Assessing coagulopathy and endothelial dysfunction in pediatric venous malformation: A thromboelastometry and syndecan-1 study

OBJECTIVE

The occurrence of unpredictable pain crises are the principal determinant of the quality of life for patients with venous malformations (VM). A definite coagulation phenomenon, characterized by an increase in D-dimer levels and the presence of phleboliths within the malformation, has been previously reported. By applying Virchow's triad and evaluating intralesional samples, our objective is to delineate the coagulation profile and the extent of endothelial dysfunction within the malformation.

METHODS

With the authorization of the Ethics Committee, a research project was undertaken on intralesional and extralesional blood samples from 30 pediatric patients afflicted with spongiform VM. Thromboelastometry analyses were performed using ROTEM Sigma, and the concentration of syndecan-1 was determined by ELISA.

RESULTS

In the ROTEM analyses, the A5, A10, and maximum clot firmness (MCF) values were below the established reference ranges in the intralesional samples in both the EXTEM and INTEM assays, indicating that intralesional clots had significant instability. Furthermore, during the investigation of the delayed fibrinolysis phase using recombinant tissue plasminogen activator (rtPA) in EXTEM analysis, widespread hyperfibrinolysis was observed intralesional. Additionally, analysis of syndecan-1 showed significant differences between extralesional and intralesional levels (p < .026) and controls (p < .03), suggesting differences in the state of endothelium.

CONCLUSIONS

For the first time, we developed a comprehensive understanding of the coagulopathic profile of VM and the role of endothelial dysfunction in its pathogenesis. These findings will enable the implementation of targeted therapies based on the individual coagulation profiles.

Geriatric cutaneous leishmaniasis: a retrospective analysis of 622 cases

BACKGROUND

Cutaneous leishmaniasis (CL) is most common in childhood because children are exposed to the parasite early and, unlike adults, do not have immunity to CL. Since CL is less common in geriatric patients, clinical and epidemiological data in this age group are limited. This study aims to compare the clinical and demographic characteristics of geriatric patients diagnosed with CL with young patients.

METHODS

In this retrospective study, 622 patients aged 65 and over and 6350 patients aged 19-64, who applied to Şanlıurfa Oriental Boil Diagnosis and Treatment Center between January 2013 and February 2024 and were diagnosed with CL by parasitological examination, were included. Clinical and demographic characteristics of patients diagnosed with CL, such as age, gender, location of the lesion, lesion size, duration of the lesion, and treatments applied due to the diagnosis of CL, were recorded. Clinical and demographic characteristics of geriatric and young patients were compared.

RESULTS

The mean age of elderly CL cases was 72.95 ± 6.54 years, and 65.2% were female. The most common clinical forms were ulcers (51.9%) and plaques (41%), respectively, in young and elderly patients. The most common locations of the lesions were upper limbs (54.8%) in all patients. The most preferred treatment method was intralesional (IL) meglumine antimoniate (MA) treatment (98.3%) in all patients. There were no difference between young and elderly CL cases in terms of mean number of lesions, average lesion duration, average lesion size, lesion location, clinical forms of lesions, and treatments options (P > 0.05).

CONCLUSIONS

Based on the results of our study, it can be said that the clinical and demographic characteristics of CL are similar in young and old patients and systemic MA treatment shows similar clinical benefit in both age groups. In addition, it can be said that systemic MA therapy can be used safely in young patients and elderly patients without contraindications. IL MA therapy can be used in elderly patients where systemic MA therapy is contraindicated.

Comparative Efficacy of Intralesional Chloroquine With Intralesional Meglumine Antimoniate in the Treatment of Cutaneous Leishmaniasis

BACKGROUND AND AIM

This comparative prospective study was conducted at the Department of Dermatology, Pak Emirates Military Hospital, Rawalpindi, from August 1, 2018, to January 31, 2019 (six months). This study aimed to compare the efficacy of intralesional chloroquine with intralesional meglumine antimoniate in the treatment of cutaneous leishmaniasis.

MATERIALS AND METHODS

A total of 64 patients fulfilling the inclusion criteria reporting to the Department of Dermatology, Pak Emirates Military Hospital were included in this study. Informed consent was taken and demographic data including patients' hospital registration number, age, gender, and number of lesions were noted. The subjects were randomly assigned into two groups. In group A, intralesional chloroquine was injected two times per week, and in group B, intralesional meglumine antimoniate was injected two times per week. The efficacy of both treatments was noted after eight weeks of treatment. Frequency and percentages were computed for qualitative variables like gender and number of lesions. Mean±standard deviation was presented for quantitative variables like age. Analysis was done to compare the proportion of both groups. Chi-square test was applied to compare the efficacy of both groups, p≤0.05 was taken as significant.

RESULTS

In this study, the mean age of patients was 29.69±08.95 years. There were 63 (98.44%) males and one (1.56%) female. In this study, efficacy was achieved in six (18.8%) patients in group A, while in 17 (53.1%) patients in group B. This difference was statistically significant, i.e., p=0.004.

CONCLUSION

This study concluded that intralesional meglumine antimoniate is more effective in treating cutaneous leishmaniasis than intralesional chloroquine.

Intralesional Injections of a TNF-α Inhibitor to Treat Orofacial Granulomatosis

We present the first documented case of successful treatment of orofacial granulomatosis by intralesional injections of a tumor necrosis factor α inhibitor to the lip. Our patient had rapid symptomatic improvement after 3 injections, and near resolution within 4 months of anti-tumor necrosis factor α therapy.

Intralesional Treatments for Invasive Cutaneous Squamous Cell Carcinoma

Cutaneous squamous cell carcinoma (cSCC) is the second most frequent cancer in humans and has the potential to progress locally, metastasize, and cause death in a subset of patients. cSCC is especially common in the elderly, and it will probably represent a major health concern in the near future. Surgery is the standard treatment for cSCC, but intralesional therapies can sometimes be considered for certain patients and under certain circumstances. The choice of intralesional treatment depends on the patient's characteristics and the clinician's previous experience and expertise. Here we are reviewing intralesional treatments for cSCC and keratoacanthoma (KA). We have started with some classic drugs, such as methotrexate and 5-fluorouracil, bleomycin, interferon, and cryosurgery, but also comment on electrochemotherapy. Finally, we have focused on novel therapies, some of which are under development, and future perspectives, including intralesional immunotherapy and oncolytic viruses.

Comparing intralesional triamcinolone and verapamil-triamcinolone injections in keloids: A single-blinded randomised clinical trial

INTRODUCTION

In this clinical trial, we investigated the efficacy of two treatment methods for keloids resulting from surgical incisions: intralesional triamcinolone injections alone versus in combination with verapamil.

MATERIAL AND METHODS

Patients were divided into two groups: one received triamcinolone alone (Group T) and the other received a triamcinolone-verapamil blend (Group VT). Regular treatments were conducted until the keloids were nearly flat or for a maximum of eight sessions.

RESULTS

Both groups showed significant improvements, but Group VT saw quicker resolution of skin redness and needed fewer sessions. Though the Vancouver Scar Scale (VSS) scores were generally similar across both groups, Group VT exhibited greater improvements, leading to lower final scores. The VT group also attained normal scar flexibility faster than the T group.

CONCLUSION

These findings suggest that the combination of verapamil and triamcinolone provides a more effective treatment for keloids, thereby highlighting the potential of verapamil in scar reduction.

Topical and Intralesional Immunotherapy for the Management of Skin Cancer in Special Locations: Lips and Eyelids

The use of topical and intralesional immunotherapy in the treatment of cutaneous malignant neoplasia in sensitive areas such as the lips and eyelids is discussed. Surgery may not be feasible or may result in deformities in these areas, making alternative treatment options necessary. A narrative literature review was conducted using MEDLINE (PubMed) as the main literature database, collecting available evidence of experiences with various topical and intralesional therapies in the aforementioned anatomical locations, ranging from case reports to clinical trials. The clearance rates and potential adverse reactions of therapeutic options such as imiquimod 5%, 5-fluorouracil (5-FU), photodynamic therapy (PDT), ingenol mebutate (IM), diclofenac, intralesional methotrexate, and interferon are reviewed. Although limited by their heterogeneity and the scarcity of clinical trials, these studies point towards promising response rates and minimal adverse effects, making these treatments viable options in selected cases.

Sufficient mesh polyhedral intralesional injection for treatment of keloids

BACKGROUND

The recurrence of keloids after intralesional injections is significant, and a review of the literature shows an inconsistent range of success rates. In this study, the modified medical proportion and intralesional injection method were intended to enhance the treatment effect.

METHODS

Twenty patients completed the study. Regional block anesthesia (lidocaine, ropivacaine) was performed. Triamcinolone acetonide (40 mg/mL), 5-fluorouracil (25 mg/mL), and ropivacaine (7.5 mg/mL) were configured in a ratio of 2:1:4 and applied on the lesion by reticular injection (horizontal fan-shaped stratified and vertical shaking pressurized injection). The minimum volume of injection per square centimeter was approximately 3.5 mL. The outcome indicators were the Vancouver Scar Scale (VSS), Visual Analogue Scale (VAS), treatment frequency.

RESULTS

The patients had an 82% ± 7% average reduction in VSS scores and 89% ± 13% and 93% ± 10% reductions in VAS scores of pain and pruritus, respectively, after an average of 2.5 ± 0.7 injections administered within 1 year.

CONCLUSION

The sufficient mesh polyhedral intralesional injection can achieve excellent results for the treatment of keloid scars.

Topical and Intralesional Immunotherapy for Melanoma In Situ: A Review

The incidence of in situ melanoma (MIS) has increased over the last decades. The mainstay of treatment for MIS, including lentigo maligna (LM), is complete surgical excision with clear margins (0.5 to 1.0 cm). Nevertheless, MIS lesions often affect elderly patients with comorbidities and involve large lesions in cosmetically sensitive areas, which means surgery is not always appropriate. Non-surgical treatments have a role in these cases, and include radiotherapy, cryosurgery, immunotherapy, laser therapy, and other topical medications. This study aims to review the applications of immunotherapy in MIS, either in monotherapy or in combination with other therapeutic alternatives. The main forms of immunotherapy used are imiquimod and, to a lesser extent, intralesional interferon-α (IL-INF-α) and ingenol mebutate (IM). IL-INF-α and IM have not been studied as extensively as imiquimod, whose results in real-life practice are encouraging. The clearance and recurrence rates reported in MIS treated with imiquimod as monotherapy, or as an adjuvant after surgery with affected or narrow margins, make imiquimod a reliable therapeutic alternative in selected cases. Also, its use as a neoadjuvant therapy before surgery was shown to reduce the final surgical defect size required to confirm negative histologic margins. In conclusion, local immunotherapy is frequently used in clinical practice and experience confirms it to be an excellent option for certain patients.

Use of Intralesional and Perilesional Human Recombinant Epidermal Growth Factor (hrEGF) in the Local Treatment of Venous Ulcer - Review Article - Expert Recommendation

Venous Ulcers (VU) represent 60-80% of all leg ulcers and are the final stage of the disease secondary to venous hypertension or valve insufficiency. Conventional treatment that focuses on its etiological factors continues to be the gold standard; however, 30% of ulcers do not heal with this treatment; thus, it has been seen that the use of growth factor can be used as an adjuvant for this pathology. A literature review was carried out to evaluate the evidence from systematic reviews, meta-analyses, case studies, and quantitative studies that respond to the objective of this analysis review in the different databases with specific inclusion criteria with publications between 2002 and 2022, initially finding the topical application of the factor and later, more recently, the intralesional and perilesional application, the latter being an alternative treatment for this type of pathology and generating some recommendations for using the Factor.

When Surgery Won't Cut It: Successful Management of Eruptive Squamous Atypia With Combination Medical Therapy

The termeruptive squamous atypia(ESA) is used to describe squamous proliferations that do not present with high-grade histologic features and for which surgical management may exacerbate the condition. Non-surgical management of ESA with radiation, local or systemic chemotherapy, retinoids, or immunotherapy have been reported with variable success. In contrast, combination treatment with retinoids, immunomodulatory or chemotherapeutic agents may result in a more durable response. We report a case of recalcitrant ESA of the lower extremities where complete clinical remission was induced with triple combination medical management with intralesional 5-fluorouracil, field treatment with topical 5-fluorouracil and imiquimod, and oral acitretin. Our case adds to the literature supporting combination medical therapy for challenging cases of ESA.

Intralesional Vitamin D3 Versus Bleomycin for Difficult-to-Heal Palmoplantar Warts: A Comparative Study

Introduction

Difficult-to-heal or recalcitrant palmoplantar warts are notoriously resistant to treatment, making treatment difficult and challenging. To improve the outcome and overcome the difficulties, various treatment options have been tried, but none is gold standard. Many comparative studies have been undertaken to assess the efficacy of various drugs; however, none of them are standardized, and no single treatment is effective. Various comparative efficacy studies have been conducted but, to the best of our knowledge, no study has been conducted comparing intralesional (IL) injection (inj) vitamin D3 (Vit D3) with the chemotherapy drug IL inj Bleomycin for difficult-to-heal palmoplantar warts. We conducted a trial to evaluate the efficacy of IL inj Vit D3 versus IL inj Bleomycin in the treatment of difficult-to-heal palmoplantar warts. The purpose of this study was to compare the efficacy of IL inj vitamin D3 versus IL inj Bleomycin as biological response modifier therapy in difficult-to-heal palmoplantar warts.

Materials and Methods

A cohort of 48 patients with difficult-to-heal warts were consecutively assigned to one of two groups: Group 1 IL inj Vit D3 (0.2-0.5 mL inj vitamin D3 600,000 IU solution 15 mg/mL) or Group 2 IL inj Bleomycin (0.2-0.4 mL of 1 U/mL solution) for a maximum of four treatments spaced 2 weeks apart, with a maximum of five warts treated at each visit for both groups. Warts were measured at baseline and at each subsequent visit. Wart's resolution was measured as 1-25%, 2-50%, 3-75%, and 4-100% reduction. Patients were followed-up for 3 months after treatment.

Results

All the 48 patients completed the study, with 26 receiving IL inj Vit D3 with complete resolution in 88.5%, partial resolution in 11.5%, and side effects in 6.2%. In 22 patients receiving IL inj Bleomycin, 95.5% had complete resolution, 4.5% had partial resolution, and 8.2% had side effects. Maximum resolution was observed in the third session. We found no recurrence after 3 months.

Conclusion

IL inj Vit D3 and IL inj Bleomycin are both safe and effective in treating difficult-to-heal palmoplantar warts with better outcomes and patient satisfaction. IL Bleomycin was significantly more effective than IL Vit D3, although the difference was not statistically significant.

Abscopal responses in patients with metastatic melanoma involving skin and subcutaneous tissues treated with intralesional IL2 plus BCG

Cutaneous melanoma is relatively common with increasing incidence and significant mortality. While the mainstay of therapy is surgical, patients with stage III and IV disease fare poorer than those with early-stage disease and often benefit from adjuvant therapies. While systemic immunotherapy has changed the landscape of melanoma treatment, for some patients systemic toxicities related to these treatments prohibit successful administration or completion of therapy. Moreover, it is becoming increasingly evident that nodal, regional, and in-transit disease appears to be resistant to systemic immunotherapy relative to responses observed in distant metastatic disease sites. In this scenario, intralesional immunotherapies may offer benefit. In this case series, we describe the use of intralesional IL-2 and BCG at our institution in ten patients with in-transit plus or minus distant cutaneous metastatic melanoma over the last twelve years. All patients received intralesional IL2 and BCG. Both treatments were very well tolerated with only grade 1/2 adverse events. In our cohort, complete clinical response was 60% (6/10), progressive disease in 20% (2/10), and no response in 20% (2/10) of patients. The overall response rate (ORR) was 70%. The median overall survival was 35.5 months and mean overall survival 43 months in this cohort. Herein we further highlight the clinical, histopathological, and radiological course of two complete responders, showing evidence of an abscopal effect with resolution of distant untreated metastasis. Together, this limited data supports the safe and effective use of intralesional IL2 and BCG for the treatment of metastatic or in-transit melanoma in this challenging patient cohort. To our knowledge, this is the first formal study to report on this combination therapy for the treatment of melanoma.

Intralesional combined furosemide and digoxin in cutaneous warts treatment: A randomized controlled clinical trial

Although being a benign lesion, Warts can affect the quality of life by causing discomfort, disfigurement, and social embarrassment besides the tendency to spread. Cutaneous wart treatment faces many challenges as the development of an antiviral drug that can eradicate the human papilloma virus (HPV) is difficult. This clinical study aimed to assess the efficacy and safety of intralesional combined furosemide and digoxin in the treatment of multiple cutaneous warts. This double blinded randomized clinical trial included 80 adult patients with multiple cutaneous warts (≥2 warts) who were randomized into two groups, Group I (40 patients) treated with intralesional combined furosemide and digoxin and Group II (40 patients) who were treated with intralesional normal saline solution as a control group, weekly till improvement or for maximum five sessions. Clinical and dermoscopic evaluation at baseline, every session, and monthly for 6 months after the last session to detect any recurrence was performed. Complete wart clearance was observed in 92.5% of patients in the intralesional combined furosemide and digoxin group (Group I) compared with 10.0% in saline group (Group II), with highly statistically significant difference (P-value = 0.000). Pain during injection in 95.0% and 45.0% of patients in Group I and Group II respectively, treatment group was superior compared to control group. Intralesional injection of combined furosemide and digoxin can be a safe and effective treatment option in multiple cutaneous warts with minimal side effects in this study.

The Anti-Psoriatic Efficacy and Safety Profile of Topical and Intralesional Methotrexate: A Literature Review

Methotrexate (MTX) has long been considered the first-line oral systemic pharmacotherapy for psoriasis. The drug has several well-known systemic side effects, such as bone marrow suppression and hepatotoxicity. To avoid them, the use of topical or intralesional administrations of MTX has become an interesting option. With the advent of novel drug delivery systems, especially nanocarriers, the usage of a high-efficacy and safe topical MTX for psoriasis has nearly been attained. This review examined the development, anti-psoriatic efficacy and adverse effects of topical forms of MTX (plain MTX; MTX with chemical enhancer; MTX using nanotechnology; MTX with protein transduction domains; MTX with liquid crystalline systems; and MTX with physical enhancer/laser) and intralesional MTX in psoriasis patients and psoriasis-induced animals. The efficacy of topical MTX varied with the drug delivery technology employed. Nevertheless, the overall safety profile of the topical forms was favourable. A 25 mg/mL MTX solution injected intralesionally at the nail matrix worked well for nail psoriasis recalcitrant to topical treatment. To improve the standard of care for patients with psoriasis, randomized controlled trials that establish the most effective MTX-delivery system are needed.

Keloid Therapy: A Neoteric Comparative Study

BACKGROUND

Keloids are considered disorders of fibroproliferation characterized by accumulation of collagen fibers in hypodermis and dermis, caused by inflammation, surgery, and trauma.

OBJECTIVES

The main goal of the study was to approach a better modality for the treatment of keloids by comparing the effects and the side effects of intralesional cryotherapy and intralesional injection of bleomycin.

METHODS

This interventional, comparative clinical trial was conducted on 60 cases and were divided equally into the group (A) combined group where who were subjected to intralesional bleomycin followed by cryotherapy in the same session, group (B) who were subjected to intralesional injection of bleomycin, and group (C) intralesional cryotherapy. All cases were subjected to clinical examination, complete history taking, dermatological examination, examination, and evaluation of scar lesion using the Vancouver scar scale.

RESULTS

There was a statistically significant decrease in pliability among the combined group. Also, pliability decreased in the bleomycin group and cryotherapy, but this decrease wasn't statistically significant. Our results revealed that there was a statistically significant decrease in lesion height among all the studied groups, but the decrease was more among the combined group.

CONCLUSION

Intralesional cryotherapy was effective as Intralesional bleomycin. Combined therapy was a valid and more effective technique with few adverse effects than either alone for keloids as it achieved a decrease in volumes of scars or accompanied symptoms.

Cutaneous Breast Cancer Metastasis Is Effectively Treated With Intralesional Interleukin-2 and Imiquimod: A Case Report and Brief Literature Review

Breast cancer is the most common non-cutaneous cancer affecting women worldwide and is a major cause of cancer-related morbidity and mortality in females. While many women are diagnosed with early-stage disease, a subset of women may present with isolated cutaneous metastases or recurrent locoregional cutaneous metastatic disease. There is a paucity of evidence for effective treatments for cutaneous breast cancer metastases. Herein, we present a case of hormone receptor negative, HER2 positive cutaneous breast cancer metastasis treated with intralesional IL-2 and topical imiquimod, which was well tolerated with only minor low grade side effects. We also present a brief literature review of immunotherapy for cutaneous breast cancer metastasis to frame the discussion around using minimally invasive local therapies for this disease. Together, this limited data suggests that intralesional IL-2 and imiquimod may be considered as a safe option when treating a patient with cutaneous breast cancer metastases.

Intratumoral therapies and in-situ vaccination for melanoma

Skin cancers are among the most physically accessible malignancies, so local delivery of a medication into the tumor, so-called intratumoral therapy, is an appealing route of drug administration. Intratumoral therapies have the potential to increase local drug concentration and/or attract immune cells to the local tumor microenvironment, possibly with fewer systemic side effects. A wide array of intratumoral agents have been studied to date in patients with advanced melanoma, including chemotherapeutic drugs, immune modulating agents, and cancer-directed vaccines. In this review, we will summarize the key pre-clinical and clinical data supporting the use of intratumoral therapy for advanced unresectable and metastatic melanoma. First, we will discuss the history of intratumoral immunotherapy for the treatment of melanoma and the various agents studied to date. Second, we will explore how intratumoral therapies can constitute an in situ vaccine, potentially leading to disease control both locally and systemically. Finally, we will highlight opportunities in the field and key future directions.

Intralesional corticosteroid injections to treat lip swelling associated with oral Crohn's disease in a child

This procedural report details the case of a 10-year-old boy with oral Crohn's disease successfully treated with intralesional corticosteroid injections. The intervention used topical anesthesia with a eutectic mixture of lidocaine 2.5%/prilocaine 2.5% cream followed by intralesional triamcinolone acetonide. This approach safely and effectively reduced patient discomfort while allowing for an acceptable and durable clinical outcome.

Remarkable efficiency of surgical shave excision of keloids followed by intralesional injection of Bleomycin. A retrospective study of 314 cases

The aim of this study was to determine the efficiency of a keloid treatment consisting of intradermal surgical shave excision followed by intralesional injections of Bleomycin. A retrospective study performed in the Department of Dermatology, CHU UCL Namur Sainte Elisabeth Clinic, Belgium between 2018 and 2019, on 314 patients with keloids—average age: 32 years (range 19–62). Patients were treated first by surgical shave excision and then after reepithelialization, monthly Bleomycin injections were used until the itching and/or pain ceased and the keloid disappeared. The satisfaction index based on Vancouver Scar Scale on the 314 patients was as follows: 87% of the patients were very satisfied with complete flattening (276 patients), 11% were moderated satisfied with significant flattening (32 patients), and 2% show recurrences (6 patients). Pain and itching disappear totally (100% of patients) based on Visual Analogue Scale. The absence of recurrence within 24 months of the last injection, leads us to believe that this can be a first choice and low‐cost treatment, whatever the phototype and the size of the lesion. This treatment can be given in all regions of the world, including in non‐industrialized or developing countries.

Intralesional Purified Protein Derivative Versus Zinc Sulfate 2% in the Treatment of pediatric warts: Clinical and Dermoscopic Evaluation

BACKGROUND

Warts are common in children and can be difficult to treat. Many treatments for warts are destructive and painful in contrast to intralesional immunotherapy using different types of antigens.

AIM

to evaluate the efficacy, safety, and tolerability of intralesional purified protein derivative (PPD) versus intralesional zinc sulfate 2% in the treatment of pediatric warts.

METHODS

This randomized clinical trial included 120 children with multiple warts divided into two equal groups. Group Ⅰ received intralesional 10 IU (0.1 ml) of PPD, group Ⅱ received intralesional zinc sulfate 2% in the largest wart every 2 weeks till improvement or for a maximum five treatment sessions. The follow up period was 6 months after the last treatment session.

RESULTS

the overall response was equal in both groups (81.7%), but the response of the injected wart was higher in the zinc sulfate group (93.4%) versus PPD group (83.3%) with no significant difference. The highest cure rates were after the 5^th session in the PPD group and the 1^st session in the zinc sulfate group with slightly lower numbers of sessions needed for cure in the zinc sulfate group (3 sessions) versus the PPD group (4 sessions). The zinc sulfate group showed statistically significant higher rates of complications (pain, inflammation, necrosis, and scar) than PPD group. The zinc sulfate group showed non-significant higher rates of recurrence during the follow up period.

CONCLUSION

Both intralesional PPD and zinc sulfate 2% are effective in pediatric warts with higher safety profile of PPD.

Clinical endpoints of needle-free jet injector treatment: An in depth understanding of immediate skin responses

Objectives

Needle‐free jet injectors have been used in dermatological practice for many years. However, predefined clinical endpoints that guide physicians to choose optimal device settings have not been clearly defined. Here, we evaluate immediate skin responses as clinical endpoints for needle‐free jet injector treatments.

Methods

We injected methylene blue in ex vivo human skin using an electronically‐controllable pneumatic injector (EPI; 3–6 bar, 50–130 µl; n = 63), and a spring‐loaded jet injector (SLI) with fixed settings (100 µl; n = 9). We measured the immediate skin papule (3D‐camera), residual surface fluid (pipette), dermal dye distribution by estimating depth and width, and subcutaneous dye deposition.

Results

EPI with 4 bar and 100 µl resulted in the largest skin papule of 48.7 mm³ (35.4–62.6 mm³) and widest dermal distribution of 8.0 mm (5.5–9.0 mm) compared to EPI with 6 bar and 100 µl (p < 0.001, p = 0.018, respectively). The skin papule volume showed a significant moderate to high positive correlation with the width and depth of dye distribution in the dermis (r_s = 0.63, r_s = 0.58, respectively; p < 0.001 for both correlations). SLI showed high variability for all outcome measures. Finally, a trend was observed that a small skin papule (≤7 mm) and little residual surface fluid (≤10% of injection volume) were warning signs for subcutaneous deposition.

Conclusions

The immediate skin papule and residual surface fluid correspond with dermal drug deposition and are relevant clinical endpoints for needle‐free jet injector treatments in dermatological practice.

Efficacy of Intralesional Aqueous Bleomycin in Treatment of Pediatric Lymphatic Malformations

Introduction

Lymphatic malformations (LMs) are an aberrant developmental anomaly of dysplastic sequestrated lymphatic vessels. Though surgical excision has been the conventional treatment modality, it has been associated with injury to adjacent structures, recurrences, and poor cosmesis. Intralesional bleomycin has shown a promising role in the treatment of LMs, and we present our experience with aqueous intralesional bleomycin in the pediatric population including infants in terms of its efficacy, complications, and parental satisfaction.

Materials and Methods

Children with clinically and ultrasound-proven macrocystic non-visceral LMs received aqueous bleomycin intralesionally under ultrasound guidance at 0.5 IU/kg/dose at monthly intervals and not exceeding five doses. Response to therapy and complications were monitored and regression graded as excellent (total disappearance), good (>50% reduction), and poor (<50% reduction).

Results

Our study included 26 children with a median age of 24 months (range 2-168) and a median weight of 12 kg (range 4-38). The most common site was the neck (37%). Duration of follow-up was 6 years (range 1-7). Response was excellent in 23/26 (88.4%) patients, good in 3/26 (11.5%), and poor in none (0%). Nine (34.6%) patients showed complete response with a single injection. None (0%) developed recurrence. Three (11.5%) children had minor complications such as fever and mild hypopigmentation. None developed any major complications. Parental satisfaction was excellent in 24/26 (92.3%) and good in 2/26 (7.7%) patients.

Conclusion

Intralesional aqueous bleomycin sclerotherapy is a safe non-surgical intervention for macrocystic pediatric LMs with reasonably good outcomes and even better parental satisfaction.

Efficacy of Fractional Carbon Dioxide Laser (FCO2) with Intralesional 5-Fluorouracil (5-FU) in the Treatment of Keloids

Context:

Managing keloids remains a challenge in clinical practice. Many therapeutic options are available, but none is universally accepted or without recurrence. Therefore, an effort is required to choose the treatment with maximal outcomes.

Aims:

To evaluate the effectiveness of combining fractional carbon dioxide (FCO₂) laser and intralesional 5-fluorouracil (5-FU) for the treatment of keloids.

Materials and Methods:

In this prospective open-label study, 24 patients received FCO₂ laser treatment, started at baseline, for a total of six sittings. The patients also received 1 mL/cm²/keloid of 5-FU (50 mg/mL) intralesionally, following irradiation, at identical time points. The primary outcome evaluated was the clinical response concerning height, pliability, vascularity, and pigmentation, using the Vancouver Score Scale (VSS). Adverse reactions and recurrences were recorded as secondary outcomes.

Results:

A significant reduction was observed in the VSS in terms of pliability and height after three treatment sessions. The mean VSS reduction was 65%, from 8.45 ± SD 0.93 at baseline to 3 ± SD 1.8 one month after the last treatment (P < 0.05). Most patients (79.1%; n = 19) showed a satisfactory response to treatment, with 57.8% (n = 11) achieving an excellent result. Adverse reactions included post-inflammatory hyperpigmentation in four patients and ulceration in two. Recurrences were reported in 21% of the patients who responded well.

Conclusions:

Combination therapy with FCO₂ laser and intralesional 5-FU showed a promising effect in the treatment of resistant keloids, with an acceptable safety profile and low recurrence rate.

Intralesional biologics for inflammatory dermatoses: A systematic review

Biologic medications are systemic therapeutic options for inflammatory dermatoses. Local forms of administration are less well-studied. To provide a summary of intralesional (IL) administration of biologics for various non-malignant inflammatory dermatologic conditions reported in the literature. A systematic review was performed in the PubMed and Embase databases from 2000 to 2020. Inclusion criteria included the local use of biologic medications for non-malignant cutaneous conditions. Quality was assessed with the modified Oxford Centre for Evidence-Based Medicine ratings. A total of 19 articles describing the use of 5 biologic medications in 9 dermatologic conditions were identified, comprising 172 patients. Conditions successfully treated with intralesional biologics included pemphigus vulgaris (rituximab), granuloma faciale (rituximab), perianal Crohn's disease (infliximab), lichen sclerosus (adalimumab), and necrobiosis lipoidica (etanercept and infliximab). Intralesional etanercept reduced pruritus associated with keloids. A case report of the use of infliximab for pyoderma gangrenosum did not demonstrate any efficacy. There was no consistent effect noted with treatments for sarcoidosis (infliximab) or cutaneous lymphoid hyperplasia (rituximab). Local administration of biologic medications may offer an additional method of treating refractory inflammatory dermatoses, but further study is needed to develop standardized dosing protocols, clarify efficacy rates, and identify optimal treatment candidates.

Intralesional delivery of glycoprotein IIb/IIIa inhibitors in acute myocardial infarction: Review and recommendations

Plaque rupture leads to a cascade of events culminating in collagen disruption, tissue factor release, platelet activation and thrombus formation. Pro-inflammatory conditions, hyperglycemia and smoking predispose to high thrombus burden (HTB) which is an independent predictor of slow or no-reflow. In patients with acute myocardial infarction (AMI), glycoprotein IIb/IIIa inhibitors (GPI) reduce thrombus burden and improve myocardial perfusion. These agents are typically administered systemically via the intravenous route or locally via an intracoronary (IC) route. However, as higher local concentrations of GPI are associated with enhanced platelet inhibition, intralesional (IL) GPI administration may be particularly effective in cases of HTB. Modest-sized randomized trials comparing IL and IC GPI delivery have reported conflicting outcomes. Some trials have demonstrated improved coronary flow and myocardial perfusion with reduced major adverse cardiac events with IL compared with IC GPI administration, whereas others have shown no significant benefits. Furthermore, although no direct comparison has been made between IL delivery using an aspiration catheter, microcatheter or a dedicated balloon-based "weeping" infusion-catheter, improved outcomes have been most consistent following GPI administration at the site of the lesion and thrombus with the dedicated infusion catheter. This review provides an update on the role and outcomes of IL GPI administration in patients with AMI and HTB. Based on the evidence we offer an algorithm demonstrating when to consider IL administration in patients with AMI undergoing intervention. We conclude with a perspective on the management of patients with STEMI and COVID-19 in whom a prothrombotic state often results in HTB.

Intralesional Candida antigen versus intralesional vitamin D3 in the treatment of recalcitrant multiple common warts

BACKGROUND

There are various therapies available for recalcitrant common warts; however no specific therapy has been established as entirely effective.

AIMS

To assess the efficacy and safety of intralesional Candida antigen injection of vs. intralesional vitamin D3 injection in the treatment of multiple recalcitrant common warts.

PATIENTS AND METHODS

A total of 80 adult patients with multiple common warts were randomly assigned to one of three groups in this study. Thirty patients were assigned to Group I, who received a 0.3 ml intralesional injection of Candida antigen. Thirty patients were assigned to Group II, who received a 0.6-ml (60 000 IU) intralesional injection of vitamin D3. Twenty patients were in Group-III, who received 0.3 ml of normal saline as a control. Each agent was injected at the base of largest wart every 3 weeks until full clearance has been obtained, or for a maximum of four sessions.

RESULTS

In the Candida antigen, vitamin D3, and saline groups, complete wart clearance was observed in 76.7 percent, 20%, and 0.0 percent, respectively. The side effects were negligible and transient, and there was no recurrence of the lesions.

CONCLUSION

Intralesional injection of Candida antigen is as a safe, simple, cost-effective treatment modality for multiple recalcitrant common warts and it outperforms intralesional vitamin D3.

Current status of intralesional agents in treatment of malignant melanoma

Prognosis of metastatic melanoma has undergone substantial improvement with the discovery of checkpoint inhibitors. Immunotherapies and targeted therapies have improved the median overall survival (OS) of metastatic melanoma from 6 months to more than 3 years. However, still about half of the patients die due to uncontrolled disease. Therefore, multiple strategies are currently being investigated to improve outcomes. One such strategy is intralesional/intratumoral (IT) therapies which can either directly kill the tumor cells or make the tumor more immunogenic to be recognized by the immune system. Talimogene laherparepvec (T-VEC), an oncolytic virus, is the first FDA approved IT therapy. This review focuses on the current status of IT agents currently under clinical trials in melanoma. Reviewed therapies include T-VEC, T-VEC with immune checkpoint inhibitors including ipilimumab and pembrolizumab or other agents, RP1, OrienX010, Canerpaturev (C-REV, HF10), CAVATAK (coxsackievirus A21, CVA21) alone or in combination with checkpoint inhibitors, oncolytic polio/rhinovirus recombinant (PVSRIPO), MAGE-A3-expressing MG1 Maraba virus, VSV-IFNbetaTYRP1, suicide gene therapy, ONCOS-102, OBP-301 (Telomelysin), Stimulation of Interferon Genes Pathway (STING agonists) including DMXAA, MIW815 (ADU-S100) and MK-1454, PV-10, toll-like receptors (TLRs) agonists including TLR-9 agonists (SD-101, CMP-001, IMO-2125 or tilsotolimod, AST-008 or cavrotolimod, MGN1703 or lefitolimod), CV8102, NKTR-262 plus NKTR-214, LHC165, G100, intralesional interleukin-2, Daromun (L19IL2 plus L19TNF), Hiltonol (poly-ICLC), electroporation including calcium electroporation and plasmid interleukin-12 electroporation (pIL-12 EP), IT ipilimumab, INT230-6 (cisplatin and vinblastine with an amphiphilic penetration enhancer), TTI-621 (SIRPαFc), CD-40 agonistic antibodies (ABBV-927 and APX005M), antimicrobial peptide LL37 and other miscellaneous agents.

Case Report: Combined Intra-Lesional IL-2 and Topical Imiquimod Safely and Effectively Clears Multi-Focal, High Grade Cutaneous Squamous Cell Cancer in a Combined Liver and Kidney Transplant Patient

Cutaneous squamous cell carcinoma (cSCC) is the second most common non-melanoma skin cancer worldwide, with ever increasing incidence and mortality. While most patients can be treated successfully with surgical excision, cryotherapy, or radiation therapy, there exist a subset of patients with aggressive cSCC who lack adequate therapies. Among these patients are solid organ transplant recipients who due to their immunosuppression, develop cSCC at a dramatically increased rate compared to the normal population. The enhanced ability of the tumor to effectively undergo immune escape in these patients leads to more aggressive tumors with a propensity to recur and metastasize. Herein, we present a case of aggressive, multi-focal cSCC in a double organ transplant recipient to frame our discussion and current understanding of the immunobiology of cSCC. We consider factors that contribute to the significantly increased incidence of cSCC in the context of immunosuppression in this patient population. Finally, we briefly review current literature describing experience with localized therapies for cSCC and present a strong argument and rationale for consideration of an IL-2 based intra-lesional treatment strategy for cSCC, particularly in this immunosuppressed patient population.

Feasibility of achieving planned surgical margins in primary spine tumor: a PTRON study

OBJECTIVE

Oncological resection of primary spine tumors is associated with lower recurrence rates. However, even in the most experienced hands, the execution of a meticulously drafted plan sometimes fails. The objectives of this study were to determine how successful surgical teams are at achieving planned surgical margins and how successful surgeons are in intraoperatively assessing tumor margins. The secondary objective was to identify factors associated with successful execution of planned resection.

METHODS

The Primary Tumor Research and Outcomes Network (PTRON) is a multicenter international prospective registry for the management of primary tumors of the spine. Using this registry, the authors compared 1) the planned surgical margin and 2) the intraoperative assessment of the margin by the surgeon with the postoperative assessment of the margin by the pathologist. Univariate analysis was used to assess whether factors such as histology, size, location, previous radiotherapy, and revision surgery were associated with successful execution of the planned margins.

RESULTS

Three hundred patients were included. The surgical plan was successfully achieved in 224 (74.7%) patients. The surgeon correctly assessed the intraoperative margins, as reported in the final assessment by the pathologist, in 239 (79.7%) patients. On univariate analysis, no factor had a statistically significant influence on successful achievement of planned margins.

CONCLUSIONS

In high-volume cancer centers around the world, planned surgical margins can be achieved in approximately 75% of cases. The morbidity of the proposed intervention must be balanced with the expected success rate in order to optimize patient management and surgical decision-making.

Complete clearance of condyloma acuminata using injection Vitamin D3

Anogenital warts (AGWs) are caused by human papilloma virus (HPV) and are transmitted by sexual route. The available options for the treatment of AGWs are cumbersome, require multiple sittings and are associated with recurrence. This is a case report of a male with condyloma acuminata who was treated successfully using injection vitamin D3. No recurrence was observed in a follow-up period of 6 months.

Peyronie's disease: pharmacological treatments and limitations

Introduction: Peyronie's disease (PD) is a disorder of the tunica albuginea from disordered and excessive deposition of collagen resulting in a palpable scar, pain, erect penile deformity and erectile dysfunction that significantly impacts patients both physically and emotionally.Areas Covered: Several treatment options have been described for PD, including shockwave therapy, traction therapy, both oral and intralesional pharmacological options, and surgery. This review seeks to examine the data for different types of non-surgical treatments for PD. We review how various treatment modalities impact several relevant clinical endpoints for Peyronie's disease, including effects on pain, penile curvature, plaque formation, and erectile function. We performed a literature search using PubMed and SCOPUS while referencing AUA, EAU, and CUA guidelines for management of Peyronie's Disease for studies published 1980-2020.Expert opinion: Intralesional collagenase injections have the strongest evidence and are the only FDA approved intralesional treatment for PD. Penile traction therapy (PTT) is low risk and may be beneficial in patients willing to invest significant time using the devices. Furthermore, oral combination therapy with other modalities may provide some benefit. Further investigation is required to better understand pathophysiology of PD and clarify the therapeutic utility of existing treatments, potentially with a multimodal strategy.

Intralesional combined digoxin and furosemide in plantar warts: Does it work?

BACKGROUND

Warts are small, benign growths caused by human papilloma virus. No treatment has yet proven 100% effective for a cure. DNA viruses rely on K + influx for replication. Both digoxin and furosemide inhibit the K + influx by interacting with cell membrane ion co-transporters. Therefore, it is hypothesized that these two compounds may be valuable in the treatment of warts.

AIMS

Our aim was to evaluate the efficacy and safety of intralesional injection of a combination of digoxin and furosemide in treatment of plantar warts.

PATIENTS/METHODS

This two-armed single blinded randomized clinical trial included 40 cases with multiple plantar warts (≥3warts) divided into 2 groups (20 cases each). The first group received intralesional normal saline and the second group received intralesional combined digoxin and furosemide, one session every week for maximum 5 injection sessions.

RESULTS

On comparing between the 2 groups regarding response to treatment (reduction in number of warts), the first group showed no change in number of warts (82 warts before and after treatment), whereas, in the second group, the number of warts before treatment was 80 while after treatment it was 40 (50% reduction in number). There was a statistically significant difference between the two groups as regard the change in the total number of warts (P < .001).

CONCLUSIONS

Intralesional injection of combined digoxin and furosemide is safe and effective treatment option in multiple plantar warts.

Saline in Dermatology: A literature review

BACKGROUND

Saline, with its different concentrations, is the most used crystalloid solution in medicine. In dermatology, no large studies investigated the benefits of saline. The aim of this article is to review the different possible uses of saline in dermatology, in order to give final recommendations based on the literature review and our experience.

METHODS

We performed a literature search based on PubMed, EMBASE, WHO Global Health Library, Virtual Health Library, Web of Science, Scopus, Google Scholar, and Research gate. using the keywords: saline, physiological, hypertonic, isotonic, hypotonic, salt solution, sodium chloride, 0.9% NaCl, solvent, drug delivery, injection mixtures, diluent, sclerosant, intravenous, intralesional, injection, topical, soaks, fomentation, inhalation, alopecia, psoriasis, scars, atopic dermatitis, eczema, bromoderma, iododerma, lipodystrophy, in various combinations with the Boolean operators AND, OR and NOT. We also hand-searched textbooks.

RESULTS

Saline was used as a diluent with intralesional injection of steroids to minimize the risk of steroid-induced atrophy, being safe and free from preservatives that may precipitate steroids at site of injection and maximize their side effects. Saline has also been used after surgery, when atrophic scars take place or anticipated, and through injection in leishmaniasis, granuloma annulare, atrophic acne scars before using other expensive and less tolerated treatment options.

CONCLUSIONS

The saline represents a helpful option as a diluent with intralesional injection of steroids in various dermatologic therapeutic indications. Moreover, the use of saline in this setting could help to minimize the risk of steroid-induced atrophy. We encourage the use of saline after surgery, when atrophic scars take place or anticipated. Also, we encourage a trial of saline injection in leishmaniasis, granuloma annulare, atrophic acne scars before using other expensive and less tolerated treatment options.

Intralesional immunotherapy for molluscum contagiosum: A review

Molluscum contagiosum (MC) is a common cutaneous viral infection with no standard treatment. The virus responsible for MC is thought to be cleared by cell mediated immunity (CMI). Intralesional immunotherapy that stimulates CMI has been shown to be an effective treatment for other cutaneous viruses. In this review, we evaluate the efficacy and safety of intralesional immunotherapy in the treatment of MC. Articles met inclusion criteria if they examined the effects of intralesional immunotherapy as a treatment for MC, with a clear outcome and reproducible methodology. 228 studies were screened and 10 studies met criteria for inclusion. Intralesional immunotherapies investigated included candida, combined measles, mumps, rubella vaccine, tuberculin purified protein derivative, vitamin D3, interferon α, and Streptococcal substrain OK-432. Studies demonstrated clearance of MC lesions following intralesional immunotherapy, with complete response rates between 36% and 100%. No serious adverse effects were noted. Intralesional immunotherapy is a safe and effective treatment option for MC in pediatric and adult patients.

The efficacy of intralesional dexamethasone versus intravenous dexamethasone in surgery for impacted third molars: A randomized controlled trial

Objectives:

A randomized prospective double-blind study was conducted to determine the efficacy of sub-mucosal local infiltration vs. intravenous dexamethasone in reducing postoperative pain, swelling and trismus after surgical removal of impacted mandibular third molars.

Materials and Methods:

Forty five patients were included in the study and were randomly divided into three groups. Each group consisted of 15 patients for which the first and second groups were given 8 mg of dexamethasone intrlesionally & intravenously respectively, at 30 minutes prior to surgery; the third group served as control. Duration of facial swelling was evaluated subjectively by the patients themselves. Severity of postoperative pain was quantified by counting the number of analgesics taken by the patients during and after surgery (six subsequent days). Postoperative trismus was determined by measuring the maximum incisal opening before surgery and on the seventh day.

Results:

Results showed that duration of postoperative edema was almost the same in the three test groups. During surgery, the intravenous dexamethasone group showed a significantly lesser pain than the other two groups; the intralesional dexamethasone group showed less marked pain than the control group. Additionally, patients who had taken steroids had a marked increase in the incisal opening postoperatively over the control group. Trismus was significantly reduced in the methylprednisolone group as compared to the dexamethasone group.

Conclusion:

It is concluded that both preoperative local infiltration and intravenous administration of dexamethasone significantly reduced postoperative pain and trismus after surgical removal of mandibular third molars. An intravenous dexamethasone is more effective in reducing postoperative inflammatory sequelae than its intralesional route.

A Study to Evaluate the Role of Intradermal and Intralesional Measles, Mumps, Rubella (MMR) Vaccine in Treatment of Common Warts

Background:

Warts are common cutaneous viral infection with a wide range of therapeutic modalities. Various agents have been tried for immunotherapy in warts.

Objectives:

Determine the role of intralesional and intradermal measles, mumps, rubella (MMR) vaccine in the treatment of common warts; to compare the efficacy of intralesional versus intradermal MMR vaccine.

Methods and Materials:

Patients diagnosed with verruca vulgaris were divided into two groups. In study group A, the individuals were injected with an intralesional MMR vaccine of 0.3 mL in the representative wart (largest) once in 3 weeks till there is complete clearance or maximum of four injections whichever is earlier, while in study group B, the individuals were injected with an intradermal MMR vaccine of 0.3 mL over the unilateral deltoid muscle area at similar intervals.

Results:

There were 33 patients in each group. In group A, 10 (30.3%) patients showed complete, 9 (27.3%) marked, 6 (18.2%) moderate, 3 (9.1%) mild, and 5 (15.2%) no response. In group B, seven (21.2%) patients showed complete, one (3.0%) marked, one (3.0%) moderate, four (12.1%) mild, and 20 (60.6%) no response. There were minimal side effects in the form of pain, erythema, itching at the injection site in a few patients, only one patient had syncope.

Conclusion:

We conclude that the MMR vaccine is an effective and safe modality of treatment for verruca vulgaris without any serious adverse effects. Also, the intralesional route showed better results in comparison to the intradermal route when we consider the treatment of a representative wart.

Treatment of Auricular Pseudocyst with Intralesional Steroid: A Study with Short-Term Follow-Up

Introduction

A pseudocyst is an uncommon, painless, benign cystic swelling on the lateral surface of the auricle with an unknown etiology. Various treatment modalities have been used with varying rates of success as this condition has high propensity for recurrence. We have used a minimally invasive treatment method for this condition to evaluate its efficacy in our setup.

Patients and Methods

This is a prospective study carried out in the department of ENT of Chitwan Medical College from May 2018 to April 2020. Complete aspiration of the pseudocyst with intralesional steroid (40 mg, triamcinolone acetonide) injection was done in 30 patients. They were followed up weekly for 4 weeks. Additional doses were injected in cases with persistence or recurrenqce before 3 weeks. Disappearance of the swelling, considered treatment success, was the main outcome. The total number of doses required for the complete resolution of the swelling along with the number of recurrences or complications, if any, were noted at the final follow-up at 4 weeks.

Results

All of our patients responded completely with intralesional triamcinolone. However, the total dose requirement for different patients varied. Out of the 30 patients, 21 (70%) responded to the single dose of the drug. Six (20%) required a second dose, while the remaining 3 (10%) patients required a third dose for complete resolution of the swelling. All three (10%) patients who received a third dose of triamcinolone complained of skin thickening, but there was no obvious cosmetic deformity.

Conclusion

Aspiration with intralesional steroid injection shows an immediate positive response in patients with auricular pseudocyst. It can achieve complete resolution of the swelling without any serious complications. Thus, it appears to be a simple and effective management of the condition in the short term.

Intralesional immunotherapy for the treatment of anogenital warts in pediatric population

BACKGROUND

The prevalence of anogenital warts is increasing in adults as well as in pediatric population. The treatment of anogenital warts is challenging, particularly in children as most conventional modalities are painful and associated with high recurrence rates.

OBJECTIVES

To evaluate the efficacy and safety of intralesional immunotherapy for the treatment of anogenital warts in pediatric patients.

METHODS

Forty child presenting with multiple anogenital warts were randomly assigned into 3 groups. The first group (15 patients) received intralesional MMR vaccine, the second group (15 patients) received intralesional Candida antigen and the third group (10 patients) received intralesional saline as a control. Each modality was injected into the largest wart at 2-week intervals until complete clearance or for a maximum of 5 sessions.

RESULTS

Highly significant difference was found between the therapeutic response of anogenital warts to both MMR vaccine and Candida antigen compared to intralesional saline (p = .005). No significant difference was observed between MMR vaccine and Candida antigen groups (p = .885). Side effects were mild and no recurrence was detected in the 6 month follow-up period.

CONCLUSIONS

Intralesional immunotherapy is a promising effective and well-tolerated treatment modality for multiple anogenital warts in children.

Insights into the Molecular Mechanisms Behind Intralesional Immunotherapies for Advanced Melanoma

The incidence of cutaneous melanoma, a highly malignant skin cancer, is increasing yearly. While surgical removal of the tumor is the mainstay of treatment for patients with locally confined disease, those with metastases face uncertainty when it comes to their treatment. As melanoma is a relatively immunogenic cancer, current guidelines suggest using immunotherapies that can rewire the host immune response to target melanoma tumor cells. Intralesional therapy, where immunomodulatory agents are injected directly into the tumor, are an emerging aspect of treatment for in-transit melanoma because of their ability to mitigate severe off-target immune-related adverse events. However, their immunomodulatory mechanisms are poorly understood. In this review, we will summarize and discuss the different intralesional therapies for metastatic melanoma with respect to their clinical outcomes and immune molecular mechanisms.

The infection rate of intralesional triamcinolone and the safety of compounding in dermatology for intradermal and subcutaneous injection: A retrospective medical record review

BACKGROUND

Intralesional injection of sterile medications remains a mainstay in dermatology, enabling a tailored, low-cost, in-office therapy. After the 2012 United States outbreak of fungal meningitis from contaminated intrathecally administered corticosteroids, there has been increased regulation of in-office compounding, regardless of the administration route. Studies demonstrating the safety data of in-office corticosteroid compounding for intradermal or subcutaneous use are lacking.

OBJECTIVE

To assess the incidence of infection caused by compounded in-office intralesional triamcinolone.

METHODS

A retrospective medical record review identified patients who received in-office intralesional corticosteroid injections in 2016. Medical documentation within 30 days of injection was reviewed for suspected infection.

RESULTS

The records of 4370 intralesional triamcinolone injections were assessed, of which 2780 (64%) were compounded triamcinolone with bacteriostatic saline. We identified 11 (0.25%) suspected localized infections, with 4 of the 11 in the compounding cohort. Of these, 7 of 11 occurred after injection of an "inflamed cyst." No hospitalizations or deaths occurred. No temporal or locational relationships were identified.

LIMITATIONS

This study was limited to 2 academic institutions. A 30-day postinjection time frame was used.

CONCLUSION

In-office compounding for intralesional dermal and subcutaneous administration is safe when sterile products are used by medical practitioners. There is no increased risk of compounded triamcinolone relative to noncompounded triamcinolone.