"Bullfrog neck," a unique morphologic trait in HIV lipodystrophy: case series and review of the literature

BACKGROUND

Human immunodeficiency virus (HIV)-associated lipodystrophy is a syndrome that occurs primarily in individuals who are being treated with highly active antiretroviral therapy (HAART).

OBSERVATIONS

We describe 3 patients with an 8- to 15-year history of HIV disease and HAART who presented a unique feature of HIV lipodystrophy, the "bullfrog neck." In addition to their features of facial lipoatrophy and "buffalo hump," patients had the unique feature of circumferential enlargement of the neck. All patients were undergoing treatment with the same non-nucleoside reverse-transcriptase inhibitor (NRTI) medication, efavirenz.

CONCLUSIONS

We present a novel finding of the bullfrog neck in 3 patients with classic features of HIV lipodystrophy. The dysmorphic features of HIV lipodystrophy present a significant therapeutic challenge because the current repertoire of treatments is only modestly effective, and the disease in patients who continue HAART regimens over the long term will progress. Review of the recent literature suggests that the individual protease inhibitors and NRTIs used may play a role in the development and progression of HIV lipodystrophy.

Treatment of CO2 laser induced hypopigmentation with ablative fractionated laser resurfacing: case report and review of the literature

BACKGROUND

The carbon dioxide laser (CO2) has been proven to be an effective device for the treatment of photoaging. However, it is associated with adverse side effects including prolonged erythema, edema, burning, milia, acne, crusting and hypo-/hyperpigmentation. Delayed onset hypopigmentation after CO, laser resurfacing can markedly detract from clinical outcomes. To overcome the disadvantages of traditional ablative and non-ablative resurfacing, fractional photothermolysis (FP) has been introduced. FP has been demonstrated in early case reports and case series to produce significant improvement in hypopigmentation of acne and surgical scars.

CASE REPORT

A 53-year-old Caucasian female with Fitzpatrick type I skin presented with a nine-month history of delayed onset hypopigmentation following ablative CO2 laser resurfacing. After a series of three treatments at eight-week intervals with an ablative fractionated CO2 laser device, the hypopigmentation and line of pigmentary demarcation between the face and neck improved by 75 percent.

CONCLUSION

Ablative fractional resurfacing is a safe and potentially effective modality for the treatment of CO2 laser induced hypopigmentation on the face.

Imiquimod 2.5% and 3.75% for the treatment of actinic keratoses: results of two placebo-controlled studies of daily application to the face and balding scalp for two 3-week cycles

BACKGROUND

Imiquimod 5% cream is approved as a 16-week regimen for the treatment of actinic keratoses involving a 25-cm(2) area of skin.

OBJECTIVE

We sought to evaluate imiquimod 2.5% and 3.75% creams for short-course treatment of the entire face and scalp.

METHODS

In two identical studies, adults with 5 to 20 lesions were randomized to placebo, or imiquimod 2.5% or 3.75% cream (1:1:1). Up to two packets (250 mg each) were applied per dose once daily for two 3-week treatment cycles, with a 3-week, no-treatment interval. Efficacy was assessed at 8 weeks posttreatment.

RESULTS

In all, 490 subjects were randomized to placebo, or imiquimod 2.5% or 3.75% cream. Median baseline lesion counts for the treatment groups were 9 to 10. Complete and partial clearance rates were 5.5% and 12.8% for placebo, 25.0% and 42.7% for imiquimod 2.5%, and 34.0% and 53.7% for imiquimod 3.75% (P < .001, each imiquimod vs placebo; P = .034, 3.75% vs 2.5% for partial clearance). Median reductions from baseline in lesion count were 23.6%, 66.7%, and 80.0% for the placebo, imiquimod 2.5%, and imiquimod 3.75% groups, respectively (P < .001 each imiquimod vs placebo). There were few treatment-related discontinuations. Temporary treatment interruption (rest) rates were 0%, 17.1%, and 27.2% for the placebo, imiquimod 2.5%, and imiquimod 3.75%, respectively.

LIMITATIONS

Local effects of imiquimod, including erythema, may have led to investigator and subject bias.

CONCLUSIONS

Both imiquimod 2.5% and 3.75% creams were more effective than placebo and had an acceptable safety profile when administered daily as a 3-week on/off/on regimen.

Rapid wound re-epithelialization and basal cell carcinoma clearance after Mohs micrographic surgery with postoperative photodynamic therapy

BACKGROUND

Methyl aminolevulinic acid photodynamic therapy (MAL-PDT) has antitumor activity and may promote wound healing Superficial and nodular basal cell carcinomas (BCCs) have been successfully treated with MAL-PDT in prior reports. In vitro and animal studies have shown more rapid re-epithelialization and decreased myofibroblast response after treatment thus suggesting that PDT may play a possible role in promotion of wound healing.

OBJECTIVES

To describe a novel case of a large multifocal BCC treated with postoperative PDT that showed results of tumor clearance and rapid re-epithelialization and to review the relevant literature.

CASE REPORT

A patient presented for Mohs micrographic surgery (MMS) after recent biopsy revealed recurrent BCC. Mohs micrographic surgery was performed, where after six stages were taken, approximately 50% of the peripheral margins of the tumor remained positive for superficial BCC. Given the large size of the wound defect (12.5 cm x 9 cm) and superficial nature of the persistent tumor, the authors opted to treat the patient with adjuvant MAL-PDT in lieu of pursuing additional stages with MMS. The patient returned the following day for adjuvant therapy with MAL-PDT. Two consecutive treatments one week apart were given as an adjunctive treatment course for persistent BCC. At follow-up four weeks after the PDT treatment, the defect had fully re-epithelialized. In the authors' clinical practice, an untreated wound of this size typically heals in 10-12 weeks. The patient has been seen in six months of follow-up to date. Review of the literature relevant to use of MAL-PDT in treatment of basal cell carcinoma and literature describing effects of PDT on wound healing was performed.

CONCLUSION

MAL-PDT may be an effective adjuvant tool against large multifocal BCCs for which surgery has not resulted in clearance. Treatment with PDT resulted in rapid re-epithelialization of the surgical wound in this case. This observation is supported by prior in vitro studies and in vivo animal experiments demonstrating more rapid re-epithelialization of wounds and decreased scarring response after PDT.

Cost effectiveness of Mohs micrographic surgery: review of the literature

BACKGROUND

A number of treatment modalities are currently in existence for non-melanoma skin cancer, including microscopically controlled surgical excision (e.g., Mohs micrographic surgery [MMS]), traditional surgical excision, radiation therapy, electrodessication and curettage, cryosurgery, photodynamic therapy and topical chemotherapeutic agents. MMS has the significant advantage of the lower recurrence rates of all treatment modalities, where five-year cure rates for MMS for primary BCCs are 1% relative to surgical excision (10.1%), electrodessication and curettage (7.7%), radiation therapy (8.7%) and cryotherapy (7.5%). Previous studies have also indicated, across specialties, that dermatologists have the highest rates for complete removal of non melanoma skin cancer (NMSC) which are significantly greater than those for otolaryngologists (P>0.02) and plastic surgeons (P<0.0008).

OBJECTIVE

To evaluate and compare the results of recent studies comparing the cost effectiveness of MMS to other treatment modalities performed by dermatologists and other physicians performing treatment of NMSC (otolaryngologic (ENT) surgeons, plastic surgeons, general surgeons).

RESULTS

MMS is equivalent in cost to excision with permanent sections, 12% less costly than office based excision with frozen sections and 27% less costly than excision with frozen sections in an ambulatory surgical center (ASC). The most significant difference between MMS and surgical excision was the facility fee of excision with frozen sections in an ASC, (differential of $443-$555). With surgical excision, 32-39% of cases require a second procedure for clear margins. Additionally, with subsequent procedures for surgical excision cases, there is likely a greater volume of tissue removed and ramifications on functional preservation and cosmesis, which are difficult to quantify.

CONCLUSION

Analysis of the existing literature on MMS relative to surgical excision confirms the value of MMS in both obtaining the highest initial cure rates and lowest recurrence rates. This analysis confirms that MMS is a cost effective treatment, which is lower in cost than surgical excision, which often includes an ASC facility fee and a subsequent re-excision procedure. Cost effectiveness analysis demonstrating the outcomes based efficiency of MMS are critical in the current health care climate with heightened sensitivity to financial pressures and declining reimbursement rates which may challenge our ability to provide patients with the optimal treatment for NMSC.

Patient safety: Part II. Opportunities for improvement in patient safety

The quality movement in medicine has prompted a shift from a "name, shame, blame" approach to medical errors to one in which each error is regarded as an opportunity to prevent future patient harm. This new culture of patient safety requires the involvement of all members of the health care team and learned skill sets related to quality improvement. A root cause analysis identifies the sources of medical errors, allowing system changes that reduce the risk. In large organizations, sentinel events and signals prompt chart reviews and reduce the reliance on voluntary reporting. Failure mode analysis prompts the development of safety nets in the case of a system failure. The second part of this two-part series on patient safety examines how the culture of patient safety is taught, how medical errors and threats to patient safety can be identified, and how engineering tools can be used to improve patient care. It also examines efforts to measure clinical effectiveness and outcomes in the practice of medicine.

LEARNING OBJECTIVES

After completing this learning activity, participants should be able to improve patient safety through an understanding of both the beneficial and adverse consequences of quality reporting, apply safety engineering tools to the practice of dermatology, and be able to establish a quality improvement plan for a dermatologic practice.

Patient safety: Part I. Patient safety and the dermatologist

Congress is grappling with ways to fund health care in the future. Much of the focus rests on paying physicians for their patients' outcomes, rather than the current system of payment for services provided during each visit. The years ahead will be years of change for American health care, with an increasing emphasis on the comparison of patient outcomes and measures of quality. Patient safety initiatives will be an integral part of the overall strategy to improve American health care. Part one of this two-part series on patient safety examines what we know about patient safety in dermatology, including data from medicolegal claims and published data on patient safety in the setting of office-based surgery. The article also focuses on how medical societies, payers, the US government, and the Board of Medical Specialties are responding to calls for accountability and improvements in patient safety.

LEARNING OBJECTIVES

After completing this learning activity, participants should be able to identify risks to patient safety based on an understanding of the major causes of legal claims against dermatologists, use published patient safety data to improve the practice of office surgery, and be able to improve patient safety through an understanding of requirements for maintenance of certification.

Ablative fractionated CO2, laser resurfacing for the neck: prospective study and review of the literature

BACKGROUND

Ablative laser resurfacing of the neck has been tested with the ultrapulsed CO2, ablative Er:YAG and short pulse duration CO2 laser with mixed results in terms of efficacy and side effect profiles. Given the preliminary reports of safety and efficacy of ablative fractional photothermolysis (AFP) for the face, we set out to assess the efficacy of AFP for the neck.

DESIGN

A prospective pilot study for neck resurfacing in 10 subjects with a series of one-to-three treatment sessions. Treatment sessions were administered at six-to-eight week intervals with blinded physician photographic analysis of improvement at two months post-treatment. Blinded physician photographic evaluation was performed of four clinical indicators, skin texture, skin laxity, rhytides and overall cosmetic outcome.

RESULTS

The number of treatments required for improvement of neck texture and laxity ranged from 1-3, with an average of 1.4. For skin texture, the mean score improved 62.9% (95% CI: 57.4%, 68.4%), skin laxity, 57.0% (53.2%, 60.8%), and rhytides, 51.4% (48.3%, 54.5%). For overall cosmetic outcome, the mean score improved 59.3% (55.1%, 63.5%) at two months post treatment.

CONCLUSION

In this prospective study, AFP was both safe and effective for the treatment of neck laxity, rhytids and skin texture. The degree of improvement observed in wrinkling, texture and laxity after AFP coupled with the benign side effect profile has not been reported with previous trials of ablative laser resurfacing of the neck.

Treatment of Poikiloderma of Civatte with ablative fractional laser resurfacing: prospective study and review of the literature

BACKGROUND

Previous laser treatments for Poikiloderma of Civatte (PC) (i.e., Pulsed dye, Intense Pulsed Light, KTP and Argon) are limited by side effect profiles and/or efficacy. Given the high degree of safety and efficacy of ablative fractional photothermolysis (AFP) for photoaging, we set out to assess the efficacy of PC with AFP.

DESIGN

A prospective pilot study for PC in 10 subjects with a series of 1-3 treatment sessions. Treatment sessions were administered at 6-8 week intervals with blinded physician photographic analysis of improvement at 2 months post-treatment. Evaluation was performed of five clinical indicators, erythema/telangiecatasia, dyschromia, skin texture, skin laxity and cosmetic outcome.

RESULTS

The number of treatments required for improvement of PC ranged from 1 to 3, with an average of 1.4. For erythema/telangiecatasia, the mean score improved 65.0% (95% CI: 60.7%, 69.3%) dyschromia, 66.7% (95% CI: 61.8%, 71.6%), skin texture, 51.7% (95% CI: 48.3%, 55.1%) and skin laxity, 52.5% (95% CI: 49.6%, 55.4%). For cosmetic outcome, the mean score improved 66.7% (95% CI: 62.6%, 70.8%) at 2 months post treatment.

CONCLUSION

In this prospective study, AFP was both safe and effective for the treatment of the vascular, pigmentary and textural components of PC. The degree of improvement observed in wrinkling, creping and laxity after AFP has not been reported with prior laser treatments for PC.

Treatment of nodules associated with port wine stains with CO2 laser: case series and review of the literature

BACKGROUND

Port wine stains (PWS) are congenital malformations of capillaries, where with progression, blood vessels become ectatic and result in disfiguring nodules.

OBJECTIVE

To search the MEDLINE database and review literature on the treatment of PWS and present 2 cases of adults with PWS, complicated by hypertrophic and nodular lesions, treated successfully with CO2 laser.

RESULTS

Two patients with PWS, with nodular and hypertrophic areas, were treated with CO2 laser. With the first patient, improvement of 90% or greater was noted in the 14 discrete nodules present within the PWS in a V2 distribution. At baseline, ectropion of the lower eyelid was noted which resolved completely after CO2 laser. With the second patient, improvement was noted as 90% or greater in the 40 of 51 discrete nodules present within the PWS extending across the right V1-V2 distribution.

CONCLUSION

Carbon dioxide ablative laser resurfacing is safe and highly effective in the treatment of the nodular and hypertrophic components of PWS. Future treatment of PWS will likely involve a hybrid approach of utilizing nonablative lasers of varying wavelengths and pulse durations and treatment with novel laser devices, with the goal of early treatment to prevent progression of PWS to disfiguring lesions.

Expanded polytetrafluoroethylene implants for soft-tissue augmentation: 5-year follow-up and literature review

BACKGROUND

Expanded polytetrafluoroethylene implants have been used successfully for augmentation of thinning lips, deep nasolabial folds, and marionette lines without the risk, recovery time, and expense of major surgery.

OBJECTIVE

The objective was to assess long-term results and patient satisfaction with expanded polytetrafluoroethylene implants.

MATERIALS AND METHODS

A retrospective chart review was performed on all patients treated with expanded polytetrafluoroethylene implants from January 1, 2001, to July 1, 2002.

RESULTS

Eighty-five implants were placed in 33 patients. Forty-six percent of implants were placed in the nasolabial folds, 34% in the lips, 16.5% in the marionette lines, 2% in the oral commisures, and 1% in the glabella. Eighty-seven percent of implants remain in place with excellent correction. Eleven implants in 6 patients were removed. Four of the 11 implants removed were considered too small by the patient and were replaced with larger implants without difficulty. The other reasons for implant removal included malposition, localized swelling, and an unnatural feel. Patient and physician satisfaction with the treatment was high.

CONCLUSION

Expanded polytetrafluoroethylene implants are a safe, effective, and permanent option for facial volume augmentation. Patients who have had their implants in place for 5 years or more continue to report high satisfaction with the treatment. The authors have indicated no significant interest with commercial supporters.

Topical photodynamic therapy for dermatologic disorders: results and complications

BACKGROUND

Topical photodynamic therapy (PDT) involves the use of a photosensitizing topical medication that is activated by a light source in the presence of oxygen leading to cellular destruction and subsequent photorejuvenation. In 1999, the US FDA approved PDT for the treatment of nonhyperkeratotic actinic keratoses (AKs) on the face and scalp.

OBSERVATIONS

The study population comprised 85 patients treated with short-contact, topical aminolevulinic acid (ALA)-PDT for a total of 247 treatments. Ninety percent of patients with a variety of dermatologic disorders had significant improvement or total clearance. Ninety-eight percent of patients had no complications. Only 2 patients in our series had a significant complication.

CONCLUSIONS

Short-contact, topical ALA-PDT is a safe and effective treatment for a variety of dermatologic disorders including photoaging and AKs.

Issues affecting specialty career paths in dermatology

As the field of medicine changes, physicians deal with ever-increasing challenges and pressures. An overview of broad career paths within the specialty of dermatology is presented and important issues affecting these subspecialty tracks are discussed. These issues include increasing regulatory controls, the medical liability crisis, competitive forces, corporate and global outsourcing threats, managed care, and reimbursement.

Second intention healing for intermediate and large postsurgical defects of the lip

BACKGROUND

The lip plays critical roles in both function and cosmesis. Many options exist for postsurgical reconstruction following excision or Mohs micrographic surgery on the lip. Second intention healing is generally reserved only for superficial and small postsurgical defects of the lip vermilion.

METHODS

We sought to evaluate second intention healing of the lip for intermediate and large partial thickness, postsurgical defects through a retrospective review of medical charts in conjunction with telephone interviews. Complication rates, time to reepithelialization, and patient satisfaction were determined for 25 patients who underwent second intention healing on the lip following Mohs micrographic surgery for non-melanoma skin cancer.

RESULTS

The majority of patients in the study demonstrated good to excellent cosmetic and functional results with minimal complications. Time to complete reepithelialization averaged 25 days. Patient satisfaction with both the healing process and final cosmetic result was very high.

LIMITATIONS

The study is a small retrospective case series. Using patient satisfaction as a primary endpoint, a limiting factor may be recall bias.

CONCLUSION

Second intention healing is an effective and satisfactory management strategy for intermediate and large postsurgical defects of the lip vermilion, including those with extension to cutaneous lip and underlying orbicularis muscle.

A new combination technique of local anesthesia for full-face dermabrasion

We present a safer, more efficient, and more effective technique for full-face dermabrasion utilizing a combination of regional nerve block anesthesia, refrigerant spray cryoanesthesia, and local infiltration anesthesia. This combination provides a pain-free procedure with little to no discomfort for the patient while avoiding the risks of intravenous sedation or general anesthesia.

Case reports: clearance of lentigines in Japanese men with the long-pulsed alexandrite laser

Benign pigmented lesions can be effectively treated with multiple modalities including lasers. The treatment of pigmented lesions in phototype IV skin is more complicated and challenging given the risk of pigmentation changes and scarring. We present the novel use of the long-pulsed Alexandrite 755 nm laser for the treatment of solar lentigines in sun-reactive phototype IV skin of patients of Japanese decent. Our Japanese patients cleared with one treatment with no pigmentary changes or scarring. No recurrences were noted to date. The long-pulsed Alexandrite 755-nm laser is a novel, safe, and effective treatment of solar lentigines in Japanese patients.

Perioperative management of von Willebrand disease in dermatologic surgery

BACKGROUND

Von Willebrand disease (VWD) is the most common inherited bleeding disorder, affecting an estimated 0.1% to 1% of the population. It is caused by a qualitative or quantitative defect of von Willebrand factor. Primary manifestations include intractable mucocutaneous bleeding after surgery or trauma.

OBJECTIVE

The objective was to review the pathophysiology and clinical features of VWD and to propose a perioperative management strategy for patients with this condition undergoing dermatologic surgery.

METHODS AND MATERIALS

Literature is reviewed.

RESULTS

The various types and clinical manifestations of this condition are reviewed, and a perioperative strategy is presented for managing patients with VWD who undergo cutaneous oncologic or cosmetic surgical procedures.

CONCLUSIONS

In most cases, dermatologic surgery can be safely performed in patients with VWD. The use of appropriate therapeutic prophylaxis in conjunction with a hematologist is indicated in high-risk, nonelective procedures.

Safety and efficacy of poly-L-lactic acid in HIV lipoatrophy and lipoatrophy of aging

BACKGROUND

Poly-L-lactic acid (PLLA) is an injectable filler used for the treatment of facial fat loss secondary to HIV and aging. The U.S. FDA approved PLLA for the treatment of HIV lipoatrophy in August 2004.

OBSERVATIONS

Sixty-five patients were treated with PLLA; 27 were HIV positive and 38 were HIV negative. The HIV patients had more severe facial lipoatrophy at presentation and improved more given their level of severity. The HIV positive patients required more treatment sessions and more PLLA to reach full correction than the non-HIV patients. Ninety-four percent of all patients had no complications and the effects of PLLA were similar in both groups. All complications were temporary and resolved over time. Patient satisfaction metrics indicated that all patients were "very satisfied" with their treatment. The HIV lipoatrophy patients indicated marked quality of life improvement.

CONCLUSIONS

PLLA is a safe, efficacious, and satisfying treatment for facial fat loss associated with HIV and aging.

A protocol for facial volume restoration with poly-L-lactic acid

Poly-L-lactic acid is a biodegradable synthetic polymer used in an injectable form for subcutaneous volume restoration. Volumetric correction following subcutaneous and deep dermal injection of poly-L-lactic acid is thought to occur through a foreign body tissue response leading to increased production of fibroblasts and subsequent neocollagenesis. Despite the growing popularity and use of this material, there has been a scarcity of published information describing proper injection technique, and many practitioners remain unfamiliar with its use. Appropriate injection technique is critical since incorrect placement of the material can lead to long-lasting unintended results. We present a protocol for successful injection of poly-L-lactic acid into the submalar and buccal regions.