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 THE MANY FACES OF ROSACEA Topical Treatment of Rosacea: A Clinical Update Supplement (NON-ACCREDITED) Download PDF |
Part 2: CME #125: What Did We Learn in 2005?
Part 2: What Did We Learn in 2005?
Dermatologic Surgery Update
Curettage of basal cell carcinomas and Mohs surgery. Many dermatologic surgeons routinely perform curettage to help delineate tumor borders before Mohs micrographic surgery. Huang et al. examined utility of pre-operative tumor curettage in Mohs micrographic surgery for primary or recurrent, well-defined basal cell carcinomas (BCCs) less than 2 cm in diameter located on the head or neck.33 For this study, 166 patients were randomized to pre-operative tumor curettage or control group followed by Mohs. The pre-operative tumor curettage group had a 399% mean surface area increase from tumor to wound surface area versus 263% for control group (p=0.0002). The pre-operative tumor curettage group had a mean absolute surface area increase of 1.78 cm2 versus 1.40 cm2 for control group (p=0.02). The preoperative tumor curettage group had fewer tissue layers removed.
Mohs micrographic surgery vs. excision of centrofacial basal cell carcinomas. Mohs has long been the standard of care for large, histologically aggressive and recurrent centrofacial BCCs in United States. Smeets et al. prospectively evaluated 397 primary and 201 recurrent centrofacial BCCs larger than 1 cm in size or smaller tumors with aggressive histologic subtype.34 Patients were randomized into two groups: One group was treated with standard surgical excision with 3-mm margins (198 primary tumors and 102 recurrent tumors) and the other group was treated with Mohs (199 primary tumors and 99 recurrent tumors). Of the 199 primary BCCs treated with surgical excision, 35 had positive surgical margins and were either re-excised (31) or treated with Mohs (3); one BCC was untreated. Of the 102 recurrent BCCs treated with surgical excision, 31 had positive surgical margins and were either re-excised (25) or treated with Mohs (5); one BCC was treated with another therapy. Of the primary carcinomas, five (3%) recurred after surgical excision compared with three (2%) after Mohs during 30 months of follow-up. Of the recurrent carcinomas, three (3%) recurred after surgical excision and none after Mohs during 18 months of follow-up.
Since BCCs are slow-growing tumors, longer follow-up data are certainly needed. However, this study does raise the question of whether all centrofacial BCCs required Mohs, which is much more labor intensive and expensive.
Cosmetic Dermatology Update
Artecoll, new permanent filler. In this double-blind, multi-center study, Cohen and Holmes compared Artecoll (an injectable wrinkle filler composed of polymethylmethacrylate microspheres and bovine collagen) with a currently approved bovine collagen dermal filler (control) in 1,334 wrinkles of the glabella, nasolabial fold, radial upper lip lines, and corner-of-the-mouth lines.35 Two hundred and fifty one patients were enrolled in this trial and follow-up safety, efficacy, investigator success rating, and subject satisfaction rating data were collected at 1, 3 and 6 months. Blinded observers using a photographic facial fold assessment scale demonstrated a combined significant improvement with Artecoll compared with bovine collagen at 6 months (p<0.001). The investigator success ratings and the subject satisfaction ratings for each of the four injections sites were superior for Artecoll. At 12 months follow-up, 111 patients injected with Artecoll showed persistence of significant augmentation. Side effects were similar in the Artecoll and control groups.
Radiance FN, long-term soft tissue filler. Tzikas evaluated clinical efficacy and patient satisfaction of Radiance FN (fine needle), which consists of 35% spherical particles of synthetic calcium hydroxylapatite blended in a gel that contains water, glycerin and sodium carboxymethylcellulose, in 90 patients.36 Subdermal injection with Radiance FN was accomplished under nerve-block anesthesia by a fanning technique. The primary areas treated were lips, nasolabial folds, glabellar rhytids, marionette lines, prejowl depressions, acne scars and surgical soft tissue defects. At 6 months, appearance, softness and overall patient satisfaction were rated good or excellent in 74%, 80% and 88% of patients, respectively. Persistent visible mucosal lip nodules were detected in seven patients (7.8%), four of whom required intervention. This last side effect is concerning.
Although the long-lasting nature of this product is desirable, the development of lip nodules must be considered and discussed with the patients undergoing this treatment.
Fake botulimun toxin type A (Botox). Four people were hospitalized in Florida when they were injected with non-FDA approved botulinum toxin type A. Dr. Bach McComb, an osteopathic physician whose license was suspended in 2003 on charges of over-prescribing painkillers, was charged with accidentally paralyzing his girlfriend, himself and two others with the fake drug.37 Dr. McComb allegedly used massive doses of unapproved bulk botulinum toxin type A, not the FDA-approved Allergan product. The product was purchased from a company named List Biological Laboratories in Campbell, CA, which makes diphtheria and anthrax for animal research.38 An investigation is currently underway.
Advances Improve Patient Care
Dermatology is an exciting and constantly evolving field. We have seen multiple advances in all aspects of dermatology in 2005, including medical dermatology, cosmetic dermatology and dermatologic surgery. Application of these advances should improve the care that we provide to our patients. We can also look forward to exciting changes in 2006.
References:
1. Oxman MN, Levin MJ, Johnson GR et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med 2005 June 2;352(22):2271-84.
2. Fridkin SK, Hageman JC, Morrison M et al. Methicillin-resistant Staphylococcus aureus disease in three communities. N Engl J Med 2005 April 7;352(14):1436-44.
3. Aronson NE, Santosham M, Comstock GW et al. Long-term efficacy of BCG vaccine in American Indians and Alaska Natives: A 60-year follow-up study. JAMA 2004 May 5;291(17):2086-91.
4. Sobel JD, Wiesenfeld HC, Martens M et al. Maintenance fluconazole therapy for recurrent vulvovaginal candidiasis. N Engl J Med 2004 August 26;351(9):876-83.
5. Chia CY, Lane W, Chibnall J, Allen A, Siegfried E. Isotretinoin therapy and mood changes in adolescents with moderate to severe acne: a cohort study. Arch Dermatol 2005 May;141(5):557-60.
6. Bremner JD, Fani N, Ashraf A et al. Functional brain imaging alterations in acne patients treated with isotretinoin. Am J Psychiatry 2005 May;162(5):983-91.
7. Hendrix CW, Jackson KA, Whitmore E et al. The effect of isotretinoin on the pharmacokinetics and pharmacodynamics of ethinyl estradiol and norethindrone. Clin Pharmacol Ther 2004 May;75(5):464-75.
8. iPLEDGE. Available at: URL: https://www. ipledgeprogram.com/. Accessed October 9, 2005.
(9. Bruggemann H, Henne A, Hoster F et al. The complete genome sequence of Propionibacterium acnes, a commensal of human skin. Science 2004 July 30;305(5684):671-3.
10. Roenigk HH, Jr., Auerbach R, Maibach H, Weinstein G, Lebwohl M. Methotrexate in psoriasis: consensus conference. J Am Acad Dermatol 1998 March;38(3):478-85.
11. Chalmers RJ, Kirby B, Smith A et al. Replacement of routine liver biopsy by procollagen III aminopeptide for monitoring patients with psoriasis receiving long-term methotrexate: a multicentre audit and health economic analysis. Br J Dermatol 2005 March;152(3):444-50.
12. Maurice PD, Maddox AJ, Green CA, Tatnall F, Schofield JK, Stott DJ. Monitoring patients on methotrexate: hepatic fibrosis not seen in patients with normal serum assays of aminoterminal peptide of type III procollagen. Br J Dermatol 2005 March;152(3):451-8.
13. Gribetz CH, Blum R, Brady C, Cohen S, Lebwohl M. An extended 16-week course of alefacept in the treatment of chronic plaque psoriasis. J Am Acad Dermatol 2005 July;53(1):73-5.
14. Leonardi CL, Papp KA, Gordon KB et al. Extended efalizumab therapy improves chronic plaque psoriasis: results from a randomized phase III trial. J Am Acad Dermatol 2005 March;52(3 Pt 1):425-33.
15. Raptiva Package Insert. Available at: URL: http://www.gene.com/gene/common/inc/pi/raptiva.jsp. Accessed October 9, 2005.
16. Menter A, Gordon K, Carey W et al. Efficacy and safety observed during 24 weeks of efalizumab therapy in patients with moderate to severe plaque psoriasis. Arch Dermatol 2005 January;141(1):31-8.
17. Papp KA, Tyring S, Lahfa M et al. A global phase III randomized controlled trial of etanercept in psoriasis: safety, efficacy, and effect of dose reduction. Br J Dermatol 2005 June;152(6):1304-12.
18. Wolfe F, Michaud K. Lymphoma in rheumatoid arthritis: the effect of methotrexate and anti-tumor necrosis factor therapy in 18,572 patients. Arthritis Rheum 2004 June;50(6):1740-51.
19. Center for Disease Control and Prevention. Available at: URL: http://www.cdc.gov/cancer/
nscpep/awareness.htm. Accessed October 9, 2005.
20. Barnhill RL, Katzen J, Spatz A, Fine J, Berwick M. The importance of mitotic rate as a prognostic factor for localized cutaneous melanoma.
J Cutan Pathol 2005 April;32(4):268-73.
21. Dyson SW, Bass J, Pomeranz J, Jaworsky C, Sigel J, Somach S. Impact of thorough block sampling in the histologic evaluation of melanomas. Arch Dermatol 2005 June;141(6):734-6.
22. Karimipour DJ, Schwartz JL, Wang TS et al. Microstaging accuracy after subtotal incisional biopsy of cutaneous melanoma. J Am Acad Dermatol 2005 May;52(5):798-802.
23. Thomas JM, Newton-Bishop J, A'Hern R et al. Excision margins in high-risk malignant melanoma. N Engl J Med 2004 February 19;350(8):757-66.
24. Feldman SR, Liguori A, Kucenic M et al. Ultraviolet exposure is a reinforcing stimulus in frequent indoor tanners. J Am Acad Dermatol 2004 July;51(1):45-51.
25. Cunha KS, Manso AC, Cardoso AS, Paixao JB, Coelho HS, Torres SR. Prevalence of oral lichen planus in Brazilian patients with HCV infection. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2005 September;100(3):330-3.
26. Lodi G, Giuliani M, Majorana A et al. Lichen planus and hepatitis C virus: a multicentre study of patients with oral lesions and a systematic review. Br J Dermatol 2004 December;151(6):1172-81.
27. Campisi G, Fedele S, Lo RL et al. HCV infection and oral lichen planus: a weak association when HCV is endemic. J Viral Hepat 2004 September;11(5):465-70.
28. Chainani-Wu N, Lozada-Nur F, Terrault N. Hepatitis C virus and lichen planus: a review. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2004 August;98(2):171-83.
29. Campisi G, Di FO, Crax A, Di SR, Margiotta V. Oral lichen planus, hepatitis C virus, and HIV: no association in a cohort study from an area of high hepatitis C virus endemicity. J Am Acad Dermatol 2004 September;51(3):364-70.
30. Laeijendecker R, Van Joost TH, Tank B, Neumann HA. Oral lichen planus and hepatitis C virus infection. Arch Dermatol 2005 July;141(7):906-7.
31. Paller AS, Lebwohl M, Fleischer AB, Jr. et al. Tacrolimus ointment is more effective than
pimecrolimus cream with a similar safety profile in the treatment of atopic dermatitis: results from 3 randomized, comparative studies. J Am Acad Dermatol 2005 May;52(5):810-22.
32. US Food and Drug Administration. Available at: URL: http://www.fda.gov/cder/drug/advisory/
elidel_protopic.htm. Accessed October 9, 2005.
33. Huang CC, Boyce S, Northington M, Desmond R, Soong SJ. Randomized, controlled surgical trial of preoperative tumor curettage of basal cell carcinoma in Mohs micrographic surgery. J Am Acad Dermatol 2004 October;51(4):585-91.
34. Smeets NW, Krekels GA, Ostertag JU et al. Surgical excision vs Mohs' micrographic surgery for basal-cell carcinoma of the face: randomised controlled trial. Lancet 2004 November 13;364(9447):1766-72.
35. Cohen SR, Holmes RE. Artecoll: a long-lasting injectable wrinkle filler material: Report of a controlled, randomized, multicenter clinical trial of 251 subjects. Plast Reconstr Surg 2004 September 15;114(4):964-76.
36. Tzikas TL. Evaluation of the Radiance FN soft tissue filler for facial soft tissue augmentation. Arch Facial Plast Surg 2004 July;6(4):234-9.
37. Four Paralyzed by Fake Botox Injections. Four Paralyzed by Fake Botox Injections 2005; Available at: URL: http://headaches.about.com/
b/a/133264.htm. Accessed October 9, 2005.
38. Bogus Botox Sounds Wake Up Call. Dermatology Times 2005; Available at: URL: http://www.dermatologytimes.com/dermatologytimes/article/articleDetail.j.... Accessed October 9, 2005.
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