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American journal of clinical dermatology [journal]
- Basal Cell Carcinoma: An Evidence-Based Treatment Update. [JOURNAL ARTICLE]
- Am J Clin Dermatol 2014 Apr 15.
Basal cell carcinoma (BCC) is the most common skin cancer. Surgical excision remains the standard of treatment, but several alternative treatment modalities exist.This review aims to provide a current analysis of evidence for the treatment of BCC; specifically, which treatments have the lowest recurrence rates and the best cosmetic outcomes.We searched PubMed (January 1946 to August 2013), Ovid MEDLINE (2003-August 2013), the Cochrane Central Register of Controlled Trials (January 1993 to August 2013), and the Cochrane Database of Systematic Reviews (The Cochrane Library Issue 9, 2013) databases for randomized controlled trials, systematic reviews, or comparative studies for the treatment of BCC.We found 615 potential articles. Two independent reviewers selected 40 studies: 29 randomized controlled trials (RCTs), seven systematic reviews, and four nonrandomized prospective trials. Treatment modalities reviewed include surgical therapy, radiotherapy and cryotherapy, photodynamic therapy (PDT), topical imiquimod, topical 5-fluorouracil (5-FU), topical solasodine glycoalkaloids, topical ingenol mebutate, intralesional 5-FU, intralesional interferon (IFN), and oral hedgehog pathway inhibitors.The available data suggest that surgical methods remain the gold standard in BCC treatment, with Mohs micrographic surgery typically utilized for high-risk lesions. Suitable alternate treatment options for appropriately selected primary low-risk lesions may include PDT, cryotherapy, topical imiquimod, and 5-FU. Radiotherapy is a suitable alternate for surgical methods for treatment in older patient populations. Electrodesiccation and curettage (ED&C) is a commonly used primary treatment option for low-risk lesions; however, there were no RCTs examining ED&C that met our inclusion criteria. New hedgehog pathway inhibitors are promising for the management of advanced BCC; however, side effects are a concern for some patients, and much remains to be learned regarding optimal treatment length, risk of recurrence, and potential development of resistance. There is insufficient evidence at present to make recommendations on topical solasodine glycoalkaloids, topical ingenol mebutate, and intralesional 5-FU and IFN-α. Overall continued research on the efficacy of treatment modalities is needed. In particular, studies should include histologic ascertainment of clearance, long-term follow-up, stratification based on tumor subtype, and comparison with surgical outcomes.
- Bilirubin Levels and Their Association with Carotid Intima Media Thickness and High-Sensitivity C-reactive Protein in Patients with Psoriasis Vulgaris. [Journal Article]
- Am J Clin Dermatol 2014 Apr; 15(2):137-42.
Psoriasis vulgaris is associated with an increased risk of atherosclerosis. Carotid intima-media thickness (cIMT) may predict atherosclerosis.We assessed the correlation between bilirubin (a potent endogenous antioxidant) levels and cIMT in patients with psoriasis vulgaris. We also compared the levels of serum total bilirubin (TBil) and its fractions in control subjects and patients with psoriasis.We enrolled 115 participants (60 patients with psoriasis vulgaris and 55 control subjects). The levels of indirect bilirubin were calculated as the difference between TBil and direct bilirubin values. cIMT was measured in both common carotid arteries.TBil levels were lower in patients with psoriasis than in the control group [median (range) 0.55 (0.30-1.23) vs. 0.59 (0.30-1.44) mg/dL] as were indirect bilirubin [0.43 (0.22-1.00) vs. 0.48 (0.25-1.12) mg/dL] and direct bilirubin [0.10 (0.01-0.23) vs. 0.13 (0.03-0.32) mg/dL]. Only direct bilirubin differed significantly (p = 0.0002) but the number of patients with higher values of TBil and indirect bilirubin were significantly greater in the control group (p = 0.0019 by the Fisher's test). The patients with psoriasis had a significantly greater cIMT compared with control subjects (0.54 ± 0.08 vs. 0.50 ± 0.07 mm, p = 0.005). High-sensitivity C-reactive protein levels were higher in patients with psoriasis compared with controls (2.95 ± 3.50 and 0.99 ± 0.72 mg/L, p < 0.001). There was a negative correlation between cIMT and TBil levels (r = -0.383, p < 0.01). The results of the correlations were reinforced by multiple regression analysis.To our knowledge, this is the first study to assess the association between TBil and cIMT in patients with psoriasis. Our results support the concept that psoriasis vulgaris is associated with an increased risk of atherosclerosis.
- 72nd annual meeting of the american academy of dermatology. [Journal Article]
- Am J Clin Dermatol 2014 Apr; 15(2):143-5.
- Information, consent and treatment of patients with morgellons disease: an ethical perspective. [Journal Article]
- Am J Clin Dermatol 2014 Apr; 15(2):71-6.
Morgellons is a medically contested diagnosis with foremost dermatological symptoms. Patients experience fibers emerging from the skin, together with a range of other somatic, psychiatric, and neurological complaints. Within the medical community, it is generally held to be a variation of delusional parasitosis/delusional infestation, which is usually treated with antipsychotics. Little attention has been paid in the literature to the ethical aspects of treating patients with Morgellons disease. The communicative strategies suggested in the literature display significant ethical issues, primarily the use of therapeutic privilege, i.e. withholding information from the patient. Since this limits patient autonomy, that approach is ethically problematic. Instead, the physician has an ethical obligation to respect the patient's autonomy, provide full information, and seek consent before initiating a psychiatric referral.
- Perioral dermatitis: a review of the condition with special attention to treatment options. [Journal Article]
- Am J Clin Dermatol 2014 Apr; 15(2):101-13.
Perioral dermatitis is a common acneiform facial eruption found in both adults and children. Its variants are periorificial and granulomatous periorificial dermatitis. The etiology of perioral dermatitis remains unknown; however, topical corticosteroid use on the face commonly precedes the manifestation of this condition. There are an overwhelming number of treatment options for perioral dermatitis, and the options in children are slightly different from those in adults for both systemic medications and topical treatment. This article provides a literature review of the various applicable treatments available based on the level and quality of the evidence by the US Preventive Service Task Force. Oral tetracycline reveals the best valid evidence. However, if the patient is less than 8 years old, then this oral therapy may not be suitable. Topical metronidazole, erythromycin, and pimecrolimus also represent effective treatment choices with good evidence. Topical corticosteroid use is common in these cases and the question of whether it is a good treatment or a cause remains unanswered. Corticosteroid cream can improve the clinical picture, but there is a risk of rebound when treatment is stopped. We propose a treatment algorithm to assist dermatologists, pediatric dermatologists, and general practitioners encountering this condition.
- Basal cell carcinoma of the axilla: review of the world literature. [Journal Article]
- Am J Clin Dermatol 2014 Apr; 15(2):95-100.
Basal cell carcinoma (BCC) of the axilla is rare; indeed, 70 axillary BCCs have been described in 69 patients. Using the PubMed database, an extensive literature search was performed on BCC, axilla, and axillary. Relevant papers were reviewed and the characteristics of individuals with BCC of the axilla were summarized. The calculated prevalence of axillary BCC was 0.17 %. They occurred predominantly in Caucasians. The majority of patients had no obvious BCC-associated risk factors. They were observed 1.2 times more often in men than in women and twice as often in the right axilla than the left axilla. They frequently presented as an asymptomatic nodule; however, associated features have included elongation of the tumor along the axillary skin lines, ulceration, and pigmentation. The axillary tumor was typically associated with either the superficial or the nodular histologic subtype of BCC. The prognosis for these patients was usually excellent following complete removal or destruction of the tumor. In conclusion, axillary BCC is a rare clinical variant of this type of skin cancer that usually presents as an asymptomatic nodule in an individual who does not have any traditional risk factors for this malignancy. The cancer was typically associated with a non-aggressive histologic subtype. Recurrence or metastasis was uncommon following treatment of the primary tumor.
- Systemic Therapies for Psoriasis: An Evidence-Based Update. [JOURNAL ARTICLE]
- Am J Clin Dermatol 2014 Feb 5.
The treatment of psoriasis has evolved over the years, with the focus now largely on the use of biologic agents. With treatment options expanding, evidence-based studies to guide physicians' treatment decisions become increasingly important.Our objective was to review current literature to provide an evidence-based update on systemic therapies for psoriasis.A systematic review of the literature was conducted from 1 January 2012 through 1 July 2013 to identify all randomized clinical trials and systematic reviews of systemic psoriasis treatments.A total of 46 publications were identified and reviewed. Randomized clinical trials for the treatment of psoriasis focused heavily on biologic agents, both currently approved agents and anti-interleukin (IL)-17 agents in development. The anti-IL-17 agents appear effective according to phase II clinical trials. Several new oral agents are being studied, and, although they do not appear as effective as the biologic agents, they may be an option as an alternative to traditional oral agents, with more favorable safety profiles. Several systematic reviews focused on efficacy among the biologics, with infliximab consistently superior to the others, and etanercept the least effective of the tumor necrosis factor-alpha inhibitors. Longer-term safety data on biologics is now available and encouraging.Current studies of traditional oral therapies are lacking.Current studies continue to support the use of biologic agents in the treatment of moderate to severe psoriasis, with better efficacy and safety profiles than traditional systemic agents. Newer anti-IL-17 agents and several new oral agents are in development and have shown promise in clinical trials.
- Medical adherence to acne therapy: a systematic review. [Journal Article]
- Am J Clin Dermatol 2014 Apr; 15(2):87-94.
Poor adherence of acne patients to treatment may equate to poor clinical efficacy, increased healthcare costs, and unnecessary treatments. Authors have investigated risk factors for poor medical adherence and how to improve this difficult problem in the context of acne.This systematic review aims to describe what methods have been used to measure adherence, what is known about acne patients' adherence to treatment, and the factors affecting adherence.A MEDLINE search was performed for randomized controlled trials published between 1978 and June 2013, focusing on patient adherence to prescribed acne medications. A test for equality of proportions was performed on studies of similar design to collectively analyze adherence to oral versus topical medication. The self-reported adherence data collected from these clinical trials were then compared with adherence data from a pharmacy database study.Studies varied in modalities of data collection, but the majority utilized subjective methods. Topical therapies were more often studied than oral. The overall oral adherence rate, as calculated by a test of equality of proportions, was 76.3 %, while the overall topical adherence rate was 75.8 % (p = 0.927). The occurrence of side effects and young age were cited as the top reasons for poor adherence, followed by forgetfulness.The MEDLINE search resulted in a limited sample of adherence studies. In addition, there is currently no standardized or fully validated method of measurement, allowing for variability in what was considered 'adherent'. Lastly, data collected via subjective methods cannot guarantee reliable results.Overall, the values reflected a population adherent to both topical and oral medications, with no significant difference in adherence between the two. However, the methodologies used by many of the studies were weak, and the findings are not consistent with results of more objective measures of adherence. The leading factors that contribute to poor adherence may be reduced with enhanced patient consultation, reminder systems, and education.
- Efficacy and Safety of a Low-level Laser Device in the Treatment of Male and Female Pattern Hair Loss: A Multicenter, Randomized, Sham Device-controlled, Double-blind Study. [Journal Article]
- Am J Clin Dermatol 2014 Apr; 15(2):115-27.
Male and female pattern hair loss are common, chronic dermatologic disorders with limited therapeutic options. In recent years, a number of commercial devices using low-level laser therapy have been promoted, but there have been little peer-reviewed data on their efficacy.To determine whether treatment with a low-level laser device, the US FDA-cleared HairMax Lasercomb(®), increases terminal hair density in both men and women with pattern hair loss.Randomized, sham device-controlled, double-blind clinical trials were conducted at multiple institutional and private practices. A total of 146 male and 188 female subjects with pattern hair loss were screened. A total of 128 male and 141 female subjects were randomized to receive either a lasercomb (one of three models) or a sham device in concealed sealed packets, and were treated on the whole scalp three times a week for 26 weeks. Terminal hair density of the target area was evaluated at baseline and at 16- and 26-week follow-ups, and analyzed to determine whether the hypothesis formulated prior to data collection, that lasercomb treatment would increase terminal hair density, was correct. The site investigators and the subjects remained blinded to the type of device they dispensed/received throughout the study. The evaluator of masked digital photographs was blinded to which trial arm the subject belonged.Seventy-eight, 63, 49, and 79 subjects were randomized in four trials of 9-beam lasercomb treatment in female subjects, 12-beam lasercomb treatment in female subjects, 7-beam lasercomb treatment in male subjects, and 9- and 12-beam lasercomb treatment in male subjects, compared with the sham device, respectively. Nineteen female and 25 male subjects were lost to follow-up. Among the remaining 122 female and 103 male subjects in the efficacy analysis, the mean terminal hair count at 26 weeks increased from baseline by 20.2, 20.6, 18.4, 20.9, and 25.7 per cm(2) in 9-beam lasercomb-treated female subjects, 12-beam lasercomb-treated female subjects, 7-beam lasercomb-treated male subjects, and 9- and 12-beam lasercomb-treated male subjects, respectively, compared with 2.8 (p < 0.0001), 3.0 (p < 0.0001), 1.6 (p = 0.0017), 9.4 (p = 0.0249), and 9.4 (p = 0.0028) in sham-treated subjects (95 % confidence interval). The increase in terminal hair density was independent of the age and sex of the subject and the lasercomb model. Additionally, a higher percentage of lasercomb-treated subjects reported overall improvement of hair loss condition and thickness and fullness of hair in self-assessment, compared with sham-treated subjects. No serious adverse events were reported in any subject receiving the lasercomb in any of the four trials.We observed a statistically significant difference in the increase in terminal hair density between lasercomb- and sham-treated subjects. No serious adverse events were reported. Our results suggest that low-level laser treatment may be an effective option to treat pattern hair loss in both men and women. Additional studies should be considered to determine the long-term effects of low-level laser treatment on hair growth and maintenance, and to optimize laser modality.
- Atopic Dermatitis: An Evidence-Based Treatment Update. [JOURNAL ARTICLE]
- Am J Clin Dermatol 2014 Jan 25.
Atopic dermatitis (AD) is a common inflammatory disorder of skin with significant comorbidities. AD care often requires a combination of treatment approaches, including emollients, topical steroids, systemic immunosuppressants and/or phototherapy.Our purpose was to review recent randomized controlled trials (RCT) and systematic reviews of AD treatments.A MEDLINE search was performed focusing on RCTs of AD treatments, with a sample size ≥15, and systematic reviews published from 2011 to 2013, limited to the English language. A total of 53 manuscripts met the inclusion/exclusion criteria, including 44 RCTs and nine systematic reviews.Investigator-initiated RCTs support the use of the systemic agents cyclosporine, methotrexate, azathioprine and mycophenolate mofetil. In one RCT, petrolatum was found to be as effective as creams containing ceramides or glycyrrhetinic acid. Additional therapeutic approaches supported by RCTs include balneotherapy, oral and/or topical probiotics, nutritional interventions, vitamin D with or without vitamin E supplementation, as well as several new topical and complementary medicines.Advances have been made with respect to AD treatment in the past few years through the use of well designed RCTs and comparative efficacy studies. However, more well designed RCTs and investigator-initiated studies are needed in order to improve the care of AD patients.