Zinc in dermatology

Zinc has numerous pharmacological uses in dermatology. Its antioxidant and immunomodulatory properties are thought to correlate with its efficacy in acne vulgaris and leishmaniasis, amongst other cutaneous conditions. We conducted a review of the literature on the use of zinc in dermatology; in particular, we investigated its role in acne vulgaris, hair loss, hidradenitis suppurativa, leishmaniasis, and warts. We searched MEDLINE selecting only articles in English and evaluating the evidence using the Oxford Center of Evidence-Based Medicine 2011 guidance. This review has found evidence to support the use of zinc in patients in infectious conditions (leishmaniasis and warts), inflammatory conditions (acne rosacea, hidradenitis suppurativa) and in hair loss disorders.Ppatients with zinc deficiency should also receive oral supplementation. Further research and large randomized controlled trials are required to investigate the role of zinc as a monotherapy.

Rosacea and Diet: What is New in 2021?

OBJECTIVE

Rosacea is a common inflammatory cutaneous condition with a complex yet unknown etiopathogenesis. Diet and certain food items are known to trigger or worsen rosacea symptoms, but conflicting and often inconsistent advice is given to patients regarding this link. We provide an up-to-date literature review on the relationship between rosacea and diet.

METHODS

Using the keywords "alcohol," "diet," "flushing," "food," "inflammation," "rosacea," "skin-gut axis" and "spice" we systemically searched the databases PubMed, MEDLINE and EMBASE for English-language articles in July 2020.

RESULTS

The most frequently reported triggers implicated in rosacea include alcohol, spicy food, cinnamaldehyde-containing foods (e.g., tomatoes, citrus fruits, chocolate), hot drinks, and histamine-rich foods (e.g., aged cheese, wine, processed meats). Some food items appear to play a protective role, such as omega-3, which appears to protect against ocular rosacea. The relationship between certain food items and the subtype of rosacea is varied, with inconsistent results shown in the few studies that examined this. As an example, alcohol worsens flushing and fatty food triggers both erythematotelangiectatatic and phymatous rosacea in susceptible individuals.

CONCLUSION

While several food types appear to be associated with exacerbation of rosacea, there are no recommendations that can be applied to all patients. Further studies are needed to examine the exact link between diet and rosacea subtypes.

Hyaluronidase in Dermatology: Uses Beyond Hyaluronic Acid Fillers

Hyaluronidase is mostly widely recognized for its off-label use in correction of complications of hyaluronic acid fillers. However, its utility in other aspects of dermatology is less widely acknowledged. We describe the varied uses of hyaluronidase in dermatology and the underlying evidence base for its dermatological indications. This includes its uses in enhancing drug delivery (for local anesthesia, keloid and hypertrophic scars, and for Kaposi’s sarcoma), in the treatment of disorders associated with mucin deposition (myxedema, scleroderma, scleredema, and cutis verticis gyrata) and its potential uses in surgery (as a pre-operative adjuvant in dermatofibrosarcoma protuberans, for periorbital edema, and for hematomas). In select circumstances, hyaluronidase might be more efficacious than more established treatments with fewer adverse effects. We propose hyaluronidase as the latest addition to our global dermatological armamentarium and implore dermatologists to consider its use to enhance their practice. J Drugs Dermatol. 2020;19(10):993-998. doi:10.36849/JDD.2020.5416.

Systemic photoprotection in 2021

Systemic photoprotection aims to negate the negative effects of ultraviolet radiation-induced DNA damage. Systemic supplements may be used as a monotherapy or in combination with topical sunscreens. Using the keywords 'carotenoids', 'flavonoids', 'systemic photoprotection', 'polyphenols' and 'polypodium leucotomos extract', we searched the databases MEDLINE and EMBASE to find relevant English-language articles. Few trials have supported the use of any of these supplements as monotherapy, impeding the recommendation of these systemic supplements as an alternative to sunscreen for photoprotection. Nicotinamide has exhibited clinically relevant benefits in reducing nonmelanoma skin cancers in trials and could be recommended as an adjunctive therapy for the most vulnerable indviduals. Further research is required, which needs to be of higher statistical power, using more clinically meaningful outcome measures with comparison to the current gold standard of care (topical photoprotection) to support the use of alternative therapies in clinical practice.

Tics in patients with encephalitis

BACKGROUND

Movement disorders have been described in the context of different types of encephalitis. Among hyperkinetic manifestations, tics have sporadically been reported in cases of encephalitis resulting from a range of aetiologies.

OBJECTIVE

This review aimed to assess the prevalence and characteristics of tics in patients with encephalitis.

METHODS

We conducted a systematic literature review of original studies on the major scientific databases, according to the standards outlined in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

RESULTS

In addition to the established association between tics and encephalitis lethargica, our literature search identified reports of tics in patients with immune-mediated pathologies (including autoimmune encephalitides affecting the N-methyl-D-aspartate receptor, voltage-gated potassium channels, and glycine receptors) and infective processes (ranging from relatively common viral pathogens, such as herpes simplex, to prions, as in Creutzfeldt-Jakob disease). Tics were most commonly reported in the post-encephalitic period and involvement of the basal ganglia was frequently observed.

DISCUSSION

The association of new-onset tics and encephalitis, in the background of other neuropsychiatric abnormalities, has practical implications, potentially improving the detection of encephalitis based on clinical features. Future research should focus on the categorisation and treatment of hyperkinetic movement disorders associated with encephalitis.

Perioral dermatitis: diagnosis, proposed etiologies and management

Perioral dermatitis is a common cutaneous condition characterized by acneiform facial eruptions often with an eczematous appearance. A granulomatous subtype exists in addition to the classic variant. Whilst topical corticosteroids have been largely implicated in this condition, its etiology is not completely understood. Using the keywords "corticosteroids," "dermatology," "fusobacteria," "perioral dermatitis", and "periorificial dermatitis" we searched the databases PubMed, MEDLINE and EMBASE to find the relevant literature. Only articles in English were chosen. The level of evidence was evaluated and selected according to the highest level working our way downwards using the Oxford Centre of Evidence-Based Medicine 2011 guidance. This systematic review found the strongest evidence to support topical corticosteroid misuse as the principal causative factor in the pathogenesis of perioral dermatitis. In terms of treatment, further research is required to robustly investigate promising treatment options including tetracyclines, topical metronidazole, topical azelaic acid, adapalene gel and oral isotretinoin.

Rosacea

Rosacea is a common cutaneous condition affecting predominantly the face. It is historically characterised into four subtypes: erythematotelangiectatic, papulopustular, phymatous and ocular rosacea. This article describes the pathophysiology, clinical features and current treatment options for rosacea, and discusses updated diagnostic criteria. General guidance is required on the need to avoid possible triggers including dietary and environmental triggers. The strongest evidence supports the use of 0.75% metronidazole, topical azelaic acid or topical ivermectin for inflammatory rosacea. Erythema should be treated with brimonidine tartrate gel, oral medication such as beta blockers or vascular laser and light-based therapy. Oral doxycycline 40 mg modified release can be used as monotherapy or in combination with other treatments for recalcitrant disease. Further understanding of the pathogenesis of rosacea could allow identification and targeted avoidance of triggers and the development of new treatment modalities.

Dapsone for acne: Still in use after half a century!

BACKGROUND

Sixty years ago, Ross discussed the use of oral dapsone in the treatment of acne vulgaris. Ross was fundamental in demonstrating the importance of this medication in dermatology. Following this, topical formulations have been used for the treatment of acne vulgaris which has not responded to traditional therapies. We explore the impact that the discovery of dapsone has had on subsequent research and clinical practice and explore the typical doses and side effects of this often sidelined therapy.

METHODS

We conducted a review of the literature on the use of dapsone for acne using key terms "acne vulgaris," "dapsone," "isotretinoin," "systemic," "topical" searching databases such as MEDLINE, EMBASE, and PubMed. Only articles in English were chosen. The level of evidence was evaluated and selected accordingly listing the studies with the highest level of evidence first using the Oxford Centre of Evidence-Based Medicine 2011 guidance.

RESULTS

Oral dapsone and topical dapsone have been used in acne vulgaris and acne fulminans. Systemic dapsone seems to be less effective than other treatment options, and further research is required to examine the use of the topical formulation for acne vulgaris compared with alternative treatments.

CONCLUSION

Dermatologists may wish to consider the use of this long-established medication for the treatment of acne vulgaris. With careful monitoring, oral dapsone is an important alternative therapy where isotretinoin is contraindicated or not tolerated.

Lessons Learned from the First Decade of Laser-Assisted Drug Delivery

Laser-assisted drug delivery augments the distribution and penetration of topically applied treatments, leading to enhanced delivery and bioavailability. We discuss the therapeutic application of laser-assisted drug delivery in clinical practice in cases of non-melanoma skin cancer, vitiligo, melasma, scarring, and alopecia (female pattern hair loss, male pattern hair loss, alopecia areata) as well as for vaccination, local anaesthesia, analgesia, viral warts, infantile haemangiomas and cosmetic uses, and we review clinical studies that have used this technique over the last decade. Our review shows that the application of laser-assisted drug delivery enhances topical agent efficacy, potentially reducing the agent concentration and duration of topical treatment required. Future research into the use of laser-assisted drug delivery before topical therapies is needed to establish the optimal techniques to enhance drug delivery and thus improve patient outcomes.

Vitiligo: an update on systemic treatments

Vitiligo is an autoimmune skin condition characterized by depigmented macules and patches, and has a huge psychosocial impact on patients. Treatment of vitiligo aims to prevent the spread of disease and facilitate repigmentation of affected lesions. The mainstay of treatment for unstable vitiligo has been topical agents (corticosteroids, calcineurin inhibitors) and phototherapy. However, systemic treatments are increasingly being shown to have a significant impact on the course of the disease as monotherapy or adjunctive therapy. Of note, oral mini-pulsed corticosteroid therapy, methotrexate, minocycline, ciclosporin, Janus kinase inhibitors and certain supplements have been used in the systemic treatment of vitiligo. We review the underlying evidence supporting the use of each of these systemic treatments.

Hydroquinone: myths and reality

Hydroquinone has pharmacological uses in disorders of pigmentation because of its ability to competitively inhibit the enzyme tyrosinase. Our contemporary review presents the strongest evidence supporting the use of hydroquinone with the most effective and tolerable formulations combining hydroquinone, retinoid and corticosteroid (modified Kligman formula or 'triple combination cream'). The risk of exogenous ochronosis is low if prescribed concentrations of ≤ 5 for a limited period with regular monitoring. Dermatologists should reassure patients that with controlled use, hydroquinone can be well-tolerated and safe for a range of hyperpigmentary conditions.

Sensory symptoms in body-focused repetitive behaviors, restless legs syndrome, and Tourette syndrome: An overlap?

Tourette syndrome (TS) is a neurodevelopmental condition characterized by multiple tics. Sensory symptoms play a key role in the clinical phenomenology and pathophysiology of TS, as most patients report premonitory urges driving tic expression. Interestingly, sensory symptoms have also been reported in other conditions characterized by repeated behaviors. This review explores the nature of sensory symptoms reported by patients with body focused repetitive behaviors (BFRBs, especially trichotillomania and skin picking disorder) and restless legs syndrome (RLS) in comparison to TS. A sense of mounting inner tension and reinforcement mechanisms driven by gratification and relief on expression of the tic or repetitive behavior appear to be implicated across all conditions. Subjective urges can be temporarily suppressed by patients with TS and selected BFRBs, whereas patients with RLS tend to report dysesthesia more frequently than a suppressible urge to move. The observed similarities in the phenomenology of sensory symptoms across these conditions raise the possibility of a comparable underlying pathophysiology. Preliminary findings suggest an overlap of neural pathways encompassing the insula, basal ganglia (putamen), and posterior cingulate cortex.

Intralesional methotrexate in dermatology: Diverse indications and practical considerations

Intralesional methotrexate (IL-MTX) is a long-established treatment, which is arguably underutilized by dermatologists. We describe the underlying evidence base and practical considerations for its broad range of cutaneous indications, including in cutaneous oncology (keratoacanthomas, squamous cell carcinomas, lymphomas), inflammatory dermatology (nail psoriasis, plaque psoriasis, pyoderma gangrenosum, cutaneous Crohn's disease, amyloidosis), cutaneous infections (viral warts) and for treatment of filler complications. In certain circumstances, IL-MTX can be more efficacious and less invasive than other treatments, with fewer adverse effects. Dermatologists should consider using IL-MTX for a range of recalcitrant cutaneous conditions, particularly for those patients not amenable to surgery or systemic therapy.

Skin flap thickness and magnet strength in Cochlear implants

Objectives: The new CI600 series cochlear implants (Nucleus^® Profile™ Plus Series; CI) are more MRI (magnetic resonance imaging) compatible. The magnet's attraction force is lower, possibly posing a problem in patients needing a higher strength magnet due to increased skin thickness. This study aims to investigate the relationship between skin thickness and magnet strength in patients undergoing cochlear implantation. Methods: This cross-sectional study used data from 46 patients with cochlear implants. Data collected included age, body mass index, magnet strength used, pre-operative and post-operative imaging and skin thickness. Results: There was a weak, positive correlation between magnet strength and skin thickness, which was not statistically significant (r(46) = 0.149, p = 0.324). There was a weak, positive correlation between magnet strength and body mass index, which was not statistically significant (r(46) = 0.113, p = 0.456). There was a moderate, positive correlation between body mass index and skin thickness, which was statistically significant (r(46) = 0.362, p = 0.012). Discussion: The increased skin thickness in patients with higher body mass indexes, might mean that these patients will require a stronger magnet. Conclusion: There are concerns that the lower attraction force in the CI600 (Nucleus^® Profile™ Plus Series) may pose a retention problem for these patients. This might mean that discussions about skin flap reduction surgery are needed.

The top 10 cosmeceuticals for facial hyperpigmentation

Disorders of facial hyperpigmentation including melasma, postinflammatory hyperpigmentation and solar lentigines are common cutaneous conditions which can have a huge impact on patients' quality of life and often prove difficult to treat. The nascent market of cosmeceutical options provides a potentially safer and efficacious alternative for treating these challenging conditions. These can be used alone or in combination with other established treatments. Many cosmeceutical products are thought to work through inhibition of tyrosinase, a key enzyme of melanogenesis. We discuss the mode of action and provide an up-to-date review of the underlying evidence base for the top 10 cosmeceutical products for hyperpigmentation and melasma. Possible safer and more efficacious cosmeceutical therapies we discuss include thiamidol, kojic acid, vitamin C, arbutin, retinol, nicotinamide, ferulic acid, resorcinol, licorice root extract, and soy.

Surgical plume in dermatology: an insidious and often overlooked hazard

Dermatologists performing surgical procedures face occupational and health hazards when exposed to surgical plume released during electrosurgical and ablative laser procedures. These hazardous fumes have toxic, infectious and carcinogenic effects. Understanding this risk is of particular importance during the COVID-19 pandemic as the understanding of the transmissibility and infectious nature of the virus is still evolving rapidly. In this article, we present the hazards from laser and surgical plumes, and discuss possible preventative measures aimed at reducing these risks.

The versatility of azelaic acid in dermatology

Azelaic acid has numerous pharmacological uses in dermatology. Its anti-inflammatory and anti-oxidant properties are thought to correlate with its efficacy in papulopustular rosacea and acne vulgaris, amongst other cutaneous conditions. We conducted a review of the literature on the use of azelaic acid in dermatology using key terms 'acne', 'azelaic acid', 'dermatology', 'melasma', 'rosacea', searching databases such as MEDLINE, EMBASE and PubMed. Only articles in English were chosen. The level of evidence was evaluated and selected accordingly listing the studies with the highest level of evidence first using the Oxford Center of Evidence-Based Medicine 2011 guidance.This review found the strongest evidence supporting the use of azelaic acid in rosacea, followed by its use off-label in melasma followed by acne vulgaris. Weaker evidence is currently available to support the use of azelaic acid in several other conditions such as hidradenitis suppurativa, keratosis pilaris and male androgenic alopecia.Azelaic acid, as a monotherapy or in combination, could be an effective first-line or alternative treatment, which is well-tolerated and safe for a range of dermatological conditions.

The role of pharmacogenetics in keloid scar treatment: A literature review

BACKGROUND

The pathophysiology of keloid scars is still not fully understood and a universally reliable effective treatment has not been identified. Pharmacogenetics explores how drug response to a particular therapy can relate to genetic variations.

PURPOSE

To investigate how pharmacogenetics could be applied to keloid scars and the relevance of this to clinical practice.

METHODS

We reviewed the literature and discuss our current knowledge of pharmacogenomics in the treatment of keloid scars. A literature search was performed using the terms 'Pharmacogenetics', 'Pharmacogenomics', 'Keloid' and 'Scar'. We searched the PubMed, MEDLINE and EMBASE databases to find the relevant articles. Only articles in English were chosen. The level of evidence was evaluated and selected accordingly listing the studies with the highest level of evidence first.

RESULTS

Treatments including corticosteroid injections and 5-fluorouracil can be effective in some patients, but less so in others. Polymorphisms of the glucocorticoid receptor and variants of CCL2, YAP1, miR-21-5p and NF-κβ might be responsible for different responses to treatments used in keloid scars such as 5-fluorouracil. Small molecule inhibitors might be utilised to target other implicated genes.

CONCLUSION

Pharmacogenetics aims to produce the most efficacious patient outcomes while reducing adverse effects. Understanding the pharmacogenetics of keloid scars could lead to a new era of personalised medicine in the treatment of keloid scars. At present, there is some evidence (level 3b/4) to suggest genetic variations that are responsible to drug response in keloids, but further research in this field is required.

LAY SUMMARY

The varied response to similar therapeutic treatments in keloids has prompted the consideration of the role of genetic variants on response in the form of pharmacogenetics. Pharmacogenetics refers to drugs and their metabolism and action based on genetic influences. The ideal scenario would involve the selection of treatment based on the individual's specific genetic variants to ensure maximum efficacy with minimal toxicity. Some evidence currently points to genetic variations in some keloid patients that might be of relevance to the treating clinician.