Update on antibacterial soaps: the FDA takes a second look at triclosans

In December of 2013 the Food and Drug Administration announced it would look further into the safety and efficacy of the biocide triclosan and requested further safety data as part of a new review with the Environmental Protection Agency. The use of triclosan has increased exponentially since its introduction in in 1972, to the point that 75% of commercial soap brands contain triclosan and 76% of a nationwide sample of adults and children excrete triclosan in the urine. This announcement raised an important dialog about the appropriate use of all over the counter biocides. Particular concerns include whether these biocides are more effective than regular soaps, whether they may create new drug resistant bacteria, and whether they may also act as hormone disruptors in humans or the environment.

News, views, and reviews. Less may be more for MRSA: the latest on antibiotics, the utility of packing an abscess, and decolonization strategies

The management of skin infections has evolved over time and new evidence suggests that less acute intervention may be as good or better. For acute treatment, evidence from the emergency medicine literature shows that empiric oral antibiotics may not improve outcomes relative to incision and drainage alone. The use of packing material for wounds after draining does not lead to a decreased rate of recurrence, more rapid healing, or fewer physician visits, but does cause more pain. For patients with multiple or recurrent skin and soft tissue infections, a comprehensive decolonization or eradication strategy is the most effective at preventing further recurrences. Several decolonization approaches exist and can be tailored to find the most appropriate for a particular individual.

News, views, and reviews. Carrots before sticks: appealing to vanity promotes sun protection

Daily broad-spectrum sunscreen use is an important intervention to prevent squamous cell carcinoma and invasive melanoma. Now dermatologists can feel confident confirming that it prevents photoaging in middle aged adults as well. A new randomized trial from Australia confirms that consistent use of broad-spectrum sunscreen can slow photoaging in adults in as little as four years in middle-aged adults. Because young adults respond better to anti-aging messages than anti-cancer messages regarding sun exposure, this data may help motivate younger patients to avoid indoor tanning and pursue consistent sun protection. Visual examples of aging over time are particularly effective for teens and young adults.

Chronic urticaria: omalizumab and review of therapeutic options

Chronic idiopathic urticaria is a rare but significantly life-altering skin disease. Recent developments in immunology have promoted our understanding of its autoimmune pathology, but treatment options have not yet developed at the same pace. When antihistamines aren't sufficient, the next steps for treatment have less evidence for support. Fortunately, a Phase III clinical trial has shown that the monoclonal antibody omalizumab, approved for use in asthma, can reduce symptoms of chronic idiopathic urticaria when added to maximal doses of H1-antihistamines. Therapeutic options for chronic idiopathic urticaria are reviewed.

Truth or fiction: risk factors for childhood atopic dermatitis

Atopic dermatitis is increasing in prevalence throughout the developed world, in parallel with asthma and hay fever. The reasons for the increase remain unclear. As a practical question, it is valuable to understand which interventions might decrease risk for childhood atopic disease. Prospective studies among infants and children are challenging to design and to execute. Fortunately, several large studies from Europe and the United States are better characterizing whether behavioral interventions such as breastfeeding, delayed introduction of solid foods, hydrolyzed protein infant formulas, or pets in the home might be protective or impart increased risk of developing atopic dermatitis. As this body of literature grows, physicians will be able to recommend behavioral interventions that can prevent atopic dermatitis in individuals and ideally decrease prevalence over the population.

Merkel cell carcinoma: banal-appearing, aggressive actor

Merkel cell carcinoma is a rare but often deadly cutaneous malignancy. It carries a 40 percent five-year mortality rate, in contrast to 15 percent for malignant melanoma, and the incidence is increasing among older and immunosuppressed patients. Dermatologists need to be aware of the particular diagnostic and treatment challenges as the incidence increases. New data is helping to identify patients most at risk, accurately stage the tumor and to optimize treatment regimens. With the recent discovery of a virus as part of the etiology of this tumor, approaches to use the body's immune system to attack the tumor have potential to significantly increase survival rates in the future. Merkel Cell carcinoma (MCC) is a rare but aggressive cutaneous malignancy. Its aggressive behavior, combined with its asymptomatic clinical presentation, means that tumors are often allowed to grow and spread before detection. As the tumor becomes better characterized and its etiology better understood, research is rapidly advancing in both pathogenesis and treatment. Since the discovery of a viral etiology for this tumor in 2008, progress is advancing rapidly.

Tamiflu: what dermatologists need to know

This article is a review of this winter's common infections and their treatments. As infectious agents become more aggressive and more resistant, new medications are needed to fight them. The recent outbreak of the H1N1 ("swine flu") influenza strain has increased, by several-fold, the use of the oral antiviral Tamiflu (oseltamivir) and Relenza (zenavimir). -As resistant skin and soft-tissue infections increase in frequency, the use of newer antibiotics is becoming more common. This article reviews the use and cutaneous side effects of antivirals and new antibiotics with a focus on those relevant to the dermatologist.

Hyperpigmentation: old problem, new therapies

Hyperpigmentation has frustrated men and women as a cosmetic concern and as a reminder of past skin injury. While photoprotection is an important part of preventing dark marks on skin, therapeutic interventions are important as well. The authors review new treatment data for fractional thermolysis,Tri-Luma, azelaic acid and chemical peels. Many therapies have been available for years, although evidence is not always extensive. The emergence of new treatments and long-term safety data offers dermatologists a greater degree of confidence as to the treatment approaches they can offer patients with hyperpigmentation.

Beyond tretinoin: cosmeceuticals for aging skin

In contrast to youthful skin, mature skin undergoes well-established clinical and microscopic changes, particularly after menopause. In particular, dermal thinning, loss of dermal collagen and decreased lipid production are complicated by the effects of life-long sun exposure. These changes manifest as wrinkling, loss of elasticity, dryness and textural changes that characterize mature skin. To effectively combat these age- and sun-related changes, a multifaceted approach is required. Any treatment for mature skin must address the many causes of skin changes, that is, collagen production, lipid balance and epidermal texture. Several currently available compounds have scientifically-established effects on skin, and are anticipated to be even more effective in combination. Women worldwide struggle with coming to terms with their aging skin, and seek ways to preserve its youthful appearance. While dermatologists' offices may offer tretinoin cream (Renova and related products), laser resurfacing approaches, volume fillers and Botox, demand also exists for topical products that preserve and improve skin tone. With the push toward "natural," "organic" and "herbal" products, public and private research has never generated more evidence for complementary therapy. During skin aging, and particularly menopause, characteristic changes occur. Topical compounds can target many aspects of the aging process. The following is a review of topical compounds that may help with particular parts of this process. How can different problems be approached? In addition to prescription approaches and physical modalities, several topical compounds, many available over the counter, show evidence for helping aged and photo-damaged skin. Clinical data exist for many of these compounds, and is divided by mechanism of action.

Rethinking squamous cell carcinoma: which are high risk, which could benefit from lymph node dissection, what's coming up in the future?

Cutaneous squamous cell carcinomas (SCCs) are common skin cancers capable of metastasis. Determining which invasive SCCs are likely to recur or metastasize will help shape recommendations for clinical management. New prospective studies help predict which patients are at the highest risk for occult metastases and may benefit from lymph node dissection. In particular, the role of tumor depth, desmoplasia, and degree of immunosuppression could be accounted for in a more specific classification system. Evidence from studies of mucosal SCCs suggests a role for sentinel lymph node biopsies for carcinomas of the head and neck in place of selective neck dissection, a finding that may be relevant to cutaneous head and neck cancers as well. In the field of SCC pathogenesis, the role of human papillomavirus (HPV) in cutaneous, as well as mucous membrane, SCCs is being further characterized. For high-risk patients with iatrogenic immunosuppression, intense surveillance and early intervention is needed.

Medication formulation affects quality of life: a randomized single-blind study of clobetasol propionate foam 0.05% compared with a combined program of clobetasol cream 0.05% and solution 0.05% for the treatment of psoriasis

For topical medications commonly used to treat dermatologic conditions, outcomes may be affected by the choice of delivery vehicles. The aim of this study was to compare quality of life (QOL), effectiveness, user satisfaction, and cost-effectiveness of 2 clobetasol regimens for the treatment of psoriasis over 14 days. In a single-blind design, 32 patients randomized into 2 groups applied either clobetasol foam 0.05% to the skin and scalp or combination clobetasol cream 0.05% to the skin and clobetasol solution 0.05% to the scalp. Psoriasis severity was measured using the standardized Psoriasis Area and Severity Index (PASI) and self-administered PASI (SAPASI). QOL was assessed via the EuroQoL-5D (EQ-5D) questionnaire and Dermatology Life Quality Index (DLQI). Cost-effectiveness was measured by the amount of medication used per body surface area (BSA) treated and by cost per point improvement in PASI score. In this study, a foam formulation performed better than a cream/solution combination by several measures. A greater absolute improvement in psoriasis severity was seen in the group using the foam than in the group using the cream/solution (mean decrease in PASI=5.0 vs 3.3, P=.05). The PASI score in the foam group decreased by 41% versus 35% in the cream/solution group (P=.17). In scalp psoriasis, the group using the foam had greater improvement in both absolute (P=.03) and percentage (P=.03) terms and than the solution group. When measuring global QOL, foam users had a significantly greater increase in EQ-5D than those using the cream/solution in absolute (P=.05, P=.02) and percentage (P=.04, P=.02) terms (first and second survey components, respectively). Differences in improvement of skin-specific QOL, quantified by DLQI scores between groups, were suggested but not statistically significant. Patients using foam spent less time applying medication compared with previous topical medications (P<.001). No significant difference in cost was appreciated between foam and cream/solution over the period after controlling for BSA (8.18 dollars vs 7.05 dollars per percentage BSA affected, P=.30).