The Rise and Fall of the Pale Puffy Lower Eyelid Pillow

This case series demonstrates an exaggerated form of the clinical presentation of a known distressing late complication of retained hyaluronic acid filler – the “pale puffy pillow.” This presentation is often, unfortunately for the patient, misdiagnosed as festoons. However, the correction with liberal hyaluronidase is simple. Additionally, we have demonstrated that ablative fractional carbon dioxide laser resurfacing is an excellent tool that may be utilized after hyaluronidase to correct the residual skin laxity.J Drugs Dermatol. 20(4):475-476. doi:10.36849/JDD.5509.

The Rise and Fall of the Pale Puffy Lower Eyelid Pillow

This case series demonstrates an exaggerated form of the clinical presentation of a known distressing late complication of retained hyaluronic acid filler – the “pale puffy pillow.” This presentation is often, unfortunately for the patient, misdiagnosed as festoons. However, the correction with liberal hyaluronidase is simple. Additionally, we have demonstrated that ablative fractional carbon dioxide laser resurfacing is an excellent tool that may be utilized after hyaluronidase to correct the residual skin laxity.J Drugs Dermatol. 20(4):475-476. doi:10.36849/JDD.5509.

The Male Aesthetic Patient: Facial Anatomy, Concepts of Attractiveness, and Treatment Patterns

<p>BACKGROUND: The number of nonsurgical aesthetic procedures performed in men is growing rapidly. However, there are limited data on treatment principles and goals for the male aesthetic patient.</p> <p>OBJECTIVE: To review the objective data available on male aging and aesthetics and to synthesize with expert opinion on treatment considerations specific to male patients.</p> <p>METHODS: Expert advisors met to discuss anatomical differences in male versus female facial anatomy related to aging, facial treatment preferences in aesthetically oriented men, and current dosing data for facial injectable treatments in male versus female patients.</p> <p>RESULTS: Symmetry, averageness, sexual dimorphism, and youthfulness are generally accepted as factors that contribute to the perception of attractiveness. There are differences between men and women in facial anatomy, concepts of attractiveness in the context of masculinity and femininity, and treatment objectives. A communication gap exists for men, as evidenced by the lack of information available online or by word of mouth about injectable treatments.</p> <p>CONCLUSIONS: Approaches to aesthetic consultation and treatment should differ between men and women based on the fundamental dissimilarities between the sexes. Educating men about available aesthetic treatments and about the safety and side effects associated with each treatment, as well as addressing concerns about their treatment results looking natural, are key considerations.</p> <p><em>J Drugs Dermatol. 2018;17(1):19-28.</em></p>.

Patient initiation and persistence with allergen immunotherapy

BACKGROUND

Allergen immunotherapy (AIT) is advised for patients with allergic rhinitis who remain symptomatic despite the use of pharmacotherapy and allergen avoidance. Several factors influence the decision to initiate and complete the AIT regimen.

OBJECTIVE

To evaluate patient initiation and persistence with subcutaneous and sublingual immunotherapies (SCIT and SLIT) according to physician recommendation.

METHODS

A retrospective review of electronic health records of patients with allergic rhinitis for whom AIT was recommended was conducted in a large private allergy practice in Pennsylvania.

RESULTS

Of 8,790 patients advised to consider AIT, 36.2% initiated AIT (57% adults, 43% children); 78% chose SCIT and 22% chose SLIT drops. Election of AIT was significantly associated with select comorbidities, specifically chronic sinusitis (8.1% for AIT vs 10% for no AIT), allergic conjunctivitis (12.5% for AIT vs 18.5% for no AIT), and asthma (33.8% for AIT vs 37.4% for no AIT; P < .05). Choice of SCIT vs SLIT drops was significantly associated with older age, female sex, select comorbidities, and more allergy medications at initiation (P < .05). Of adults, 30.2% completed at least 3 years of recommended treatment. Median time on treatment was longer for adults on SCIT vs SLIT drops (3 vs 1.6 years). Similarly, 35.4% of children completed treatment, with a longer median time on treatment for SCIT (4.7 years) vs SLIT drops (3.5 years).

CONCLUSION

A minority of patients initiated AIT according to allergist recommendation and a subset of these patients completed therapy. AIT might be an underused option that could benefit patients unable to manage allergic rhinitis symptoms by other means.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01549340.

Retrospective study of the treatment of infantile hemangiomas using a combination of propranolol and pulsed dye laser

BACKGROUND

Infantile hemangioma (IH) clearance may be slow or incomplete in response to pulsed dye laser (PDL) or propranolol alone.

OBJECTIVES

To evaluate whether IH treated with PDL and propranolol displayed more rapid and complete clearance than IH treated with propranolol alone.

MATERIALS AND METHODS

Retrospective review of facial-segmental IH treated with propranolol and PDL and controls treated with propranolol was conducted. Blinded physicians used patient photographs to select clearance level and the earliest date of near-complete clearance. Days of propranolol, PDL sessions, and propranolol dose, each until date of near-complete clearance; total days of propranolol; and total propranolol dose were recorded.

RESULTS

Infantile hemangiomas treated concurrently with propranolol and PDL achieved complete clearance (6/12) more often than IH treated with propranolol followed by PDL (2/5) or IH treated with propranolol alone (1/8; difference in clearance scores p = .01) and achieved near-complete clearance after fewer days of propranolol (mean 92 days for concurrent propranolol and PDL vs 288 days for propranolol; p < .001). Cumulative propranolol dose until near-complete clearance was lowest in the concurrent propranolol and PDL group (149.16 vs. 401.25 mg/kg for propranolol; p < .001).

CONCLUSION

Facial-segmental IH treated with propranolol and PDL displayed morerapid and complete clearance and required a lower cumulative propranolol dose to achieve near-complete clearance.

Ablative fractional resurfacing for involuted hemangioma residuum

BACKGROUND Given the natural tendency for 15% to 40% of infantile hemangiomas to spontaneously involute over time, much debate surrounds the issue of treatment. Until recently, effective therapies to improve the appearance of residual textural skin changes in these patients were lacking. We suggest the use of ablative fractional resurfacing for the treatment of textural skin changes resulting from involuted hemangiomas. OBSERVATIONS All patients treated with an ablative fractional carbon dioxide laser experienced considerable flattening of the fibrofatty residual tissue, with at least 50% to 75% improvement in color, texture, and overall appearance. CONCLUSION While additional future studies are needed, we believe that ablative fractional resurfacing should be considered for the treatment of textural skin changes associated with involuted infantile hemangiomas.

Treatment of port-wine stains with a short pulse width 532-nm Nd:YAG laser

BACKGROUND AND OBJECTIVE

Pulsed dye laser treatment often results in port-wine stain (PWS) improvement; however, results vary. A frequency-doubled neodymium-doped yttrium aluminum garnet (Nd:YAG) laser that allows for shorter pulse widths along with large spot sizes and high fluences has been developed for the treatment of cutaneous vascular lesions.

STUDY DESIGN

A prospective, controlled study was performed in 5 adults with PWS using a frequency-doubled Nd:YAG laser (Excel V; Cutera Inc, Brisbane, CA) in 4 quadrants, using spot sizes of 6 to 10 mm, fluences of 4.8 to 9 J/cm2, and pulse durations of 3 to 6 ms. An adjacent control area was not treated. Each was assessed immediately posttreatment for purpura and edema and at 1 month for PWS color, size, texture, and thickness. Skin biopsies obtained immediately after and at 1 month posttreatment were evaluated.

RESULTS

All treatment quadrants displayed purpura. At 1-month follow-up, all treatment quadrants showed at least 1 grade of color improvement, from a minimum of 1% to 25% to a maximum of 51% to 75% improvement (12/20 quadrants with 1%-25% improvement, 3/20 with 26%-50%, 5/20 with 51%-75%, and 0/20 with 76%-100%). Histologic evaluation of treatment quadrants revealed vascular changes ranging 0.35 to 4 mm in depth. Immediately posttreatment, thrombi and extravasated red blood cells were observed in treatment quadrants. Histology at 1 month revealed decreased number and diameter of vessels in treatment quadrants (superficial vessels decreased by mean 1.1 vessels per section [13%], and diameter by 3.0 μm [47%], midlevel vessels decreased in number by 2.3 [20%], diameter by 2.42 μm [25%], and deep vessels decreased in number by 1.5 [83%], and diameter by 7.44 μm [88%]).

CONCLUSIONS

A single treatment with a short pulse width, frequency-doubled Nd:YAG laser resulted in safe and effective improvement of PWS, with up to 75% improvement in color observed at 1 month. Histologic evaluation demonstrated vascular injury at depths of 0.35 to 4 mm with a reduction in vessel number and size at multiple dermal levels.

Reduction of thickened flap using fractional carbon dioxide laser

BACKGROUND AND OBJECTIVE

The paramedian forehead flap is an excellent choice when repairing a large nasal defect. However, even when carefully thinned, the flap may develop a bulky appearance, an ill-fitting contour, or trap door deformity. When on the face, these suboptimal results can be quite distressing. Surgical and non-surgical options for improvement exist. Surgical options include additional debulking and reorientation of the flap. Non-surgical options include intralesional corticosteroids or 5-flourouracil, dermabrasion, and ablative and non-ablative laser resurfacing. Each option has limited benefit as well potential side effects.

STUDY DESIGN/MATERIALS AND METHODS

Case report.

RESULTS

In this report, we present dramatic improvement of a thickened paramedian forehead flap using the Fraxel Re:pair, a fractional carbon dioxide (CO(2) ) laser (Solta Medical, Inc. Hayward, CA).

CONCLUSION

To our knowledge, this is the first case in the literature demonstrating successful reduction of a bulky flap using a fractional ablative laser.

Investigation into optimal treatment intervals of facial port-wine stains using the pulsed dye laser

BACKGROUND

Port-wine stains (PWS) affect 0.3% to 0.5% of newborns and pulsed dye laser (PDL) remains the treatment of choice. Optimal treatment intervals have not been established.

OBJECTIVE

We sought to validate the optimal treatment intervals for the management of facial PWS with PDL.

METHODS

In all, 24 infants with facial PWS who received at least 5 treatments with the PDL at 2-, 3-, and 4-week intervals at a private laser and skin surgery center from 2009 to 2010 were identified by a retrospective chart review. Safety and efficacy were compared by blinded investigators.

RESULTS

Side effects were equivalent in all interval groups and included only expected short-term erythema, edema, purpura, and mild postinflammatory hyperpigmentation. No patient developed hypopigmentation, scarring, or infection. All interval groups showed 50% to 100% clearance of their PWS after 5 treatments. Complete or near-complete clearance was seen in 6 of 8 (75%) and 7 of 8 (87.5%) patients in the 2- and 3-week interval groups, respectively, as compared with 3 of 8 (37.5%) patients in the 4-week interval group.

LIMITATIONS

This was a retrospective chart review from a single institution. Long-term side effects and recurrence rates were not assessed.

CONCLUSION

We conclude that PDL treatments at 2-, 3-, and 4-week intervals are effective for the management of facial PWS in infants with minimal short-term side effects. Shorter treatment intervals may allow for relatively more rapid and more effective treatment.

Do lasers or topicals really work for nonmelanoma skin cancers?

Novel strategies are urgently needed to address the millions of nonmelanoma skin cancers treated in the United States annually. The need is greatest for those patients who are poor surgical candidates or those prone to numerous nonmelanoma skin cancers and therefore at risk for marked disfigurement. Traditional treatment strategies include electrosurgery with curettage, radiation therapy, cryotherapy, excision, and Mohs micrographic surgery. Alternatives to traditional treatment, including topical medications and light or laser therapies, are becoming popular; however, there are various degrees of efficacy among these alternative tactics. These alternatives include topical retinoids, peels, 5-fluorouracil, imiquimod, photodynamic therapy, and lasers. The purpose of this paper is to review the available data regarding these alternative strategies and permit the reader to have a sense of which therapies are reasonable options for care.

Glomuvenous Malformations (Familial generalized multiple glomangiomas)

A 15-year-old boy with a diagnosis of generalized multiple glomangiomas was referred for evaluation and treatment of enlarging and increasingly painful lesions on his right ankle. The patient underwent a series of two treatments with long-pulsed KTP 1064 nm laser that resulted in substantial improvement in appearance and decreased pain. Generalized glomuvenous malformations, or multiple glomangiomas, are the less common presentation of proliferation of glomus cells and may have extracutaneous involvement. Whereas surgical management is often employed and definitive for solitary lesions, interventions such as laser therapy, may be beneficial for improvement of functional impairment and cosmesis as was observed in our patient.

Delayed and recurring blisters in the donor graft site of a burn patient

A 79-year-old woman presented for evaluation of non-healing skin graft donor sites. The patient underwent split thickness skin graft repair two-and-a-half years ago as a consequence of severe burns from a fire that affected 10 to 15 percent of her body. Donor sites included her thighs and flanks. After initial healing, intermittent and paroxysmal, eroded and crusted, erythematous plaques have continued to arise at various donor sites. Normal skin has remained uninvolved. Histopathologic analysis showed a poor basement membrane zone. The patient's findings represented delayed and recurring blistering in the donor graft site that is uncommonly observed in burn patients.

Alkaptonuria

A 69-year-old woman presented with a 30-year history of lower back and large joint pain of the hips and shoulders. On examination blue-grey, pigmented macules were present over the cartilaginous portions of the ears and on the sclera. Past medical history included aortic stenosis. Urine homogentisic acid level was elevated, which is diagnostic for alkaptonuria. Alkaptonuria is an autosomal recessive disorder that results in deficiency of homogentisic acid oxidase and in the accumulation of homogentisic acid in connective tissue. Disease can result in blue-grey pigmentation of the cartilage, sclerae, face, and hands as well as severe arthropathy and cardiac valve disease. Treatment is limited at this time. Promising early reports of the use of nitisinone have prompted ongoing trials of this therapeutic agent.

Sarcoidal tattoo granuloma

A 41-year-old man presented for evaluation of a widespread eruption. The eruption started six months beforehand as bumps within pre-existing black tattoos over his trunk and arms. One month later, the patient developed eye pain and the diagnosis of a uveitis was made. A different eruption soon followed, which the patient described as patches of rough skin. Finally, the patient developed discrete patches of hair thinning. The clinical examination, history, skin biopsy findings, and elevated angiotensin-1 converting enzyme and immunoglobulin levels supported the diagnosis of systemic sarcoidosis, which manifested as a sarcoidal tattoo granuloma, perifollicular cutaneous sarcoidosis, and uveitis.

Fluticasone furoate nasal spray: Profile of an enhanced-affinity corticosteroid in treatment of seasonal allergic rhinitis

Of the classes of pharmacotherapy for seasonal allergic rhinitis, intranasal corticosteroids are the preferred treatment and are recommended in practice guidelines as first-line pharmacotherapy for rhinitis with prominent nasal congestion. The enhanced-affinity intranasal corticosteroid fluticasone furoate nasal spray (GW685698X), is one of the newest additions to the armamentarium for allergic rhinitis. This review summarizes the preclinical and clinical data on fluticasone furoate nasal spray and discusses its place in pharmacotherapy for seasonal allergic rhinitis. Important attributes of fluticasone furoate in seasonal allergic rhinitis include low systemic bioavailability (<0.5%), onset of symptom relief as early as eight hours after initiation of treatment, 24-hour symptom relief with once-daily dosing, comprehensive coverage of both nasal and ocular symptoms, safety and tolerability with daily use, and availability in a side-actuated device that makes medication delivery simple and consistent. With these attributes, fluticasone furoate nasal spray has the potential to enhance patient satisfaction and compliance and reduce the need for polypharmacy in the management of seasonal allergic rhinitis.

Radiofrequency devices for body shaping: a review and study of 12 patients

Radiofrequency (RF) devices such as ThermaCool TC (Solta Medical Inc., Hayward, CA) offer a nonablative and noninvasive treatment option for unwanted skin concerns of the head, neck, and body. Relatively fewer studies address RF treatment on the body when compared with the head and neck. The purpose of this report is to investigate the use of the ThermaCool TC system with the novel Thermage Multiplex Tip for the enhancement of body shape. Additionally, this report will review the literature of RF technology with a concentration on body shaping. Twelve subjects underwent ThermaCool TC treatments using the Thermage Multiplex Tip. Waist circumference, standardized photographs, skin laxity score, global aesthetic improvement score, and patient satisfaction surveys were assessed at baseline and several follow-up visits after treatment. Average waist circumference and skin laxity scores decreased after ThermaCool TC treatment, using the Thermage Multiplex Tip at follow-up visits held at 1, 2, 4, and 6 months after treatment. Global aesthetic improvement score and patient satisfaction surveys reflected these objective clinical improvements. RF devices, such as the ThermaCool TC offer a nonablative and noninvasive treatment option for unwanted skin findings of the head, neck, and body.

Hyperimmunoglobulin E syndrome with a novel STAT3 mutation

A 35-year-old man with severe eczematous dermatitis and recurrent staphylococcal skin infections, some of which required hospitalization, is presented. Other medical concerns include recurrent oral staphylococcal infections, otitis media, ocular herpes simplex virus keratitis, asthma, steroid-induced gastritis, steroid-induced cataracts, recurrent upper respiratory infections, and acute pharyngitis. Past medical history includes retained dentition of six primary teeth, two episodes of childhood pneumonia that required hospitalization, and three wrist and ankle fractures. Laboratory data showed an eosinophil count of 2,400 cells/ml; the highest IgE level was 17,028 IU/mL. Considering the clinical and laboratory findings, the diagnosis of hyperimmunoglobulin E syndrome was made. DNA sequencing showed a novel signal transducer and activator of transcription 3 (STAT3) gene mutation within intron 12, specifically adenine to cytosine, two base pairs upstream of exon 13.

Mometasone furoate improves nasal and ocular symptoms of seasonal allergic rhinitis in adolescents

Seasonal allergic rhinitis (SAR) is common in adolescents. However, few studies have investigated the effectiveness of intranasal corticosteroids (INSs) for nasal and ocular symptoms of SAR solely in adolescents. The purpose of this study was to determine the safety and efficacy of the INS mometasone furoate nasal spray (MFNS) in adolescents; a post hoc analysis was conducted of adolescents who had participated in a study with adults. Data were analyzed retrospectively for subjects aged 12-17 years with moderate or severe SAR randomized to mometasone furoate, 200 mcg once daily (n = 86), or placebo (n = 82) for 15 days in a multicenter, double-blind, placebo-controlled study. Symptom scores (0 = none to 3 = severe) were recorded in diaries twice daily. End points included changes from baseline in total nasal symptom score (TNSS), individual nasal symptom score (rhinorrhea, congestion, itching, and sneezing), and total ocular symptom score (TOSS). Over 15 days, a significantly greater decrease from baseline in mean TNSS was observed in subjects receiving mometasone furoate (-2.47; -28.8%) compared with those receiving placebo (-0.9; -9.6%; p < 0.001). Significant improvement versus placebo was seen for each full day of treatment. Mometasone furoate significantly improved individual nasal symptoms (p < or = 0.03) and TOSS (p = 0.011) versus placebo. The incidence of adverse events was similar for both treatment groups. MFNS, 200 mcg once daily, is an effective and well-tolerated treatment for symptoms of SAR in adolescents.

Efficacy and safety of fixed-dose loratadine/montelukast in seasonal allergic rhinitis: effects on nasal congestion

A need exists for safe, effective therapy for the relief of the symptoms of allergic rhinitis (AR) that also consistently relieves nasal congestion, the most common and bothersome symptom. This study was performed to assess efficacy and safety of a once-daily tablet containing 10 mg of loratadine, an antihistamine, and 10 mg of montelukast, a leukotriene antagonist (SCH 445761) versus placebo and pseudoephedrine (PSE; 240 mg once-daily formulation; active comparator). In a multicenter, parallel-group, double-blind, double-dummy, randomized study, 1095 subjects with documented history of seasonal AR and positive skin-prick test to a prevailing aeroallergen were treated for 15 days with fixed-dose combination loratadine/montelukast (L/M), PSE, or placebo. After randomization, subjects rated severity of nasal congestion and measured peak nasal inspiratory flow (PNIF) rate in the morning and evening. The change in quality of life from baseline was also assessed. L/M and PSE were significantly more effective than placebo in alleviating nighttime and daytime nasal congestion and improving PNIF rate, an objective measure of nasal obstruction. There were no significant differences between L/M and PSE for any efficacy analysis including improvement in the quality of life. Subjects treated with L/M experienced a similar incidence of total adverse events versus placebo and a lower incidence of total adverse events (including dizziness, insomnia, jitteriness, nausea, and dry mouth) versus PSE. Nasal decongestant activity of L/M was significantly higher than that of placebo and similar to that of PSE in symptomatic AR subjects. L/M showed a safety profile similar to placebo and was better tolerated than PSE. Thus, L/M offers a safe and efficacious alternative to PSE for the treatment of nasal congestion associated with AR.

Efficacy and safety of desloratadine/pseudoephedrine combination vs its components in seasonal allergic rhinitis

BACKGROUND

Antihistamines are first-line therapy for the treatment of seasonal allergic rhinitis (AR); however, an oral decongestant is often added to improve control of nasal congestion.

OBJECTIVE

To examine whether a tablet combining the nonsedating antihistamine desloratadine and the decongestant pseudoephedrine was more effective than either drug administered alone in reducing the symptoms of seasonal AR, including nasal congestion.

PATIENTS AND METHODS

In this multicenter, double-blind study, participants (N = 598) with symptomatic seasonal AR were administered either a combination tablet of desloratadine 2.5 mg/pseudoephedrine 120 mg (DL/PSE) bid, a desloratadine 5.0 mg qd and a placebo tablet, or pseudoephedrine 120 mg bid. Participants assessed their symptom severity twice daily over the 2-week treatment period.

RESULTS

The primary variable to assess the effects of the antihistamine component--mean change from baseline in average AM/PM reflective total symptom score (TSS), excluding nasal congestion--was significantly greater (-6.54) for DL/PSE than for desloratadine (-5.09) or pseudoephedrine (-5.07) monotherapy (P < .001 for both). The primary variable to assess the effects of the decongestant component--mean change from baseline in average AM/PM reflective nasal congestion score--was also significantly greater (-0.93) for DL/PSE than for desloratadine (-0.66) or pseudoephedrine (-0.75) (P < .001 vs desloratadine; P = .006 vs pseudoephedrine).

CONCLUSION

This study demonstrated that DL/PSE therapy was more effective in reducing symptoms of seasonal AR, including nasal congestion, than the individual components when administered alone, thus supporting use of this combination in participants with symptomatic seasonal AR and prominent nasal congestion.

Proliferating trichilemmal cyst with focal calcification

A 64-year-old man presented with a superficial, well-demarcated, skin-colored tumor on the left posterior scalp that measured 4 x 5 x 6 cm. The tumor was nearly hairless, rubbery, non-tender, and mobile over the underlying subcutaneous tissues. The lesion had grown slowly since arising approximately 30 years ago. Treatment options were declined in the past. However, with relatively more rapid growth over the past five years, the nodule began to cause intermittent pain and interfere with the patient's ability to lie on his back. The patient denied a history of similar lesions in himself or his family. A biopsy specimen showed a ruptured proliferating trichilemmal cyst with focal calcification. Complete excision is recommended for all benign proliferating variants owing to their potential for locally aggressive behavior and malignant transformation.

Invasive squamous-cell carcinoma and arsenical keratoses

A 42-year-old man presented with a six-month history of a slowly-enlarging ulcer on his right sole, a 30-year history of altered pigmentation of the trunk and extremities, and hyperkeratotic papules of the palms and soles. Histopathologic examination showed an invasive squamous-cell carcinoma of the right sole and hyperkeratosis with keratinocyte atypia of the left finger and left lateral foot. The clinical and histopathologic findings are consistent with chronic arsenicism, which most commonly occurs in the setting of drinking contaminated water or after occupational exposure. Evaluation should include a physical examination, basic laboratory work-up, and measurement of a 24-hour urine arsenic concentration. Vigilant surveillance for the development of cutaneous malignancies is required. Oral retinoids may be helpful in reducing hyperkeratosis secondary to chronic arsenicism.

Extramammary Paget disease

A 59-year-old man presented with a well-demarcated, tender ulcer at the base of the penile shaft that had been present for approximately five years. The ulcer had been responsive neither to topical antibacterials, antifungals, and glucocorticoids nor to oral acyclovir. A biopsy specimen showed an intra-epidermal neoplasm consistent with extramammary Paget disease (EMPD) based on light microscopy and immunohistochemistry. Patients with EMPD require extensive medical evaluation because of its association with adnexal carcinoma and visceral malignant conditions. Evaluation should include a full body skin and lymph node examination, colonscopy, cystoscopy, and sex-specific studies including pelvic and breast examinations, with imaging for women and prostate examination with prostate specific antigen levels for men. Close monitoring after treatment is important because of the recognized risk of recurrence and malignant conditions.

Intranasal mometasone furoate alleviates the ocular symptoms associated with seasonal allergic rhinitis: results of a post hoc analysis

BACKGROUND

Burdensome symptoms of allergic rhinitis (AR) include nasal and ocular symptoms such as itching, tearing and redness. Intranasal corticosteroids are efficacious in the treatment of nasal symptoms of AR.

OBJECTIVE

It was the aim of this study to determine the efficacy of the intranasal corticosteroid mometasone furoate nasal spray (MFNS) in relieving ocular symptoms associated with seasonal AR (SAR).

METHODS

Ocular symptom data were analyzed for subjects >or=12 years of age, randomized to MFNS 200 mug q.d. (n = 176) or placebo (n = 177) in a placebo-controlled, double-blind clinical trial. Post hoc efficacy analysis assessed the mean change from baseline in subject-reported total ocular symptom scores (TOSS) averaged over the treatment period.

RESULTS

Mean baseline TOSS was 4.91 for the MFNS group and comparable (5.05) for the placebo group - combined average for individual symptoms such as itching, tearing and redness ranged from 0 (no symptoms) to 9 (all symptoms, severe). Mean change from baseline in TOSS averaged over days 1-15 was -1.42 for the MFNS group and -0.94 for the placebo group (p = 0.02), for an observed treatment difference of 0.49 (statistical data rounded to 2 decimal positions). Improvement in individual symptoms (eye itching, tearing and redness) contributed to this treatment effect; the greatest improvement occurred with tearing, which decreased -0.52 from the baseline score 1.59 in the MFNS group and -0.31 from 1.67 in those receiving placebo (p < 0.01), for an observed treatment difference of 0.21. Treatment with MFNS was safe and well tolerated.

CONCLUSION

MFNS is effective in reducing ocular symptoms of SAR, in addition to its established efficacy in reducing nasal symptoms of SAR.

Clinical benefits of combination treatment with mometasone furoate nasal spray and loratadine vs monotherapy with mometasone furoate in the treatment of seasonal allergic rhinitis

BACKGROUND

Intranasal corticosteroids and nonsedating antihistamines are the drug classes most often prescribed to treat allergic rhinitis (AR). Treatment guidelines recommend a combination of these agents for moderate-to-severe AR. However, clinical studies have found that combining an antihistamine with an intranasal corticosteroid provides few or no advantages over monotherapy with an intranasal corticosteroid.

OBJECTIVE

To compare the efficacy of mometasone furoate nasal spray (NS) plus loratadine with that of monotherapy with the individual agents in patients 12 years and older with at least a 2-year history of seasonal AR.

METHODS

In a multicenter, randomized, double-blind, parallel-group, placebo-controlled clinical study, 702 patients were randomized to receive mometasone furoate NS, 200 microg, plus loratadine, 10 mg (n = 169); mometasone furoate NS, 200 microg (n = 176); loratadine, 10 mg (n = 181); or placebo (n = 176) once daily for 15 days. Primary efficacy variables were total nasal symptom score (TNSS) and total symptom score (TSS) as recorded on diary cards.

RESULTS

No statistically significant differences were observed between mometasone furoate NS plus loratadine and mometasone furoate NS monotherapy for the primary efficacy variables. For TNSS and TSS, all 3 active drug therapies were more effective than placebo (P < or = .02). Both mometasone furoate NS treatment regimens were more effective than loratadine or placebo for TNSS (P < .01 for both) and TSS (P < or = .03 for both), whereas loratadine was more effective than placebo for TNSS only (P = .02).

CONCLUSIONS

Combination therapy with mometasone furoate NS and loratadine provided benefits similar to monotherapy with mometasone furoate NS for the symptoms of seasonal AR. Therefore, mometasone furoate NS monotherapy was shown to be an effective treatment for seasonal AR.

One-year trial on safety and normal linear growth with flunisolide HFA in children with asthma

Flunisolide hydrofluoroalkane (HFA) has efficacy equivalent to that of flunisolide chlorofluorocarbon (CFC) at one third the dose of the CFC formulation, a reduction from 250 microg/puff for flunisolide CFC to 85 microg/puff for flunisolide HFA. Flunisolide HFA delivers a smaller particle size (1.2 microm) in solution, resulting in improved lung deposition as compared with flunisolide CFC (3.8 microm), which is delivered in suspension. An added built-in spacer has reduced oropharyngeal deposition that may result in fewer adverse events and make it easier to use. The objective of this study was to compare the year-long safety of flunisolide HFA (daily dosage 340 microg) with that of CFC beclomethasone dipropionate (BDP) (daily dosage 336 microg) and cromolyn sodium (daily dosage 6,400 microg) in children 4-11 years old with mild-to-moderate asthma. The effects of these drugs on linear growth and growth velocity were also compared. The study was a 1-year open-label, parallel-group trial. Changes in physical examinations (including growth), adverse events, vital signs, electrocardiograms, cosyntropin stimulation tests, mouth and throat cultures for Candida albicans, and laboratory findings were analyzed. Patients 4-5 years old received flunisolide HFA only. In total, 235 children were evaluated (152 receiving flunisolide HFA, 39 BDP, and 44 cromolyn). The incidence of adverse events was comparable among treatment groups; most were mild or moderate and considered unrelated to treatment. Among patients 6-11 years old, mean changes from baseline height at week 52 were 6.2 cm for the flunisolide HFA and cromolyn groups and 5.1 cm for the BDP group. Thus growth in children receiving flunisolide HFA was unaffected by 1 year of treatment. Changes from baseline in other parameters, including response to cosyntropin stimulation, were insignificant and similar among the 3 treatment groups. At the dosages studied, and following 1 year of treatment, flunisolide HFA with its small particle size and built-in spacer is safe and well tolerated in children 4-11 years old. There are no adverse effects associated with hypothalamic pituitary axis (HPA) function of flunisolide HFA, including linear growth in children 6-11 years old when compared with BDP and cromolyn sodium.

A dose-ranging study of mometasone furoate aqueous nasal spray in children with seasonal allergic rhinitis

BACKGROUND

The efficacy and safety of mometasone furoate aqueous nasal spray (MFNS; Nasonex) 200 microg once daily for the treatment and prophylaxis of seasonal allergic rhinitis (SAR) and treatment of perennial rhinitis have been demonstrated in adults. However, the dose response of MFNS in pediatric patients has not yet been characterized.

OBJECTIVE

This study was conducted to determine the dose-response relationship of 3 different doses of MFNS in a pediatric population.

METHODS

This was a multicenter, double-blind, active- and placebo-controlled study of 679 children 6 to 11 years of age with histories of SAR and documented positive skin test responses. Patients were randomized to one of the following treatment groups for 4 weeks: MFNS 25 microgram once daily, MFNS 100 microgram once daily, MFNS 200 microgram once daily, beclomethasone dipropionate 84 microgram twice daily (168 microgram/day), or placebo. Physician evaluations were performed at days 4, 8, 15, and 29, and patient evaluations were analyzed for days 1 to 15 and 16 to 29.

RESULTS

The mean reduction from baseline in physician-evaluated total nasal symptom scores at day 8 (the primary efficacy variable) was significantly greater in the MFNS and beclomethasone dipropionate groups than in the placebo group (P </=.02). No significant differences were observed among the 3 MFNS groups. However, as treatment continued, symptoms in patients treated with MFNS 100 or 200 microgram once daily continued to improve, whereas those treated with MFNS 25 microgram once daily demonstrated little further improvement. By day 29, MFNS 100 and 200 microgram once daily both were significantly more effective than MFNS 25 microgram once daily in relieving symptoms of SAR, but MFNS 200 microgram provided no additional benefit over MFNS 100 microgram. All doses of MFNS were well tolerated, and cosyntropin stimulation tests performed before and after treatment found no evidence of hypothalamic-pituitary-adrenal axis suppression.

CONCLUSION

These results indicate that the most appropriate therapeutic dosage of MFNS in the treatment of SAR in children 6 to 11 years of age is 100 microgram once daily. In addition, MFNS at doses up to 200 microgram once daily for 4 weeks was well tolerated and had no detectable effects on hypothalamic-pituitary-adrenal axis function.