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Psoriasis is associated with multiple comorbidities, including cardiovascular diseases. With the advent of anti-inflammatory therapy, there has been much investigation into whether treatments for psoriasis may reduce the risk for cardiovascular events. In a Journal of the European Academy of Dermatology and Venereology article published online on October 10, Ahlehoff et al examined the rate of cardiovascular events—cardiovascular death, myocardial infarction, and stroke—in patients with severe psoriasis treated with systemic anti-inflammatory drugs.

Individual-level linkage of administrative registries was utilized to perform a longitudinal nationwide cohort study in Denmark. Time-dependent multivariable adjusted Cox regression was used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs) of cardiovascular events associated with use of biological drugs, methotrexate, cyclosporine, retinoids, and other antipsoriatic therapies (ie, topical treatments, phototherapy, climate therapy).

The investigators included a total of 6902 patients (9662 treatment exposures) with a maximum follow-up of 5 years. Incidence rates per 1000 patient-years for cardiovascular events were highest for retinoids and other therapies (18.95 and 14.63, respectively) followed by methotrexate, cyclosporine, and biological drugs (6.28, 6.08, and 4.16, respectively). Relative to other therapies, methotrexate (HR, 0.53; 95% CI, 0.34-0.83) was associated with reduced risk for the composite end point. A comparable but nonsignificant protective effect was observed with biological drugs (HR, 0.58; 95% CI, 0.30-1.10), whereas no protective effect was apparent with cyclosporine (HR, 1.06; 95% CI, 0.26-4.27) and retinoids (HR, 1.80; 95% CI, 1.03-2.96). Tumor necrosis factor inhibitors (HR, 0.46; 95% CI, 0.22-0.98) were linked to reduced event rates but the IL-12/IL-23 inhibitor ustekinumab (HR, 1.52; 95% CI, 0.47-4.94) was not.

The authors concluded that systemic anti-inflammatory treatment with methotrexate was associated with lower rates of cardiovascular events during long-term follow-up compared to patients treated with other antipsoriatic therapies.

What’s the issue?

This study is consistent with other investigations evaluating the cardioprotective benefit of therapies for psoriasis. The cardioprotective benefits of methotrexate and tumor necrosis factor inhibitors have been previously reported. Further investigation will help to elucidate the role of these drugs as well as newer therapies in the reduction of comorbidities. Does this study influence your perception of therapies for psoriasis?

We want to know your views! Tell us what you think.

Psoriasis is associated with multiple comorbidities, including cardiovascular diseases. With the advent of anti-inflammatory therapy, there has been much investigation into whether treatments for psoriasis may reduce the risk for cardiovascular events. In a Journal of the European Academy of Dermatology and Venereology article published online on October 10, Ahlehoff et al examined the rate of cardiovascular events—cardiovascular death, myocardial infarction, and stroke—in patients with severe psoriasis treated with systemic anti-inflammatory drugs.

Individual-level linkage of administrative registries was utilized to perform a longitudinal nationwide cohort study in Denmark. Time-dependent multivariable adjusted Cox regression was used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs) of cardiovascular events associated with use of biological drugs, methotrexate, cyclosporine, retinoids, and other antipsoriatic therapies (ie, topical treatments, phototherapy, climate therapy).

The investigators included a total of 6902 patients (9662 treatment exposures) with a maximum follow-up of 5 years. Incidence rates per 1000 patient-years for cardiovascular events were highest for retinoids and other therapies (18.95 and 14.63, respectively) followed by methotrexate, cyclosporine, and biological drugs (6.28, 6.08, and 4.16, respectively). Relative to other therapies, methotrexate (HR, 0.53; 95% CI, 0.34-0.83) was associated with reduced risk for the composite end point. A comparable but nonsignificant protective effect was observed with biological drugs (HR, 0.58; 95% CI, 0.30-1.10), whereas no protective effect was apparent with cyclosporine (HR, 1.06; 95% CI, 0.26-4.27) and retinoids (HR, 1.80; 95% CI, 1.03-2.96). Tumor necrosis factor inhibitors (HR, 0.46; 95% CI, 0.22-0.98) were linked to reduced event rates but the IL-12/IL-23 inhibitor ustekinumab (HR, 1.52; 95% CI, 0.47-4.94) was not.

The authors concluded that systemic anti-inflammatory treatment with methotrexate was associated with lower rates of cardiovascular events during long-term follow-up compared to patients treated with other antipsoriatic therapies.

What’s the issue?

This study is consistent with other investigations evaluating the cardioprotective benefit of therapies for psoriasis. The cardioprotective benefits of methotrexate and tumor necrosis factor inhibitors have been previously reported. Further investigation will help to elucidate the role of these drugs as well as newer therapies in the reduction of comorbidities. Does this study influence your perception of therapies for psoriasis?

We want to know your views! Tell us what you think.

Psoriasis is associated with multiple comorbidities, including cardiovascular diseases. With the advent of anti-inflammatory therapy, there has been much investigation into whether treatments for psoriasis may reduce the risk for cardiovascular events. In a Journal of the European Academy of Dermatology and Venereology article published online on October 10, Ahlehoff et al examined the rate of cardiovascular events—cardiovascular death, myocardial infarction, and stroke—in patients with severe psoriasis treated with systemic anti-inflammatory drugs.

Individual-level linkage of administrative registries was utilized to perform a longitudinal nationwide cohort study in Denmark. Time-dependent multivariable adjusted Cox regression was used to estimate hazard ratios (HRs) with 95% confidence intervals (CIs) of cardiovascular events associated with use of biological drugs, methotrexate, cyclosporine, retinoids, and other antipsoriatic therapies (ie, topical treatments, phototherapy, climate therapy).

The investigators included a total of 6902 patients (9662 treatment exposures) with a maximum follow-up of 5 years. Incidence rates per 1000 patient-years for cardiovascular events were highest for retinoids and other therapies (18.95 and 14.63, respectively) followed by methotrexate, cyclosporine, and biological drugs (6.28, 6.08, and 4.16, respectively). Relative to other therapies, methotrexate (HR, 0.53; 95% CI, 0.34-0.83) was associated with reduced risk for the composite end point. A comparable but nonsignificant protective effect was observed with biological drugs (HR, 0.58; 95% CI, 0.30-1.10), whereas no protective effect was apparent with cyclosporine (HR, 1.06; 95% CI, 0.26-4.27) and retinoids (HR, 1.80; 95% CI, 1.03-2.96). Tumor necrosis factor inhibitors (HR, 0.46; 95% CI, 0.22-0.98) were linked to reduced event rates but the IL-12/IL-23 inhibitor ustekinumab (HR, 1.52; 95% CI, 0.47-4.94) was not.

The authors concluded that systemic anti-inflammatory treatment with methotrexate was associated with lower rates of cardiovascular events during long-term follow-up compared to patients treated with other antipsoriatic therapies.

What’s the issue?

This study is consistent with other investigations evaluating the cardioprotective benefit of therapies for psoriasis. The cardioprotective benefits of methotrexate and tumor necrosis factor inhibitors have been previously reported. Further investigation will help to elucidate the role of these drugs as well as newer therapies in the reduction of comorbidities. Does this study influence your perception of therapies for psoriasis?

We want to know your views! Tell us what you think.

In late September 2014, the US Food and Drug Administration approved the medication apremilast for treatment of moderate to severe plaque psoriasis in adults who are candidates for phototherapy or systemic therapy. It was previously approved for psoriatic arthritis in March 2014. Its mechanism includes selective inhibition of phosphodiesterase 4, resulting in increased intracellular cyclic adenosine monophosphate levels, indirectly mediating production of inflammatory mediators in many cell types, namely decreasing tumor necrosis factor α and IL-23 and increasing IL-10. Orally dosed at 30 mg twice daily, safety and efficacy was determined via 2 multicenter, randomized, double-blind, placebo-controlled trials—ESTEEM 1 and ESTEEM 2 (N=1257)—that highlighted a PASI-75 (psoriasis area severity index) in 30% of patients in the first 4 months and up to 88% of patients with PASI-75 in the first year (J Am Acad Dermatol. 2014;70(suppl 1):AB164). Additionally, according to results presented at a recent European Academy of Dermatology and Venereology meeting in early October 2014, pruritus and difficult areas such as the scalp, palmoplantar area, and nails showed significant improvement at week 16 (P<.0001). The most common side effects were diarrhea, nausea, upper respiratory infection, and headache, which occurred most often in the first 2 weeks of therapy. The medication does not require routine laboratory monitoring; however, because weight loss is possible, it is recommended that weight should be periodically checked. There are no contraindications aside from hypersensitivity to the drug itself, and caution should be taken in patients with unstable depression, suicidal ideation, or severe renal impairment. It is pregnancy category C.

What’s the issue?

Because it is administered orally; is dually indicated for plaque psoriasis and psoriatic arthritis; and does not require laboratory monitoring, alcohol consumption restrictions, category X classification, or immunosuppressive infection or cancer risk, the window-shopping appeal of this drug seems attractive compared to the veteran and contemporary pharmaceutical army of psoriasis therapy. However, based on the ESTEEM studies, meager apremilast PASI scores are not blowing us away like those of biologic medications. At a time when the evolution of medications for psoriasis seems like a revolving door for new products highlighting new mechanisms in new pathways in even newer cells in relationship to inflammation, how will this drug fit in?

We want to know your views! Tell us what you think.

In late September 2014, the US Food and Drug Administration approved the medication apremilast for treatment of moderate to severe plaque psoriasis in adults who are candidates for phototherapy or systemic therapy. It was previously approved for psoriatic arthritis in March 2014. Its mechanism includes selective inhibition of phosphodiesterase 4, resulting in increased intracellular cyclic adenosine monophosphate levels, indirectly mediating production of inflammatory mediators in many cell types, namely decreasing tumor necrosis factor α and IL-23 and increasing IL-10. Orally dosed at 30 mg twice daily, safety and efficacy was determined via 2 multicenter, randomized, double-blind, placebo-controlled trials—ESTEEM 1 and ESTEEM 2 (N=1257)—that highlighted a PASI-75 (psoriasis area severity index) in 30% of patients in the first 4 months and up to 88% of patients with PASI-75 in the first year (J Am Acad Dermatol. 2014;70(suppl 1):AB164). Additionally, according to results presented at a recent European Academy of Dermatology and Venereology meeting in early October 2014, pruritus and difficult areas such as the scalp, palmoplantar area, and nails showed significant improvement at week 16 (P<.0001). The most common side effects were diarrhea, nausea, upper respiratory infection, and headache, which occurred most often in the first 2 weeks of therapy. The medication does not require routine laboratory monitoring; however, because weight loss is possible, it is recommended that weight should be periodically checked. There are no contraindications aside from hypersensitivity to the drug itself, and caution should be taken in patients with unstable depression, suicidal ideation, or severe renal impairment. It is pregnancy category C.

What’s the issue?

Because it is administered orally; is dually indicated for plaque psoriasis and psoriatic arthritis; and does not require laboratory monitoring, alcohol consumption restrictions, category X classification, or immunosuppressive infection or cancer risk, the window-shopping appeal of this drug seems attractive compared to the veteran and contemporary pharmaceutical army of psoriasis therapy. However, based on the ESTEEM studies, meager apremilast PASI scores are not blowing us away like those of biologic medications. At a time when the evolution of medications for psoriasis seems like a revolving door for new products highlighting new mechanisms in new pathways in even newer cells in relationship to inflammation, how will this drug fit in?

We want to know your views! Tell us what you think.

In late September 2014, the US Food and Drug Administration approved the medication apremilast for treatment of moderate to severe plaque psoriasis in adults who are candidates for phototherapy or systemic therapy. It was previously approved for psoriatic arthritis in March 2014. Its mechanism includes selective inhibition of phosphodiesterase 4, resulting in increased intracellular cyclic adenosine monophosphate levels, indirectly mediating production of inflammatory mediators in many cell types, namely decreasing tumor necrosis factor α and IL-23 and increasing IL-10. Orally dosed at 30 mg twice daily, safety and efficacy was determined via 2 multicenter, randomized, double-blind, placebo-controlled trials—ESTEEM 1 and ESTEEM 2 (N=1257)—that highlighted a PASI-75 (psoriasis area severity index) in 30% of patients in the first 4 months and up to 88% of patients with PASI-75 in the first year (J Am Acad Dermatol. 2014;70(suppl 1):AB164). Additionally, according to results presented at a recent European Academy of Dermatology and Venereology meeting in early October 2014, pruritus and difficult areas such as the scalp, palmoplantar area, and nails showed significant improvement at week 16 (P<.0001). The most common side effects were diarrhea, nausea, upper respiratory infection, and headache, which occurred most often in the first 2 weeks of therapy. The medication does not require routine laboratory monitoring; however, because weight loss is possible, it is recommended that weight should be periodically checked. There are no contraindications aside from hypersensitivity to the drug itself, and caution should be taken in patients with unstable depression, suicidal ideation, or severe renal impairment. It is pregnancy category C.

What’s the issue?

Because it is administered orally; is dually indicated for plaque psoriasis and psoriatic arthritis; and does not require laboratory monitoring, alcohol consumption restrictions, category X classification, or immunosuppressive infection or cancer risk, the window-shopping appeal of this drug seems attractive compared to the veteran and contemporary pharmaceutical army of psoriasis therapy. However, based on the ESTEEM studies, meager apremilast PASI scores are not blowing us away like those of biologic medications. At a time when the evolution of medications for psoriasis seems like a revolving door for new products highlighting new mechanisms in new pathways in even newer cells in relationship to inflammation, how will this drug fit in?

We want to know your views! Tell us what you think.

Striae cutis distensae, colloquially known as stretch marks, are extremely common and are difficult to treat. Hexsel et al (Dermatol Surg. 2014;40:537-544) published a randomized pilot study to evaluate the efficacy of superficial dermabrasion versus topical tretinoin in the treatment of striae cutis distensae. Thirty-two women were enrolled and all had early (<6 months) striae rubra measuring up to a maximum of 5 mm in length. Exclusion criteria included any striae alba in the area. Two treatment groups were randomized: one received 16 weekly sessions of localized superficial dermabrasion, and the other group applied tretinoin cream 0.05% daily for 16 weeks. All participants were assessed at 4, 8, 12, and 16 weeks. A 3-mm diamond tip rotating at 10,000 revolutions per minute was used for the dermabrasion. The clinical end point of the superficial dermabrasion was no pain or bleeding. Tretinoin was applied once daily at night. The 5-point global aesthetic improvement scale was used to assess patient improvement and biopsies were done in willing participants.

Both groups experienced significant reduction in the width and length of the striae cutis distensae from baseline (P<.05). No differences were seen between the 2 groups, and the global aesthetic improvement scale score did not differ between the 2 groups. Fourteen participants had adverse events including pruritus, erythema, burning, scaling, crusts, swelling, and papules. There was no statistically significant difference in adverse events between treatments; however, the tretinoin group did experience more scaling, pruritus, and erythema. Eight biopsies were done in the dermabrasion group and 1 was done in the tretinoin group. The dermabrasion group showed histologic evidence of epidermal and dermal improvement with a decrease in elastolysis, collagen fragmentation, and epidermal atrophy, as well as an increase in neocollagenesis.

What’s the issue?

Striae cutis distensae is a common and often distressing skin condition. It is well known that treating early striae rubra may be more efficacious than treating later striae alba. Many methods have been employed to treat striae rubra including lasers and creams. This study places superficial dermabrasion against tretinoin in a prospective manner. Although both treatment groups saw improvement, the tretinoin group was noted to experience more scaling, pruritus, and erythema, which can affect treatment adherence and compliance. Dermabrasion was shown to have beneficial effects via histologic examination, not just on the appearance of the striae but also on the skin structures. Dermabrasion can be a suitable option for patients who cannot pursue more costly laser treatments or expensive tretinoin prescriptions. When a patient presents with striae, what is your go-to treatment?

We want to know your views! Tell us what you think.

Reader Comment
How do you rationalize that dermabrasion is less expensive than tretinoin? Patients can purchase it online if their insurance won't cover it.

--Deborah Ohlhausen, MD

Author Comment

This article points out that dermabrasion can be a suitable treatment option. Tretinoin can be expensive if not covered by insurance. Online purchase is not recommended due to the question of safety and efficacy. Therefore, dermabrasion may be a suitable alternative as pointed out by this study.

--Anthony M. Rossi, MD

Striae cutis distensae, colloquially known as stretch marks, are extremely common and are difficult to treat. Hexsel et al (Dermatol Surg. 2014;40:537-544) published a randomized pilot study to evaluate the efficacy of superficial dermabrasion versus topical tretinoin in the treatment of striae cutis distensae. Thirty-two women were enrolled and all had early (<6 months) striae rubra measuring up to a maximum of 5 mm in length. Exclusion criteria included any striae alba in the area. Two treatment groups were randomized: one received 16 weekly sessions of localized superficial dermabrasion, and the other group applied tretinoin cream 0.05% daily for 16 weeks. All participants were assessed at 4, 8, 12, and 16 weeks. A 3-mm diamond tip rotating at 10,000 revolutions per minute was used for the dermabrasion. The clinical end point of the superficial dermabrasion was no pain or bleeding. Tretinoin was applied once daily at night. The 5-point global aesthetic improvement scale was used to assess patient improvement and biopsies were done in willing participants.

Both groups experienced significant reduction in the width and length of the striae cutis distensae from baseline (P<.05). No differences were seen between the 2 groups, and the global aesthetic improvement scale score did not differ between the 2 groups. Fourteen participants had adverse events including pruritus, erythema, burning, scaling, crusts, swelling, and papules. There was no statistically significant difference in adverse events between treatments; however, the tretinoin group did experience more scaling, pruritus, and erythema. Eight biopsies were done in the dermabrasion group and 1 was done in the tretinoin group. The dermabrasion group showed histologic evidence of epidermal and dermal improvement with a decrease in elastolysis, collagen fragmentation, and epidermal atrophy, as well as an increase in neocollagenesis.

What’s the issue?

Striae cutis distensae is a common and often distressing skin condition. It is well known that treating early striae rubra may be more efficacious than treating later striae alba. Many methods have been employed to treat striae rubra including lasers and creams. This study places superficial dermabrasion against tretinoin in a prospective manner. Although both treatment groups saw improvement, the tretinoin group was noted to experience more scaling, pruritus, and erythema, which can affect treatment adherence and compliance. Dermabrasion was shown to have beneficial effects via histologic examination, not just on the appearance of the striae but also on the skin structures. Dermabrasion can be a suitable option for patients who cannot pursue more costly laser treatments or expensive tretinoin prescriptions. When a patient presents with striae, what is your go-to treatment?

We want to know your views! Tell us what you think.

Reader Comment
How do you rationalize that dermabrasion is less expensive than tretinoin? Patients can purchase it online if their insurance won't cover it.

--Deborah Ohlhausen, MD

Author Comment

This article points out that dermabrasion can be a suitable treatment option. Tretinoin can be expensive if not covered by insurance. Online purchase is not recommended due to the question of safety and efficacy. Therefore, dermabrasion may be a suitable alternative as pointed out by this study.

--Anthony M. Rossi, MD

Striae cutis distensae, colloquially known as stretch marks, are extremely common and are difficult to treat. Hexsel et al (Dermatol Surg. 2014;40:537-544) published a randomized pilot study to evaluate the efficacy of superficial dermabrasion versus topical tretinoin in the treatment of striae cutis distensae. Thirty-two women were enrolled and all had early (<6 months) striae rubra measuring up to a maximum of 5 mm in length. Exclusion criteria included any striae alba in the area. Two treatment groups were randomized: one received 16 weekly sessions of localized superficial dermabrasion, and the other group applied tretinoin cream 0.05% daily for 16 weeks. All participants were assessed at 4, 8, 12, and 16 weeks. A 3-mm diamond tip rotating at 10,000 revolutions per minute was used for the dermabrasion. The clinical end point of the superficial dermabrasion was no pain or bleeding. Tretinoin was applied once daily at night. The 5-point global aesthetic improvement scale was used to assess patient improvement and biopsies were done in willing participants.

Both groups experienced significant reduction in the width and length of the striae cutis distensae from baseline (P<.05). No differences were seen between the 2 groups, and the global aesthetic improvement scale score did not differ between the 2 groups. Fourteen participants had adverse events including pruritus, erythema, burning, scaling, crusts, swelling, and papules. There was no statistically significant difference in adverse events between treatments; however, the tretinoin group did experience more scaling, pruritus, and erythema. Eight biopsies were done in the dermabrasion group and 1 was done in the tretinoin group. The dermabrasion group showed histologic evidence of epidermal and dermal improvement with a decrease in elastolysis, collagen fragmentation, and epidermal atrophy, as well as an increase in neocollagenesis.

What’s the issue?

Striae cutis distensae is a common and often distressing skin condition. It is well known that treating early striae rubra may be more efficacious than treating later striae alba. Many methods have been employed to treat striae rubra including lasers and creams. This study places superficial dermabrasion against tretinoin in a prospective manner. Although both treatment groups saw improvement, the tretinoin group was noted to experience more scaling, pruritus, and erythema, which can affect treatment adherence and compliance. Dermabrasion was shown to have beneficial effects via histologic examination, not just on the appearance of the striae but also on the skin structures. Dermabrasion can be a suitable option for patients who cannot pursue more costly laser treatments or expensive tretinoin prescriptions. When a patient presents with striae, what is your go-to treatment?

We want to know your views! Tell us what you think.

Reader Comment
How do you rationalize that dermabrasion is less expensive than tretinoin? Patients can purchase it online if their insurance won't cover it.

--Deborah Ohlhausen, MD

Author Comment

This article points out that dermabrasion can be a suitable treatment option. Tretinoin can be expensive if not covered by insurance. Online purchase is not recommended due to the question of safety and efficacy. Therefore, dermabrasion may be a suitable alternative as pointed out by this study.

--Anthony M. Rossi, MD

We are always conscious of the use of systemic medications in older patients, as they may have the potential for more toxicity. For dermatologists, use of systemic medications in psoriasis represents a large share of our total use. Theoretically, we are concerned that older patients may be more likely to develop serious infections and malignancies. Older psoriasis patients also represent a growing demographic, and they are underrepresented in clinical trials.

In an article published online on September 3, 2014, in the Journal of the European Academy of Dermatology and Venereology, Medina et al performed an analysis to evaluate the safety of systemic psoriasis therapy in patients older than 65 years compared to younger patients. Patients registered in Biobadaderm, a Spanish national registry of psoriasis patients treated with systemic therapy, were divided into 2 categories: elderly (≥65 years) and younger patients (<65 years). Rates of adverse events (AEs) were described by severity and type. The risks were compared in both groups, taking into account exposure to classic or biologic drugs using Cox regression.

In the overall study population, 175 (9.8%) of 1793 patients were elderly. The authors found that overall risk for AEs was not higher in elderly patients; the drug group–adjusted hazard ratio (HR) was 1.09 (95% confidence interval [CI], 0.93-1.3). However, serious AEs were more common in older patients, with a drug group–adjusted HR of 3.2 (95% CI, 2.0-5.1). Age-adjusted HR of all AEs was lower for patients exposed to biologics compared to classic drugs in the whole sample (HR, 0.7 [95% CI, 0.6-0.7]). Age did not seem to modify the effect of therapy (biologic vs classic) in the risk for AEs (likelihood ratio test for interaction: P=.12 for all AEs; P=.09 for serious AEs).

The authors concluded that serious AEs were more common in elderly patients. They argued, however, that these serious AEs might be related to other factors associated with this age group and not due to the treatment itself. Use of biologics was associated with lower risk for AEs in the whole group. There were no differences in this association between young and old. These results are reassuring, though uncontrolled confounding could not be excluded as an explanation for these findings. The power of the study to detect differences was low.

What’s the issue?

The results indicate that overall there is no increase in AEs in older patients. More data will need to be evaluated to see if the incidence of serious AEs is due to medication use or endogenous health factors. How do you approach the use of systemic medications in older patients?

We want to know your views! Tell us what you think.

We are always conscious of the use of systemic medications in older patients, as they may have the potential for more toxicity. For dermatologists, use of systemic medications in psoriasis represents a large share of our total use. Theoretically, we are concerned that older patients may be more likely to develop serious infections and malignancies. Older psoriasis patients also represent a growing demographic, and they are underrepresented in clinical trials.

In an article published online on September 3, 2014, in the Journal of the European Academy of Dermatology and Venereology, Medina et al performed an analysis to evaluate the safety of systemic psoriasis therapy in patients older than 65 years compared to younger patients. Patients registered in Biobadaderm, a Spanish national registry of psoriasis patients treated with systemic therapy, were divided into 2 categories: elderly (≥65 years) and younger patients (<65 years). Rates of adverse events (AEs) were described by severity and type. The risks were compared in both groups, taking into account exposure to classic or biologic drugs using Cox regression.

In the overall study population, 175 (9.8%) of 1793 patients were elderly. The authors found that overall risk for AEs was not higher in elderly patients; the drug group–adjusted hazard ratio (HR) was 1.09 (95% confidence interval [CI], 0.93-1.3). However, serious AEs were more common in older patients, with a drug group–adjusted HR of 3.2 (95% CI, 2.0-5.1). Age-adjusted HR of all AEs was lower for patients exposed to biologics compared to classic drugs in the whole sample (HR, 0.7 [95% CI, 0.6-0.7]). Age did not seem to modify the effect of therapy (biologic vs classic) in the risk for AEs (likelihood ratio test for interaction: P=.12 for all AEs; P=.09 for serious AEs).

The authors concluded that serious AEs were more common in elderly patients. They argued, however, that these serious AEs might be related to other factors associated with this age group and not due to the treatment itself. Use of biologics was associated with lower risk for AEs in the whole group. There were no differences in this association between young and old. These results are reassuring, though uncontrolled confounding could not be excluded as an explanation for these findings. The power of the study to detect differences was low.

What’s the issue?

The results indicate that overall there is no increase in AEs in older patients. More data will need to be evaluated to see if the incidence of serious AEs is due to medication use or endogenous health factors. How do you approach the use of systemic medications in older patients?

We want to know your views! Tell us what you think.

We are always conscious of the use of systemic medications in older patients, as they may have the potential for more toxicity. For dermatologists, use of systemic medications in psoriasis represents a large share of our total use. Theoretically, we are concerned that older patients may be more likely to develop serious infections and malignancies. Older psoriasis patients also represent a growing demographic, and they are underrepresented in clinical trials.

In an article published online on September 3, 2014, in the Journal of the European Academy of Dermatology and Venereology, Medina et al performed an analysis to evaluate the safety of systemic psoriasis therapy in patients older than 65 years compared to younger patients. Patients registered in Biobadaderm, a Spanish national registry of psoriasis patients treated with systemic therapy, were divided into 2 categories: elderly (≥65 years) and younger patients (<65 years). Rates of adverse events (AEs) were described by severity and type. The risks were compared in both groups, taking into account exposure to classic or biologic drugs using Cox regression.

In the overall study population, 175 (9.8%) of 1793 patients were elderly. The authors found that overall risk for AEs was not higher in elderly patients; the drug group–adjusted hazard ratio (HR) was 1.09 (95% confidence interval [CI], 0.93-1.3). However, serious AEs were more common in older patients, with a drug group–adjusted HR of 3.2 (95% CI, 2.0-5.1). Age-adjusted HR of all AEs was lower for patients exposed to biologics compared to classic drugs in the whole sample (HR, 0.7 [95% CI, 0.6-0.7]). Age did not seem to modify the effect of therapy (biologic vs classic) in the risk for AEs (likelihood ratio test for interaction: P=.12 for all AEs; P=.09 for serious AEs).

The authors concluded that serious AEs were more common in elderly patients. They argued, however, that these serious AEs might be related to other factors associated with this age group and not due to the treatment itself. Use of biologics was associated with lower risk for AEs in the whole group. There were no differences in this association between young and old. These results are reassuring, though uncontrolled confounding could not be excluded as an explanation for these findings. The power of the study to detect differences was low.

What’s the issue?

The results indicate that overall there is no increase in AEs in older patients. More data will need to be evaluated to see if the incidence of serious AEs is due to medication use or endogenous health factors. How do you approach the use of systemic medications in older patients?

We want to know your views! Tell us what you think.

A recently published prospective cohort study reported that sildenafil use may increase the risk for melanoma (JAMA Intern Med. 2014;174:964-970). BRAF activation, which is pathogenic in some melanoma variants, downregulates phosphodiesterase 5A and sildenafil downregulates phosphodiesterase 5A, surmising that either one may enhance melanoma invasion. The Health Professionals’ Follow-up Study cohort was utilized, which has prospectively evaluated male health professionals’ nutrition and incidences of serious illnesses since 1986. In 2000, more than 25,000 men were interviewed about sildenafil use for erectile dysfunction, and the incidence of skin cancer was obtained by questionnaire every 2 years for 10 years. The questionnaire showed that 142 melanomas were diagnosed, and recent or prior sildenafil use (with no breakdown of frequency of dosing) was significantly associated with increased risk for melanoma (hazard ratio, 1.84 for recent use; 1.92 for ever use) adjusted for age, erectile dysfunction without sildenafil, and several skin-related and genetic melanoma risk factors. No other types of skin cancer exhibited this risk trend.

What’s the issue?

Vascular tone and manipulation of such is a contender as a hot topic in melanoma given that even aspirin has been implicated as a risk factor. Unfortunately, similar to the aspirin data, without a true continuum providing any sildenafil dosage or frequency relationship to the development of melanoma, especially for this very short half-life medication, we likely cannot consider sildenafil as a hazard in patients at high risk for melanoma as we do for smokers and oral contraceptives, or alcoholics and terbinafine. Because UV radiation is the only behavioral risk factor linked to melanoma and considering that so many of our male patients take this class of drug, in your opinion what percentage of your patients in this risk category follow strict sun protection? Should we mention this potential association to them?

We want to know your views! Tell us what you think.

A recently published prospective cohort study reported that sildenafil use may increase the risk for melanoma (JAMA Intern Med. 2014;174:964-970). BRAF activation, which is pathogenic in some melanoma variants, downregulates phosphodiesterase 5A and sildenafil downregulates phosphodiesterase 5A, surmising that either one may enhance melanoma invasion. The Health Professionals’ Follow-up Study cohort was utilized, which has prospectively evaluated male health professionals’ nutrition and incidences of serious illnesses since 1986. In 2000, more than 25,000 men were interviewed about sildenafil use for erectile dysfunction, and the incidence of skin cancer was obtained by questionnaire every 2 years for 10 years. The questionnaire showed that 142 melanomas were diagnosed, and recent or prior sildenafil use (with no breakdown of frequency of dosing) was significantly associated with increased risk for melanoma (hazard ratio, 1.84 for recent use; 1.92 for ever use) adjusted for age, erectile dysfunction without sildenafil, and several skin-related and genetic melanoma risk factors. No other types of skin cancer exhibited this risk trend.

What’s the issue?

Vascular tone and manipulation of such is a contender as a hot topic in melanoma given that even aspirin has been implicated as a risk factor. Unfortunately, similar to the aspirin data, without a true continuum providing any sildenafil dosage or frequency relationship to the development of melanoma, especially for this very short half-life medication, we likely cannot consider sildenafil as a hazard in patients at high risk for melanoma as we do for smokers and oral contraceptives, or alcoholics and terbinafine. Because UV radiation is the only behavioral risk factor linked to melanoma and considering that so many of our male patients take this class of drug, in your opinion what percentage of your patients in this risk category follow strict sun protection? Should we mention this potential association to them?

We want to know your views! Tell us what you think.

A recently published prospective cohort study reported that sildenafil use may increase the risk for melanoma (JAMA Intern Med. 2014;174:964-970). BRAF activation, which is pathogenic in some melanoma variants, downregulates phosphodiesterase 5A and sildenafil downregulates phosphodiesterase 5A, surmising that either one may enhance melanoma invasion. The Health Professionals’ Follow-up Study cohort was utilized, which has prospectively evaluated male health professionals’ nutrition and incidences of serious illnesses since 1986. In 2000, more than 25,000 men were interviewed about sildenafil use for erectile dysfunction, and the incidence of skin cancer was obtained by questionnaire every 2 years for 10 years. The questionnaire showed that 142 melanomas were diagnosed, and recent or prior sildenafil use (with no breakdown of frequency of dosing) was significantly associated with increased risk for melanoma (hazard ratio, 1.84 for recent use; 1.92 for ever use) adjusted for age, erectile dysfunction without sildenafil, and several skin-related and genetic melanoma risk factors. No other types of skin cancer exhibited this risk trend.

What’s the issue?

Vascular tone and manipulation of such is a contender as a hot topic in melanoma given that even aspirin has been implicated as a risk factor. Unfortunately, similar to the aspirin data, without a true continuum providing any sildenafil dosage or frequency relationship to the development of melanoma, especially for this very short half-life medication, we likely cannot consider sildenafil as a hazard in patients at high risk for melanoma as we do for smokers and oral contraceptives, or alcoholics and terbinafine. Because UV radiation is the only behavioral risk factor linked to melanoma and considering that so many of our male patients take this class of drug, in your opinion what percentage of your patients in this risk category follow strict sun protection? Should we mention this potential association to them?

We want to know your views! Tell us what you think.

Global travel has become ubiquitous for recreational, occupational, educational, humanitarian, and other purposes. For this reason, those who travel may encounter and acquire diseases from countries outside their normal habitat. A recent fascinating session from the Summer American Academy of Dermatology Meeting, “Infectious Disease and Infestations in Returned Travelers: The Americas,” highlighted current trends relating to this phenomenon.

Dr. Natasha Mesinkovska noted that Americans are most likely to travel within the Americas, particularly to Mexico, Canada, and the Dominican Republic, but also to England and France. Conversely, approximately 66 million visitors from other regions visit the United States annually. GeoSentinel surveillance clinics suggest that diarrhea and febrile illness, such as malaria, are the most common concerns reported among returning travelers who are ill. Dermatologic concerns account for approximately 18% of all problems (Int J Infect Dis. 2008;12:593-602), and many of these are either cosmopolitan infections (eg, scabies, herpes, staphylococcal) or specific tropical infections (eg, cutaneous larva migrans, tungiasis, leishmaniasis, myiasis). Because many tropical infections are associated with insect vectors, particularly mosquitoes, the prophylactic use of repellant products such as 30% to 35% DEET is advisable. Also, travelers should avoid contact with sand, soil, stagnant water, and farm animals; drink only pasteurized liquids; close hotel windows; and sleep under mosquito netting, where appropriate.

Dr. Ron (Ronald) Rapini reviewed the various diagnostic procedures that may be used for unusual infections associated with the Americas. Diagnostic techniques include potassium hydroxide preparation, routine biopsy, biopsy with special stains, culture, and serologic testing. For example, South American blastomycosis is associated with 90% sensitive and 80% specific serologic test, and Gomori methenamine-silver or Periodic acid–Schiff stains may reveal the characteristic mariner’s wheel organisms in tissue.

Dr. Dirk Elston reviewed the nuances of dealing with worms and insects. Ivermectin may be given to kill the maggots that cause myiasis; the dead maggots can then be easily removed about a week later, as spines that lodge them into the tissue have retracted. A snake venom extractor may be utilized to suck these maggots out of infested tissue. Recurring scabies may lead to chronic impetigo and thence to glomerulonephritis and renal failure. Use of the dermatoscope may aid in the diagnosis of scabies. Many cases of so-called prurigo nodularis may actually be due to repeated bed bug bites. Both reduviid bugs and wild and domestic mammals have been found to harbor the etiologic trypanosomes of Chagas disease within the continental United States (Clin Microbiol Rev. 2011;24:655-681). Cyclic fevers should at least suggest the diagnosis of the tick-borne illness babesiosis.

Dr. Jose Dario Martinez reviewed the problem of “rash and fever.” Among the common culprits associated with such a presentation are dengue and chikungunya. Both are mosquito borne and both have now been seen in the United States, most commonly in returning travelers but also rarely as autochthonous infection. “Islands of normal in a sea of red”–appearing skin associated with fever, headache, retro-orbital pain, any sign of bleeding diathesis, and thrombocytopenia suggests dengue hemorrhagic fever. IgM serologic tests may be positive approximately 5 days into the infection, but polymerase chain reaction tests may be even more rapid. Promising work on a 3-dose quadrivalent dengue vaccine recently has been published (Lancet. July 10, 2014. doi:10.1016/S0140-6736(14)61142-9). Chikungunya, once previously limited to parts of Asia and Africa, is now present in the Americas. As of August 2014, local transmission had been identified in 31 countries or territories in the Caribbean, Central America, South America, or North America including the United States. Clinically, this disorder resembles dengue with less bleeding diathesis and more severe polyarthralgia. Reverse transcription–polymerase chain reaction testing can confirm the diagnosis in less than a week after infection. Treatment is supportive only, and a vaccine is under testing.

I discussed the ever-expanding worldwide epidemic of bed bug infestation, as verified by reports on a global bed bug registry Web site. Although bed bugs have not yet been reported to transmit disease to humans, the bite is pruritic and may be associated with severe emotional ramifications (Psychosomatics. 2012;53:85-91). Bed bugs can be detected by visual inspection of typical hiding places within 3 feet of the bed; expensive but very sensitive lures and bed bug–detecting canines also can be used to verify an infestation. Clearing bed bug infestations may require a complex multipronged approach, including thorough vacuuming and steaming, placing traps and desiccants, spreading insecticides, and thermal remediation. To avoid bringing bed bugs into the home following a trip, travelers are advised to check for bed bug infestation of hotel rooms, keep luggage off the floor and hang clothing up high, and launder clothes immediately upon returning home.

What’s the issue?

Travelers are potentially subject to many complications relating to their sojourn, particularly those of an infectious nature. Bugs and worms and unicellular parasites account for many of these complications. This situation is not static but remains perpetually evolving, as evidenced by the recent and rapid appearance of chikungunya, a virus in North America. To whom would you turn for advice or consultation if your patient returned from an exotic destination with a fever and skin abnormalities with which you have no familiarity?

We want to know your views! Tell us what you think.

Global travel has become ubiquitous for recreational, occupational, educational, humanitarian, and other purposes. For this reason, those who travel may encounter and acquire diseases from countries outside their normal habitat. A recent fascinating session from the Summer American Academy of Dermatology Meeting, “Infectious Disease and Infestations in Returned Travelers: The Americas,” highlighted current trends relating to this phenomenon.

Dr. Natasha Mesinkovska noted that Americans are most likely to travel within the Americas, particularly to Mexico, Canada, and the Dominican Republic, but also to England and France. Conversely, approximately 66 million visitors from other regions visit the United States annually. GeoSentinel surveillance clinics suggest that diarrhea and febrile illness, such as malaria, are the most common concerns reported among returning travelers who are ill. Dermatologic concerns account for approximately 18% of all problems (Int J Infect Dis. 2008;12:593-602), and many of these are either cosmopolitan infections (eg, scabies, herpes, staphylococcal) or specific tropical infections (eg, cutaneous larva migrans, tungiasis, leishmaniasis, myiasis). Because many tropical infections are associated with insect vectors, particularly mosquitoes, the prophylactic use of repellant products such as 30% to 35% DEET is advisable. Also, travelers should avoid contact with sand, soil, stagnant water, and farm animals; drink only pasteurized liquids; close hotel windows; and sleep under mosquito netting, where appropriate.

Dr. Ron (Ronald) Rapini reviewed the various diagnostic procedures that may be used for unusual infections associated with the Americas. Diagnostic techniques include potassium hydroxide preparation, routine biopsy, biopsy with special stains, culture, and serologic testing. For example, South American blastomycosis is associated with 90% sensitive and 80% specific serologic test, and Gomori methenamine-silver or Periodic acid–Schiff stains may reveal the characteristic mariner’s wheel organisms in tissue.

Dr. Dirk Elston reviewed the nuances of dealing with worms and insects. Ivermectin may be given to kill the maggots that cause myiasis; the dead maggots can then be easily removed about a week later, as spines that lodge them into the tissue have retracted. A snake venom extractor may be utilized to suck these maggots out of infested tissue. Recurring scabies may lead to chronic impetigo and thence to glomerulonephritis and renal failure. Use of the dermatoscope may aid in the diagnosis of scabies. Many cases of so-called prurigo nodularis may actually be due to repeated bed bug bites. Both reduviid bugs and wild and domestic mammals have been found to harbor the etiologic trypanosomes of Chagas disease within the continental United States (Clin Microbiol Rev. 2011;24:655-681). Cyclic fevers should at least suggest the diagnosis of the tick-borne illness babesiosis.

Dr. Jose Dario Martinez reviewed the problem of “rash and fever.” Among the common culprits associated with such a presentation are dengue and chikungunya. Both are mosquito borne and both have now been seen in the United States, most commonly in returning travelers but also rarely as autochthonous infection. “Islands of normal in a sea of red”–appearing skin associated with fever, headache, retro-orbital pain, any sign of bleeding diathesis, and thrombocytopenia suggests dengue hemorrhagic fever. IgM serologic tests may be positive approximately 5 days into the infection, but polymerase chain reaction tests may be even more rapid. Promising work on a 3-dose quadrivalent dengue vaccine recently has been published (Lancet. July 10, 2014. doi:10.1016/S0140-6736(14)61142-9). Chikungunya, once previously limited to parts of Asia and Africa, is now present in the Americas. As of August 2014, local transmission had been identified in 31 countries or territories in the Caribbean, Central America, South America, or North America including the United States. Clinically, this disorder resembles dengue with less bleeding diathesis and more severe polyarthralgia. Reverse transcription–polymerase chain reaction testing can confirm the diagnosis in less than a week after infection. Treatment is supportive only, and a vaccine is under testing.

I discussed the ever-expanding worldwide epidemic of bed bug infestation, as verified by reports on a global bed bug registry Web site. Although bed bugs have not yet been reported to transmit disease to humans, the bite is pruritic and may be associated with severe emotional ramifications (Psychosomatics. 2012;53:85-91). Bed bugs can be detected by visual inspection of typical hiding places within 3 feet of the bed; expensive but very sensitive lures and bed bug–detecting canines also can be used to verify an infestation. Clearing bed bug infestations may require a complex multipronged approach, including thorough vacuuming and steaming, placing traps and desiccants, spreading insecticides, and thermal remediation. To avoid bringing bed bugs into the home following a trip, travelers are advised to check for bed bug infestation of hotel rooms, keep luggage off the floor and hang clothing up high, and launder clothes immediately upon returning home.

What’s the issue?

Travelers are potentially subject to many complications relating to their sojourn, particularly those of an infectious nature. Bugs and worms and unicellular parasites account for many of these complications. This situation is not static but remains perpetually evolving, as evidenced by the recent and rapid appearance of chikungunya, a virus in North America. To whom would you turn for advice or consultation if your patient returned from an exotic destination with a fever and skin abnormalities with which you have no familiarity?

We want to know your views! Tell us what you think.

Global travel has become ubiquitous for recreational, occupational, educational, humanitarian, and other purposes. For this reason, those who travel may encounter and acquire diseases from countries outside their normal habitat. A recent fascinating session from the Summer American Academy of Dermatology Meeting, “Infectious Disease and Infestations in Returned Travelers: The Americas,” highlighted current trends relating to this phenomenon.

Dr. Natasha Mesinkovska noted that Americans are most likely to travel within the Americas, particularly to Mexico, Canada, and the Dominican Republic, but also to England and France. Conversely, approximately 66 million visitors from other regions visit the United States annually. GeoSentinel surveillance clinics suggest that diarrhea and febrile illness, such as malaria, are the most common concerns reported among returning travelers who are ill. Dermatologic concerns account for approximately 18% of all problems (Int J Infect Dis. 2008;12:593-602), and many of these are either cosmopolitan infections (eg, scabies, herpes, staphylococcal) or specific tropical infections (eg, cutaneous larva migrans, tungiasis, leishmaniasis, myiasis). Because many tropical infections are associated with insect vectors, particularly mosquitoes, the prophylactic use of repellant products such as 30% to 35% DEET is advisable. Also, travelers should avoid contact with sand, soil, stagnant water, and farm animals; drink only pasteurized liquids; close hotel windows; and sleep under mosquito netting, where appropriate.

Dr. Ron (Ronald) Rapini reviewed the various diagnostic procedures that may be used for unusual infections associated with the Americas. Diagnostic techniques include potassium hydroxide preparation, routine biopsy, biopsy with special stains, culture, and serologic testing. For example, South American blastomycosis is associated with 90% sensitive and 80% specific serologic test, and Gomori methenamine-silver or Periodic acid–Schiff stains may reveal the characteristic mariner’s wheel organisms in tissue.

Dr. Dirk Elston reviewed the nuances of dealing with worms and insects. Ivermectin may be given to kill the maggots that cause myiasis; the dead maggots can then be easily removed about a week later, as spines that lodge them into the tissue have retracted. A snake venom extractor may be utilized to suck these maggots out of infested tissue. Recurring scabies may lead to chronic impetigo and thence to glomerulonephritis and renal failure. Use of the dermatoscope may aid in the diagnosis of scabies. Many cases of so-called prurigo nodularis may actually be due to repeated bed bug bites. Both reduviid bugs and wild and domestic mammals have been found to harbor the etiologic trypanosomes of Chagas disease within the continental United States (Clin Microbiol Rev. 2011;24:655-681). Cyclic fevers should at least suggest the diagnosis of the tick-borne illness babesiosis.

Dr. Jose Dario Martinez reviewed the problem of “rash and fever.” Among the common culprits associated with such a presentation are dengue and chikungunya. Both are mosquito borne and both have now been seen in the United States, most commonly in returning travelers but also rarely as autochthonous infection. “Islands of normal in a sea of red”–appearing skin associated with fever, headache, retro-orbital pain, any sign of bleeding diathesis, and thrombocytopenia suggests dengue hemorrhagic fever. IgM serologic tests may be positive approximately 5 days into the infection, but polymerase chain reaction tests may be even more rapid. Promising work on a 3-dose quadrivalent dengue vaccine recently has been published (Lancet. July 10, 2014. doi:10.1016/S0140-6736(14)61142-9). Chikungunya, once previously limited to parts of Asia and Africa, is now present in the Americas. As of August 2014, local transmission had been identified in 31 countries or territories in the Caribbean, Central America, South America, or North America including the United States. Clinically, this disorder resembles dengue with less bleeding diathesis and more severe polyarthralgia. Reverse transcription–polymerase chain reaction testing can confirm the diagnosis in less than a week after infection. Treatment is supportive only, and a vaccine is under testing.

I discussed the ever-expanding worldwide epidemic of bed bug infestation, as verified by reports on a global bed bug registry Web site. Although bed bugs have not yet been reported to transmit disease to humans, the bite is pruritic and may be associated with severe emotional ramifications (Psychosomatics. 2012;53:85-91). Bed bugs can be detected by visual inspection of typical hiding places within 3 feet of the bed; expensive but very sensitive lures and bed bug–detecting canines also can be used to verify an infestation. Clearing bed bug infestations may require a complex multipronged approach, including thorough vacuuming and steaming, placing traps and desiccants, spreading insecticides, and thermal remediation. To avoid bringing bed bugs into the home following a trip, travelers are advised to check for bed bug infestation of hotel rooms, keep luggage off the floor and hang clothing up high, and launder clothes immediately upon returning home.

What’s the issue?

Travelers are potentially subject to many complications relating to their sojourn, particularly those of an infectious nature. Bugs and worms and unicellular parasites account for many of these complications. This situation is not static but remains perpetually evolving, as evidenced by the recent and rapid appearance of chikungunya, a virus in North America. To whom would you turn for advice or consultation if your patient returned from an exotic destination with a fever and skin abnormalities with which you have no familiarity?

We want to know your views! Tell us what you think.

In the article “Classification of Masseter Hypertrophy for Tailored Botulinum Toxin Type A Treatment” (Plast Reconstr Surg. 2014;134:209e-218e), Xie et al systemically classified and compared degrees of masseter hypertrophy and then prospectively used this system to tailor treatment with botulinum toxin type A. The authors identified 5 different bulging types of a contracted masseter: minimal, mono, double, triple, and excessive. Ultrasound studies and cadaver dissections were used to identify the bulging type and showed that the masseter consists of 3 different muscle layers that exhibit different directions of muscle contraction. These muscle layers are innervated by separate nerve branches that originate from the nervus massetericus, the most prominent part of the masseter bulge corresponding to the distribution region of the nervus massetericus in the central lower one-third region. The authors concluded that an injection close to the nerve endings at this site of insertion would allow for a reduced injection dosage and limited dispersion. Therefore, they chose the most prominent point of the bulging masseter while clenching as the ideal initial injection point.

What’s the issue?

The off-label use of botulinum toxin type A for the treatment of masseter hypertrophy is becoming more popular. It has been used for aesthetic volume reduction of the masseter and lower-face recontouring. Masseter hypertrophy can cause a prominent mandibular angle resulting in a wide counter of the lower face, which can be a cause of aesthetic concern in women and men as well as individuals of many ethnicities, such as those of Asian descent. The reported doses of neurotoxin as well as injection points and techniques vary, making it difficult to translate into clinical practice. Xie et al have suggested a tailored approach to the treatment of masseter hypertrophy rather than injecting in a prototypical approach. The authors had the patient clench and palpated the masseter to classify it into 1 of 5 types. Then the main injection point was into the belly of the most prominent bulge. Further injection points (range, 1–3) were used depending on the type of masseter hypertrophy. The minimal dose of botulinum toxin type A used was 20 U with the highest amount being 40 U. The greatest effect in reduction of masseter hypertrophy occurred at 3 months. Adverse effects encountered were on par with prior reports and included unnatural smile, concavity below the zygomatic arch, and even paradoxical bulging. The overall complication rate was 9.1% (20/220), but it was 60% among patients who received higher doses. With this classification system and injection pattern described, the authors noted a reduction in injection dose and therefore complication rates as well as significantly reduced masseter volume and improved lower face contour (P<.01). When it comes to masseter injections and lower-face shaping, what is your method?

We want to know your views! Tell us what you think.

In the article “Classification of Masseter Hypertrophy for Tailored Botulinum Toxin Type A Treatment” (Plast Reconstr Surg. 2014;134:209e-218e), Xie et al systemically classified and compared degrees of masseter hypertrophy and then prospectively used this system to tailor treatment with botulinum toxin type A. The authors identified 5 different bulging types of a contracted masseter: minimal, mono, double, triple, and excessive. Ultrasound studies and cadaver dissections were used to identify the bulging type and showed that the masseter consists of 3 different muscle layers that exhibit different directions of muscle contraction. These muscle layers are innervated by separate nerve branches that originate from the nervus massetericus, the most prominent part of the masseter bulge corresponding to the distribution region of the nervus massetericus in the central lower one-third region. The authors concluded that an injection close to the nerve endings at this site of insertion would allow for a reduced injection dosage and limited dispersion. Therefore, they chose the most prominent point of the bulging masseter while clenching as the ideal initial injection point.

What’s the issue?

The off-label use of botulinum toxin type A for the treatment of masseter hypertrophy is becoming more popular. It has been used for aesthetic volume reduction of the masseter and lower-face recontouring. Masseter hypertrophy can cause a prominent mandibular angle resulting in a wide counter of the lower face, which can be a cause of aesthetic concern in women and men as well as individuals of many ethnicities, such as those of Asian descent. The reported doses of neurotoxin as well as injection points and techniques vary, making it difficult to translate into clinical practice. Xie et al have suggested a tailored approach to the treatment of masseter hypertrophy rather than injecting in a prototypical approach. The authors had the patient clench and palpated the masseter to classify it into 1 of 5 types. Then the main injection point was into the belly of the most prominent bulge. Further injection points (range, 1–3) were used depending on the type of masseter hypertrophy. The minimal dose of botulinum toxin type A used was 20 U with the highest amount being 40 U. The greatest effect in reduction of masseter hypertrophy occurred at 3 months. Adverse effects encountered were on par with prior reports and included unnatural smile, concavity below the zygomatic arch, and even paradoxical bulging. The overall complication rate was 9.1% (20/220), but it was 60% among patients who received higher doses. With this classification system and injection pattern described, the authors noted a reduction in injection dose and therefore complication rates as well as significantly reduced masseter volume and improved lower face contour (P<.01). When it comes to masseter injections and lower-face shaping, what is your method?

We want to know your views! Tell us what you think.

In the article “Classification of Masseter Hypertrophy for Tailored Botulinum Toxin Type A Treatment” (Plast Reconstr Surg. 2014;134:209e-218e), Xie et al systemically classified and compared degrees of masseter hypertrophy and then prospectively used this system to tailor treatment with botulinum toxin type A. The authors identified 5 different bulging types of a contracted masseter: minimal, mono, double, triple, and excessive. Ultrasound studies and cadaver dissections were used to identify the bulging type and showed that the masseter consists of 3 different muscle layers that exhibit different directions of muscle contraction. These muscle layers are innervated by separate nerve branches that originate from the nervus massetericus, the most prominent part of the masseter bulge corresponding to the distribution region of the nervus massetericus in the central lower one-third region. The authors concluded that an injection close to the nerve endings at this site of insertion would allow for a reduced injection dosage and limited dispersion. Therefore, they chose the most prominent point of the bulging masseter while clenching as the ideal initial injection point.

What’s the issue?

The off-label use of botulinum toxin type A for the treatment of masseter hypertrophy is becoming more popular. It has been used for aesthetic volume reduction of the masseter and lower-face recontouring. Masseter hypertrophy can cause a prominent mandibular angle resulting in a wide counter of the lower face, which can be a cause of aesthetic concern in women and men as well as individuals of many ethnicities, such as those of Asian descent. The reported doses of neurotoxin as well as injection points and techniques vary, making it difficult to translate into clinical practice. Xie et al have suggested a tailored approach to the treatment of masseter hypertrophy rather than injecting in a prototypical approach. The authors had the patient clench and palpated the masseter to classify it into 1 of 5 types. Then the main injection point was into the belly of the most prominent bulge. Further injection points (range, 1–3) were used depending on the type of masseter hypertrophy. The minimal dose of botulinum toxin type A used was 20 U with the highest amount being 40 U. The greatest effect in reduction of masseter hypertrophy occurred at 3 months. Adverse effects encountered were on par with prior reports and included unnatural smile, concavity below the zygomatic arch, and even paradoxical bulging. The overall complication rate was 9.1% (20/220), but it was 60% among patients who received higher doses. With this classification system and injection pattern described, the authors noted a reduction in injection dose and therefore complication rates as well as significantly reduced masseter volume and improved lower face contour (P<.01). When it comes to masseter injections and lower-face shaping, what is your method?

We want to know your views! Tell us what you think.

Patch testing is one of the major diagnostic tools in the evaluation of allergic contact dermatitis. One limitation of patch testing is the use of steroids prior to testing. Because steroids may suppress a positive test reaction, the use of topical steroids on the test site or oral steroids should be discontinued for at least 2 weeks prior to testing. Therefore, it is interesting to consider the effect of biologics on the reliability of patch testing.

Kim et al (Dermatitis. 2014;25:182-190) evaluated the prevalence of positive patch tests in psoriasis patients receiving biologics and whether these results differed from those of psoriasis patients who were not receiving biologics. An institutional review board–approved retrospective chart review was performed for individuals with psoriasis who were patch tested from January 2002 to 2012 at Tufts Medical Center in Boston, Massachusetts. Patients were selected if they had a history of psoriasis, psoriatic arthritis, and patch testing as identified by International Classification of Diseases, Ninth Revision, codes 696.1, 696.0, and 95044, respectively, in their medical records. Patients were patch tested using a modified North American Contact Dermatitis Group standard and cosmetics series. Readings were performed at 48 hours and 72 to 96 hours. The North American Contact Dermatitis Group grading system was used to grade reactions. 

The chart review included 15 psoriasis patients who were on biologics (cases) and 16 psoriasis patients who were not on biologics (control subjects). The biologics used were ustekinumab (n=7), etanercept (n=4), adalimumab (n=3), and infliximab (n=1). The authors determined that 80% (12/15) of cases had at least 1 positive reaction compared with 81% (13/16) of control subjects, 67% (10/15) of cases had 2+ positive reactions compared with 63% (10/16) of control subjects, and 27% (4/15) of cases had 3+ positive reactions compared with 38% (6/16) of control subjects. These differences were not statistically significant.

Given the limitation of the small number of patients evaluated, the authors concluded that biologics do not appear to influence the abilities of patients with psoriasis to mount a positive patch test.

What’s the issue?

This study is small, but the findings do give an indication that the biologic agents utilized for psoriasis do not suppress patch test reactions. These data are not typically what we collect in this population, but it is nice to know. What has been your experience in patch testing patients on biologic therapy?

We want to know your views! Tell us what you think.

Patch testing is one of the major diagnostic tools in the evaluation of allergic contact dermatitis. One limitation of patch testing is the use of steroids prior to testing. Because steroids may suppress a positive test reaction, the use of topical steroids on the test site or oral steroids should be discontinued for at least 2 weeks prior to testing. Therefore, it is interesting to consider the effect of biologics on the reliability of patch testing.

Kim et al (Dermatitis. 2014;25:182-190) evaluated the prevalence of positive patch tests in psoriasis patients receiving biologics and whether these results differed from those of psoriasis patients who were not receiving biologics. An institutional review board–approved retrospective chart review was performed for individuals with psoriasis who were patch tested from January 2002 to 2012 at Tufts Medical Center in Boston, Massachusetts. Patients were selected if they had a history of psoriasis, psoriatic arthritis, and patch testing as identified by International Classification of Diseases, Ninth Revision, codes 696.1, 696.0, and 95044, respectively, in their medical records. Patients were patch tested using a modified North American Contact Dermatitis Group standard and cosmetics series. Readings were performed at 48 hours and 72 to 96 hours. The North American Contact Dermatitis Group grading system was used to grade reactions. 

The chart review included 15 psoriasis patients who were on biologics (cases) and 16 psoriasis patients who were not on biologics (control subjects). The biologics used were ustekinumab (n=7), etanercept (n=4), adalimumab (n=3), and infliximab (n=1). The authors determined that 80% (12/15) of cases had at least 1 positive reaction compared with 81% (13/16) of control subjects, 67% (10/15) of cases had 2+ positive reactions compared with 63% (10/16) of control subjects, and 27% (4/15) of cases had 3+ positive reactions compared with 38% (6/16) of control subjects. These differences were not statistically significant.

Given the limitation of the small number of patients evaluated, the authors concluded that biologics do not appear to influence the abilities of patients with psoriasis to mount a positive patch test.

What’s the issue?

This study is small, but the findings do give an indication that the biologic agents utilized for psoriasis do not suppress patch test reactions. These data are not typically what we collect in this population, but it is nice to know. What has been your experience in patch testing patients on biologic therapy?

We want to know your views! Tell us what you think.

Patch testing is one of the major diagnostic tools in the evaluation of allergic contact dermatitis. One limitation of patch testing is the use of steroids prior to testing. Because steroids may suppress a positive test reaction, the use of topical steroids on the test site or oral steroids should be discontinued for at least 2 weeks prior to testing. Therefore, it is interesting to consider the effect of biologics on the reliability of patch testing.

Kim et al (Dermatitis. 2014;25:182-190) evaluated the prevalence of positive patch tests in psoriasis patients receiving biologics and whether these results differed from those of psoriasis patients who were not receiving biologics. An institutional review board–approved retrospective chart review was performed for individuals with psoriasis who were patch tested from January 2002 to 2012 at Tufts Medical Center in Boston, Massachusetts. Patients were selected if they had a history of psoriasis, psoriatic arthritis, and patch testing as identified by International Classification of Diseases, Ninth Revision, codes 696.1, 696.0, and 95044, respectively, in their medical records. Patients were patch tested using a modified North American Contact Dermatitis Group standard and cosmetics series. Readings were performed at 48 hours and 72 to 96 hours. The North American Contact Dermatitis Group grading system was used to grade reactions. 

The chart review included 15 psoriasis patients who were on biologics (cases) and 16 psoriasis patients who were not on biologics (control subjects). The biologics used were ustekinumab (n=7), etanercept (n=4), adalimumab (n=3), and infliximab (n=1). The authors determined that 80% (12/15) of cases had at least 1 positive reaction compared with 81% (13/16) of control subjects, 67% (10/15) of cases had 2+ positive reactions compared with 63% (10/16) of control subjects, and 27% (4/15) of cases had 3+ positive reactions compared with 38% (6/16) of control subjects. These differences were not statistically significant.

Given the limitation of the small number of patients evaluated, the authors concluded that biologics do not appear to influence the abilities of patients with psoriasis to mount a positive patch test.

What’s the issue?

This study is small, but the findings do give an indication that the biologic agents utilized for psoriasis do not suppress patch test reactions. These data are not typically what we collect in this population, but it is nice to know. What has been your experience in patch testing patients on biologic therapy?

We want to know your views! Tell us what you think.

In early July, a media blast regarding the safety of spray sunscreens was disseminated. Consumer Reports commented on a US Food and Drug Administration (FDA) investigation of sunscreen in the spray vehicle, stating that consumers should not apply them on children until the safety of these agents is determined by an ongoing FDA analysis. The focus of FDA concern is the inhalation of nanoparticles in these products, particularly those containing titanium dioxide. The report also provided instructions for safe application of spray sunscreen in adults, such as avoiding the face and applying evenly for best results.

What’s the issue?

I read this consumer article with great interest and attention. I not only use spray sunscreen on my toddler and myself, but I also often recommend it to patients who despise the feel and inconvenience of cream-based sunscreens. Also, the ability to independently reach areas such as the mid-back provides ease of application in the spray form. That being said, I do note that these sunscreens should not be used on the face and should be applied outdoors to reduce inhalation. The age of nanomedicine provides an unknown risk, given the potential of new and more invasive chemical exposure. However, the aggressiveness with which this report was disseminated through the press was not well founded.

The FDA started this investigation in 2011, which was disclosed by Consumer Reports using a tiny asterisk in the July 2014 report. The FDA has not made any statements for or against spray sunscreens except to say that consumers should avoid open flames during application. In fact, the American Academy of Dermatology’s educational page on sunscreen has acknowledged the unknown risk of spray sunscreens since 2011. Given that this consumer “update,” which did not provide any new information, was released by the press in the throes of the summer sun, it has bolstered patient doubts about what dermatologists recommend regarding sunscreen and its safety. Do you use or recommend spray sunscreens? How do you feel about the manner in which the popular media depicts sunscreens in recent years?

We want to know your views! Tell us what you think.

Reader Comments

I usually ask our patients to apply sprays outside and directed so the spray is dispersed downwind if possible. This at the beach or golf course. I also ask them to hold their breaths to not inhale the mist. I still however ask to use a cream or lotion at home and use the sprays as a secondary application.

--Michael A. Scannon, MD

Darrel Rigel showed several years ago that most people use one quarter to one third the proper amount of sunscreen needed to attain the SPF on the label. Sprays encourage using even less. In a use test I performed for a sunscreen company several years ago, our subjects had white round patches of unburned skin among their sunburns. Uniform coverage is difficult to achieve.
--Christopher G. Nelson, MD

In early July, a media blast regarding the safety of spray sunscreens was disseminated. Consumer Reports commented on a US Food and Drug Administration (FDA) investigation of sunscreen in the spray vehicle, stating that consumers should not apply them on children until the safety of these agents is determined by an ongoing FDA analysis. The focus of FDA concern is the inhalation of nanoparticles in these products, particularly those containing titanium dioxide. The report also provided instructions for safe application of spray sunscreen in adults, such as avoiding the face and applying evenly for best results.

What’s the issue?

I read this consumer article with great interest and attention. I not only use spray sunscreen on my toddler and myself, but I also often recommend it to patients who despise the feel and inconvenience of cream-based sunscreens. Also, the ability to independently reach areas such as the mid-back provides ease of application in the spray form. That being said, I do note that these sunscreens should not be used on the face and should be applied outdoors to reduce inhalation. The age of nanomedicine provides an unknown risk, given the potential of new and more invasive chemical exposure. However, the aggressiveness with which this report was disseminated through the press was not well founded.

The FDA started this investigation in 2011, which was disclosed by Consumer Reports using a tiny asterisk in the July 2014 report. The FDA has not made any statements for or against spray sunscreens except to say that consumers should avoid open flames during application. In fact, the American Academy of Dermatology’s educational page on sunscreen has acknowledged the unknown risk of spray sunscreens since 2011. Given that this consumer “update,” which did not provide any new information, was released by the press in the throes of the summer sun, it has bolstered patient doubts about what dermatologists recommend regarding sunscreen and its safety. Do you use or recommend spray sunscreens? How do you feel about the manner in which the popular media depicts sunscreens in recent years?

We want to know your views! Tell us what you think.

Reader Comments

I usually ask our patients to apply sprays outside and directed so the spray is dispersed downwind if possible. This at the beach or golf course. I also ask them to hold their breaths to not inhale the mist. I still however ask to use a cream or lotion at home and use the sprays as a secondary application.

--Michael A. Scannon, MD

Darrel Rigel showed several years ago that most people use one quarter to one third the proper amount of sunscreen needed to attain the SPF on the label. Sprays encourage using even less. In a use test I performed for a sunscreen company several years ago, our subjects had white round patches of unburned skin among their sunburns. Uniform coverage is difficult to achieve.
--Christopher G. Nelson, MD

In early July, a media blast regarding the safety of spray sunscreens was disseminated. Consumer Reports commented on a US Food and Drug Administration (FDA) investigation of sunscreen in the spray vehicle, stating that consumers should not apply them on children until the safety of these agents is determined by an ongoing FDA analysis. The focus of FDA concern is the inhalation of nanoparticles in these products, particularly those containing titanium dioxide. The report also provided instructions for safe application of spray sunscreen in adults, such as avoiding the face and applying evenly for best results.

What’s the issue?

I read this consumer article with great interest and attention. I not only use spray sunscreen on my toddler and myself, but I also often recommend it to patients who despise the feel and inconvenience of cream-based sunscreens. Also, the ability to independently reach areas such as the mid-back provides ease of application in the spray form. That being said, I do note that these sunscreens should not be used on the face and should be applied outdoors to reduce inhalation. The age of nanomedicine provides an unknown risk, given the potential of new and more invasive chemical exposure. However, the aggressiveness with which this report was disseminated through the press was not well founded.

The FDA started this investigation in 2011, which was disclosed by Consumer Reports using a tiny asterisk in the July 2014 report. The FDA has not made any statements for or against spray sunscreens except to say that consumers should avoid open flames during application. In fact, the American Academy of Dermatology’s educational page on sunscreen has acknowledged the unknown risk of spray sunscreens since 2011. Given that this consumer “update,” which did not provide any new information, was released by the press in the throes of the summer sun, it has bolstered patient doubts about what dermatologists recommend regarding sunscreen and its safety. Do you use or recommend spray sunscreens? How do you feel about the manner in which the popular media depicts sunscreens in recent years?

We want to know your views! Tell us what you think.

Reader Comments

I usually ask our patients to apply sprays outside and directed so the spray is dispersed downwind if possible. This at the beach or golf course. I also ask them to hold their breaths to not inhale the mist. I still however ask to use a cream or lotion at home and use the sprays as a secondary application.

--Michael A. Scannon, MD

Darrel Rigel showed several years ago that most people use one quarter to one third the proper amount of sunscreen needed to attain the SPF on the label. Sprays encourage using even less. In a use test I performed for a sunscreen company several years ago, our subjects had white round patches of unburned skin among their sunburns. Uniform coverage is difficult to achieve.
--Christopher G. Nelson, MD

In a recently published article in the Journal of Cosmetic Dermatology (2014;13:91-98), Goodier et al compared low volume deep placement cheek injection and mid to deep dermal nasolabial fold injection for the correction of nasolabial folds with hyaluronic acid (HA) filler. In this split-face study, 3 injection techniques were utilized: (1) deep bolus injection into the mid to lateral cheek, (2) mid to deep dermal injection into the nasolabial fold, or (3) both techniques. Results were assessed in 4 to 6 weeks by a blinded investigator.

Globally, patients and investigators noted no statistical difference using the wrinkle severity score. All 3 techniques showed improvement. Patients preferred injection using both techniques, which was associated with the greatest amount of filler product injected. The authors concluded that injection of a dermal HA filler into either the nasolabial fold or mid to lateral cheek resulted in similar improvement for the correction of the nasolabial folds.

What’s the issue?

Although this study used a single HA agent, it showed that patients’ nasolabial folds improved using both techniques: deep depot placement in the cheeks and mid to deep dermal nasolabial fold injection. It may come as no surprise that patients in this study showed a slight preference for both techniques. Although the trend now is to add volume and not fill, a combination of these techniques may give the best outcomes. What do you use in your practice? A study comparing different HA fillers available or one comparing HA to non-HA products would be interesting. Which agents do you use in your practice for nasolabial fold correction?

We want to know your views! Tell us what you think.

In a recently published article in the Journal of Cosmetic Dermatology (2014;13:91-98), Goodier et al compared low volume deep placement cheek injection and mid to deep dermal nasolabial fold injection for the correction of nasolabial folds with hyaluronic acid (HA) filler. In this split-face study, 3 injection techniques were utilized: (1) deep bolus injection into the mid to lateral cheek, (2) mid to deep dermal injection into the nasolabial fold, or (3) both techniques. Results were assessed in 4 to 6 weeks by a blinded investigator.

Globally, patients and investigators noted no statistical difference using the wrinkle severity score. All 3 techniques showed improvement. Patients preferred injection using both techniques, which was associated with the greatest amount of filler product injected. The authors concluded that injection of a dermal HA filler into either the nasolabial fold or mid to lateral cheek resulted in similar improvement for the correction of the nasolabial folds.

What’s the issue?

Although this study used a single HA agent, it showed that patients’ nasolabial folds improved using both techniques: deep depot placement in the cheeks and mid to deep dermal nasolabial fold injection. It may come as no surprise that patients in this study showed a slight preference for both techniques. Although the trend now is to add volume and not fill, a combination of these techniques may give the best outcomes. What do you use in your practice? A study comparing different HA fillers available or one comparing HA to non-HA products would be interesting. Which agents do you use in your practice for nasolabial fold correction?

We want to know your views! Tell us what you think.

In a recently published article in the Journal of Cosmetic Dermatology (2014;13:91-98), Goodier et al compared low volume deep placement cheek injection and mid to deep dermal nasolabial fold injection for the correction of nasolabial folds with hyaluronic acid (HA) filler. In this split-face study, 3 injection techniques were utilized: (1) deep bolus injection into the mid to lateral cheek, (2) mid to deep dermal injection into the nasolabial fold, or (3) both techniques. Results were assessed in 4 to 6 weeks by a blinded investigator.

Globally, patients and investigators noted no statistical difference using the wrinkle severity score. All 3 techniques showed improvement. Patients preferred injection using both techniques, which was associated with the greatest amount of filler product injected. The authors concluded that injection of a dermal HA filler into either the nasolabial fold or mid to lateral cheek resulted in similar improvement for the correction of the nasolabial folds.

What’s the issue?

Although this study used a single HA agent, it showed that patients’ nasolabial folds improved using both techniques: deep depot placement in the cheeks and mid to deep dermal nasolabial fold injection. It may come as no surprise that patients in this study showed a slight preference for both techniques. Although the trend now is to add volume and not fill, a combination of these techniques may give the best outcomes. What do you use in your practice? A study comparing different HA fillers available or one comparing HA to non-HA products would be interesting. Which agents do you use in your practice for nasolabial fold correction?

We want to know your views! Tell us what you think.