virtual consultations. The number of patients coming to them for a consultation has drastically reduced. Only 2% of the responders are still performing minor procedures with proper care. Almost two-thirds do not have systems in place to train their residents and fellows due to the disruptions caused by the pandemic. The rest of them have started to take the virtual route of teaching through webinars, virtual rounds, and providing access to online journals to continue their teaching. Only 18.6% of dermatologists at work were provided with personal protective equipment. TD has opened new doors to virtual consultation and it was evident that 54.4% of doctors are willing to continue it in the future even after the pandemic is over.

CONCLUSION

TD platforms hold great promise to improve access to high-quality dermatologic care in the future. Results from this survey of Indian dermatologists suggest that TD is the future of dermatology as it will be accessed by patients in remote areas and it is a cost-effective move for the patients.

Subcorneal pustular dermatosis: Comprehensive review and report of a case presenting during pregnancy

Subcorneal pustular dermatosis (SPD), also known as Sneddon-Wilkinson disease, is a rare, relapsing, sterile pustular eruption of unknown etiology that develops most commonly in middle-aged or mature women. This article reviews the presentation, associations, and management of the condition and highlights advances in pathophysiology. Onset of SPD during pregnancy has not been reported. Herein, we report a case of SPD that developed during pregnancy. The patient was treated with dapsone without complications for her or the fetus. An association between T helper (Th) 17 and Th2 environments in the development of SPD has been advocated. Pregnancy is characterized by a predominance of Th2 responses and increased interleukin-17 levels and thus may favor the development of the condition.

Atypical Clinical Presentation of Hidradenitis Suppurativa in a Patient with Severe Mannose-Binding Lectin Deficiency

Mannose-binding lectin (MBL) deficiency is associated with recurrent infections, autoimmune and inflammatory skin disease, and vascular complications. MBL deficiency is not a recognized comorbidity in hidradenitis suppurativa (HS); the latter is associated with the group of autoinflammatory disorders. A 32-year-old woman presented with a history of recurrent painful, deep-seated abscesses and pustular lesions since the age of 13 years. Lesions were noted predominantly in HS distribution, i.e., submammary, inguinal, and perianal areas were affected. However, unusual locations (jawlines, neck) were also affected. The patient fulfilled the clinical criteria for HS but the presentation was atypical because lesions were noted in unusual locations, most lesions were in Hurley stage 1 (sparsity of sinus tracts and scarring), and most cultures from abscesses and pustular lesions were negative. The excruciating pain caused by constantly developing abscesses had a profound impact on the patient's quality of life. Laboratory workup showed an exceptionally low serum MBL level. Treatment was challenging with only a temporary, mild response to oral antibiotic therapy and no response to immunosuppressive and hormonal therapies. This atypical HS presentation may reflect an enhancement of proinflammatory mechanisms. Health care providers should be aware of this clinicopathologic presentation so that the establishment of HS diagnosis is not delayed and the patient receives appropriate counseling.

Combination therapy of recalcitrant severe psoriasis with psoriatic arthritis, diabetes nephropathy, and liver cirrhosis

OBJECTIVE

Treatment of recalcitrant moderate-to-severe psoriasis can be challenging. Combination therapy of biologics and immunosuppressive agents can be a new strategy for treating therapy-resistant cases with comorbidities, where many systemic medications are contraindicated.

CASE PRESENTATION

We report a case of a 62-year-old diabetic man with a 30-year history of severe plaque psoriasis and psoriatic arthritis with cirrhosis and diabetic nephropathy that was treated successfully in combination with apremilast and etanercept after multiple previous unsuccessful treatment attempts.

CONCLUSION

There are no data supporting the combination of apremilast and etanercept in the management of recalcitrant cases of moderate-to-severe psoriasis and multiple comorbidities including psoriatic arthritis, diabetic nephropathy, and cirrhosis. In patients who do not respond to multiple approaches for the treatment of psoriasis, combination therapy with biologic agents and new systemic medications may lead to dramatic disease control.

A novel association of efavirenz induced severe cutaneous adverse reactions with HLA- DRB1*03:01: A case-control study from North-East India

HIV-infected patients have a higher risk of developing cutaneous reactions to drugs than the general population. Severe cutaneous adverse reactions (SCARs) are not uncommon in patients taking antiretroviral therapy (HAART]. To evaluate HLA class I and II allele frequencies in HIV patients on HAART who develop SCARs due to nevirapine (NVP] or efavirenz (EFZ] containing regime and compare this genotype composition with HAART tolerant patients and healthy organ donors. A case-control study for 4 years was conducted with four subsets of patients hailing from north-east India:Cohort 1- HIV seropositive patients who developed SCARs due to EFZ (n = 8];Cohort 2 - HIV seropositive patients who developed SCARs due to NVP (n = 15]; Cohort 3 -HIV seropositive NVP/EFZ-tolerant patients (n = 18]; Cohort 4 - Healthy HIV seronegative organ donors (n = 169].Cohort 3 & 4 acted as control-group. These patients were genotyped for the HLA-A, HLA-B, HLA-C, HLA-DRB1, HLA-DQB1, and HLA-DPB1 by a sequence-based HLA typing method. HLA-DRB1*03:01 allele revealed a significant association with EFZ regimen-induced SCARs in 62.5% patients compared with only 5.56% observed in HAART-tolerant patients and 4.14% in healthy organ. HLA-B*3505was found to be significantly associated with NVP induced SCARs. We found significant novel association of HLA-DRB1*03:01 with EFZ induced SCARs in North-East Indian HIV patients. Thus, HLA-DRB*03:01 may be useful as a genetic marker to avoid EFZ induced serious cutaneous rashes. The molecular HLA characterization of these alleles may provide a novel insight into the immunological basis of the antiretroviral drug reactions.

Evaluating resurfacing modalities in aesthetics

Skin resurfacing for cutaneous rejuvenation has evolved with the development of a plethora of nonsurgical and minimally invasive modalities. We have highlighted the advances in laser therapy, chemical peels, radiofrequency, microneedling, and platelet-rich plasma therapy. We have also included studies providing head-to-head comparisons between procedures and discussed relevant debates in the field. We have examined additionally combination treatments and resurfacing in acne scars, melasma, and skin of color.

Availability of personal protective equipment among dermatologists in the COVID-19 pandemic: Assessment and risk factors in a web-based, global study

BACKGROUND

The availability of personal protective equipment (PPE) among dermatologists during the Coronavirus Disease 2019 (COVID-19) pandemic has not been studied.

METHODS

We have assessed PPE availability among dermatologists and relevant aspects of hospital service by surveying 733 dermatologists.

RESULTS

Considerable percentages of respondents had to purchase their own PPE (40.2%) and were not provided with it at the hospital (37.7%). Only 27% of respondents provided hospital service, and 18.4% were assigned to nondermatologic duty. A substantial percentage (64.4%) indicated the availability of hospital-issued management guidelines (HIMG) for COVID-19 patients. Nearly half of the survey participants (49.1%) responded that the health care system was not equipped for the pandemic. Purchasing one's own PPE was strongly associated with the private practice setting and continent, with the highest rates in Central and South America and in Europe (P < .001). PPE availability at a hospital was associated with 2 continents, with the highest rates in Europe and in North America (P < .001). In logistic regression, the most important factor reducing the odds ratio (OR) for purchasing their own PPE was HIMG for COVID-19 patients (OR, 0.55; 95% confidence interval [CI], 0.32-0.97). Respondents' assessment that the health care system was equipped for COVID-19 was the most powerful increaser of OR for PPE availability (OR, 9.43; 95% CI, 5.37-16.56) followed by >1,000 COVID-19 cases in a participant's country.

CONCLUSIONS

Substantial percentages of respondents had to purchase their own PPE and were not provided with it at the hospital. Strategies to increase PPE availability should be implemented by hospitals, industry, and government authorities.

Evolving eponymous signs in diagnostic dermoscopy

Dermoscopy is a very useful technique devised for an earlier diagnosis of skin melanoma with a clinic-pathological correlation. Later it was found to be beneficial for the diagnosis of many other pigmented skin lesions, such as seborrheic keratosis, pigmented basal cell carcinoma, hemangioma, blue nevus, atypical nevus, and mole, which can often clinically simulate melanoma. Of late, its use in general clinical dermatology is growing with the recognition of new and specific patterns in conditions such as hair disorders, inflammatory disorders, and infections/infestation. It is still in the evolving phase and many new signs are described presently. Eponyms are used almost daily in dermatology practice. The eponyms in dermoscopy, trichoscopy, and onychoscopy are based on the imaginative capability of the authors and they have been very much successful in describing them. It becomes easier to memorize and identify the various appearances for early diagnosis and management. In this article we attempt to highlight the various dermoscopic signs described in dermatology.

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