Erythema toxicum neonatorum revisited

Erythema toxicum neonatorum (ETN) is a common neonatal dermatologic disorder that usually is evident within the first 48 hours of life. Characteristic lesions include erythema, wheals, papules, and pustules. This transient rash resolves spontaneously without sequelae over the course of a week. Histologically, ETN shows an abundance of eosinophils. Although it has been recognized and described for centuries, the etiology and pathogenesis of ETN remain unclear.

[Treatment of localized gingival erythema]

Forms of a localized erythema can be observed occasionally as an expression of inflamed gingiva. It is characterized by a localized sharply demarcated and painless swelling of the gingiva with considerable redness. The differential diagnosis is not unequivocal and appropriate diagnosis and therapy are a challenge. In the present case presentation we report on three cases, which showed good disease remission after simple antiseptic prophylactic measures. Based on the available literature possible etiologic factors are reviewed and a pragmatic treatment strategy is discussed.

Novel 3-in-1 wavelength light source for photorejuvenation

The objective of this study was to evaluate a novel flashlamp emitting light device which represents the first light-based device for skin rejuvenation with the ability to shift the wavelength spectrum depending on the application. Three distinct programs adjust the wavelengths to accommodate the melanin and hemoglobin absorption, and also adjust the pulse width and cooling depending on the needs of the patient. Patients received treatment on the left side of the face or other body part; the untreated side served as the control.

Palmar erythema

Palmar erythema (PE), an often overlooked physical finding, is due to several physiologic or systemic pathologic states. PE can exist as a primary physiologic finding or as a secondary marker of systemic pathology. Primary or physiologic PE can be due to heredity, occurs in at least 30% of pregnant women as a result of associated alterations in the function of the skin and its microvasculature, or may be a diagnosis of exclusion (i.e. idiopathic PE). Secondary PE from systemic pathology encompasses a wide range of disease states. Twenty-three percent of patients with liver cirrhosis, from varying causes, can manifest PE as a result of abnormal serum estradiol levels. Patients with a rare neonatal liver disease such as Wilson disease and hereditary hemochromatosis may exhibit PE along with the other systemic manifestations of the genodermatoses. PE has been reported to occur in >60% of patients with rheumatoid arthritis and is associated with a favorable prognosis. Up to 18% of patients with thyrotoxicosis and 4.1% of patients with diabetes mellitus can have PE. This cutaneous manifestation of diabetes occurs more often than the more classic diseases such as necrobiosis lipoidica diabeticorum (0.6%). PE can be seen in early gestational syphilis and among patients with human T-lymphotrophic virus-1-associated myelopathy. Drug-induced PE with hepatic damage has been documented with use of amiodarone, gemfibrozil, and cholestyramine, while topiramate and albuterol (salbutamol) have been reported to cause PE in the setting of normal liver function. Fifteen percent of patients with both metastatic and primary brain neoplasms may have PE. Increased levels of angiogenic factors and estrogens from solid tumors have been postulated as the cause of PE in such cases. Erythema ab igne can mimic PE, and patients with atopic diathesis are more likely to have PE than matched control subjects. Smoking and chronic mercury poisoning are environmental causes of PE.No treatment of primary PE is indicated. If medication is the cause of PE, the drug responsible should be discontinued if possible. Identification of PE related to underlying disorders should be followed by treatment of the underlying condition. In light of the numerous etiologies of PE, this article reviews the current literature and provides a framework to help guide the clinician in determining the cause of PE in patients presenting with this finding.

Intense pulsed light versus advanced fluorescent technology pulsed light for photodamaged skin: a split-face pilot comparison

Intense pulsed light (IPL) has been a popular nonablative treatment of photodamage. A prospective, randomized, controlled, single-blinded, split-face pilot study compared the efficacy and safety of 2 multitechnology broadband pulsed light platform devices: an IPL device (Lumenis One, Lumenis Corporation, Santa Clara, CA) and a fluorescent pulsed light with advanced fluorescent technology (AFT, Harmony System, Alma Lasers, Buffalo Grove, IL) device. Eight volunteer subjects (skin types I-IV) with a 2.0 mean Global Score for Photoaging (scale 0-4) participated in the study. Subjects received 3 to 5 treatments 3 weeks apart in which one side of the face was treated with the IPL device and the other side with the AFT device. During each treatment session, the face received 3 complete passes without anesthesia. Treatment was aggressive and parameters were determined by test spot application. Treatment endpoints were mild erythema. Results were evaluated by clinical observations of the investigator and comparison of pre- and post-treatment photographs by subjects and 2 blinded dermatologists. Blinded evaluators agreed that improvements in dyspigmentation, telangiectasias, erythema, and skin texture were similar on both sides of the face. Subject assessments of discomfort during treatment were also comparable. Adverse effects were not observed.

Red ear syndrome

The red ear syndrome is a rare syndrome originally described by Lance in 1994. It involves pain in and around the ear and associated autonomic phenomena, the most significant of which is cutaneous erythema of the ear ipsilateral to the pain and obvious to the patient and examiner during the attack. It may well represent an auriculo-autonomic cephalgia and/or be part of the group of disorders recognized as trigeminal autonomic cephalalgias. As a syndrome, it still lacks specificity in regard to etiology, mechanisms, and treatment but is important to recognize clinically because of its associations.

Pimecrolimus 1 percent cream and pulsed dye laser in treatment of a patient with reticular erythematous mucinosis syndrome

We report on the efficacy of twice daily application of pimecrolimus 1 percent cream in a 48-year-old woman with reticular erythematous mucinosis (REM) syndrome and compare its results with pulsed dye laser (PDL) on the other side of her chest and back. The patient was previously treated by hydroxychloroquine but only a fair response was observed. After application of 5 months of pimecrolimus, the lesions completely resolved and the result was comparable with the other side of her body treated by pulsed dye laser PDL. Topical pimecrolimus and pulsed dye laser appear to be effective and safe treatments for REM.

Palmar-plantar erythrodysesthesia (PPE): a literature review with commentary on experience in a cancer centre

Palmar-plantar erythrodysesthesia (PPE) or hand-foot syndrome (HFS) is a relatively common side effect of cytotoxic chemotherapy. Many cytotoxic drugs have been reported to cause the condition but it is more frequently associated with 5 fluorouracil (5FU), liposomal doxorubicin and cytarabine. The oral 5FU precursor, capecitabine is frequently associated with PPE and with the recent extension of its use to adjuvant treatment, the incidence of PPE is likely to increase. The initial symptoms are dysesthesia and tingling in the palms, fingers and soles of feet and erythema, which may progress to burning pain with dryness, cracking, desquamation, ulceration and oedema. Palms of the hands are more frequently affected than soles of the feet. This condition is painful and distressing to patients and in some incidences it results in patients not being able to work or perform normal daily activities. It can also result in treatment interruptions which impact on the efficacy of the treatment regimen. Effective and appropriate patient education from a specialist nurse prior to treatment is an essential part of patient management which will facilitate early identification of the symptoms and therefore prevent treatment delays and PPE progression. This article reviews current knowledge of the condition, including classification, and discussion of the findings of a clinical audit in a cancer centre. It includes the incidence, grading, management and impact of PPE on normal daily activities.

A new method of skin erythrosis evaluation in digital images

In the clinical field, reproducible and comparable assessments of skin color are needed for objective evaluation of lesions and efficacy of treatments. In order to provide objective, quantitative color information in skin lesions, devices such as reflectance spectrophotometer and reflectance colorimeter have been successfully used during the past decade, though they are too expensive and technically complex to be handled in routine clinical situations. Reflectance skin color measurements require direct contact of the probe with the skin, and the compression significantly influences readings. Color measurements obtained from digitized images have been proposed as a simple and cost-effective way to evaluate skin color and promote efficacy of treatments. The disadvantage is its direct and close relation to the ambient light: even if an accurate control of subject illumination is provided, readings vary between different laboratories. We propose a standard system for computerized color image analysis of skin erythrosis modification after Intense Pulsed Light (IPL) treatments, making it possible to compare readings taken by different observers in different environmental light conditions. The goal of our study is the introduction of fixed color internal controls in digital imaging in order to calculate a normalization factor of measurements, resulting not in a method of absolute quantification of erythema or erythrosis but in a method that provides the possibility of translation and comparison of the red values between systems in different environmental conditions. Between December 2004 and May 2005 we evaluated 30 patients at the Department of Plastic and Reconstructive Surgery at the University "La Sapienza" of Rome. Three points of standard colored paper (Red Green Blue) were applied with a plastic pattern (standard intersection lines) and white point in non involved area for skin control. For every patient we took a series of pictures pre-treatment and after a standard cycle of 5/6 IPL. We evaluate the grade of reproducibility of our procedure with a careful analysis of pre-treatment digital images obtained in different environmental conditions. The statistic analysis of the standard deviation between the values of R obtained (using different light conditions), and the respective normalized valor (normalized to the referent image), did not show any significant statistical difference and allows us to achieve our goal: the reproducibility of the results.

Utilization of intense pulsed light in the treatment of face and neck erythrosis

Erythrosis is a clinical manifestation characterized by parossistic vasodilatations followed by fixed superficial venular dilatations localized at the face, neck, décolleté and pinnas. To date, a variety of lasers have been used for treating vascular skin lesions. This study will describe the response on these vascular lesions using the intense pulsed light (IPL) source. Twenty-two female patients and twelve men, aged between 19 and 65, had a phototype ranging from 2 to 4 on the Fitzpatrick scale. The technique is based on a pulsed light of high intensity obtained with a vascular filter of 560 nm. They underwent five treatments of twenty minutes each, at intervals of twenty-one days, with a variable fluency between 9-12 J/cm2 and impulse time of 10-20 ms. The sheaf used is a rectangular spot of 2 cm x 5 cm. In twenty-four patients we obtained a total regression of the cutaneous manifestation after 5 applications, whilst another two patients showed only an attenuation of the erythema. In five cases with erythrosis the erythema persisted after the end of the treatment, although the patients were satisfied with the evident benefits. In two patients affected by Civatte's poikiloderma of the neck we obtained differing results: In the first case an evident positive response of the clinical picture was perceived after only two application of the IPL; in the second case, the benefits were evident after 3-4 applications of IPL at a higher fluency of up to 14 J/ cm2. One patient in treatment with oral antibiotics showed good results from the first application with regression of the erythema up to its disappearance. Collateral effects are not reported, although there was a long-standing (more than 48 hours) post-treatment erythema in only one case. The IPL system, with its broad range of technical variables, is an effective tool in achieving meaningful and lasting clearance of erythrosis.

The assessment of erythema and thickness on burn related scars during pressure garment therapy as a preventive measure for hypertrophic scarring

The aim of this study was threefold: (1) Assess the pressure loss of two types of pressure garments that are used in the treatment of hypertrophic scars after burn injury, (2) investigate the influence of two different levels of compression on erythema and thickness of burn scars and (3) examine the association between erythema and thickness. The study was a prospective trial in which 76 burn scars in 60 patients were objectively assessed with the Minolta Chromameter CR-300 for erythema and with the Dermascan C for thickness of the scar over a period of 3 months. Each patient was randomly assigned to a "normal" or "lower" compression class treatment, with respectively mean values of 15 and 10 mmHg pressure after wearing the garment for 1 month. Measurements for both parameters were taken at 0, 1, 2 and 3 months of treatment. Pressure garments with "normal" compression did lose significantly more compression over 1 month (4.82 mmHg) than did the garments from the low compression class (2.57 mmHg). Scars that were treated with garments from a "normal" compression class did score significantly better for thickness compared to the "low" compression class. The difference in thickness was most evident at 1 month. Thereafter no further significant improvement between the two different treatments over time could be obtained. This difference was not found for erythema. Positive correlations could be found between erythema and thickness values at all of the three test points while changes in erythema and thickness only correlated significantly after the first month. The pattern of change of both parameters correlated at a high level of significance after 3 months of treatment. These data suggest that pressure garments that deliver a pressure of at least 15 mmHg pressure tend to accelerate scar maturation and that measurements of the pattern of change of the erythema can be used to predict changes in scar thickness and vice versa.

Short-Term Side Effects of Fractional Photothermolysis

OBJECTIVE

To ascertain the immediate and short-term side effects of fractional photothermolysis for the treatment of a variety of skin disorders involving the face, neck, chest, and hands.

METHODS

Physician-administered questionnaires were given during 60 follow-up visits for fractional photothermolysis treatment for a variety of facial skin disorders in patients with skin types ranging from I to IV. The questionnaire addressed 14 possible side effects, pain, and limitation of social activities. In addition, all patients were asked about any additional side effects not mentioned in the survey. An analysis of the data was performed once 60 surveys had been collected.

RESULTS

All patients (100%) undergoing fractional photothermolysis had transient post-treatment erythema. Other frequently reported post-treatment side effects were transient and included facial edema (82%), dry skin (86.6%), flaking (60%), a few (one to three) small, superficial scratches (46.6%), pruritus (37%), and bronzing (26.6%). Other more rarely reported effects included transient increased sensitivity (10%) and acneiform eruption (10%). Most patients reported that the pain level was easily tolerated, with an average pain score of 4.6 on a scale of 10. Most patients (72%) reported limiting social engagements for an average of 2 days after treatment. There were no long-lasting adverse events noted in our survey.

CONCLUSION

Fractional photothermolysis to treat dermatologic conditions on the face, neck, chest, and hands is a well-tolerated and safe procedure with several immediate, and slightly delayed, post-treatment side effects. In our experience, these side effects were transient and limited to erythema, edema, dry skin, flaking skin, superficial scratches, pruritus, increased sensitivity, and acneiform eruption. Importantly, we did not see the development of post-treatment scarring, herpetic activation, hypopigmentation, hyperpigmentation, persistent erythema, persistent edema, or infection.

Accelerated reduction of post-skin-resurfacing erythema and discomfort with a combination of non-thermal blue and near infrared light

The prolonged crusting and erythematic phases following chemical and laser skin resurfacing create discomfort and aggravate patients. Depending on the aggressiveness of the procedure, post-procedure erythema may last from three weeks to several months. iClearXL (CureLight Ltd) is a non-contact, non-thermal blue (405-420 nm)/near infrared (850-900 nm) dual-band light source emitting up to 60 J/cm2 on a 30 cm by 30 cm treatment area. The blue component of the light source has been proven to have a significant anti-inflammatory effect, whereas the near infrared component enhances vascular circulation as well as lymphatic drainage in the thin, necrotized papillary layer. Facial skin laser resurfacing was performed on twelve patients. Starting one day after resurfacing, six patients received a daily 20-minute treatment of blue (405-420 nm)/near infrared (850-900 nm) light for six consecutive days, and six control patients were treated with the usual topical care protocol. Twelve days after the procedure, the treated group had a weighted average erythema score of 0.33 as compared to 1.33 in the control group. Two months after the procedure, the treated group had a weighted average erythema score of 0.16 as compared to 0.83 in the control group. Twelve days after the procedure, the treated group had a weighted average discomfort score of 0.33 as compared to 0.83 in the control group. The tested combination of non-thermal blue (405-420 nm)/near infrared (850-900 nm) dual-band light was found to significantly shorten the duration of post-laser-resurfacing erythema and discomfort with no side effects.

Blood vessel changes during pregnancy: a review

The profound endocrine upheaval of pregnancy is frequently associated with changes in the function and structure of the blood and lymph microvasculature of the skin and mucosae. Palmar erythema is frequent but rarely severe and is associated with burning sensations. Spider telangiectasias develop in the majority of pregnant White women but are less often identified in women with darker skin. Hemangiomas and glomus tumors occur in one-third of women. A firm edema may develop on the face and extremities in the final months of pregnancy. Venous hypertension and varicosities of the lower limbs are common. Gingivitis, gum hypertrophy, and pyogenic granuloma are common in the oral cavity. The vaginal mucosa is also affected, showing a violaceous aspect, at times accompanied by varicosities of the vulva. Many gestational vascular changes regress spontaneously in the postpartum phase. Some vascular tumors may need to be treated with a vascular laser or intense pulsed light.