Recent Developments

Tattoo Removal by Non-Physicians Poses Dangers
A new literature review examining the potential risks and pitfalls of laser tattoo removal when performed by non-physicians has identified four major areas of risk (Journal of the European Academy of Dermatology 24(7): 756-762). They are rare but potentially severe allergic or toxic effects of decomposition products of the tattoo pigments; bodily harm caused by out-of-specification usage of the laser devices; malignant disease that is obscured within the area of a tattoo and requires meticulous dermatological diagnosis; and insufficient pre-operative consultation of patients about the risks, side effects, and realistic expectations on the therapeutic outcome. Thus, the researchers conclude that laser tattoo removal by non-medical professionals is unacceptable from the standpoint of patient safety and suggest that lawsshould be in place to ban the practice.

Data Support Tretinoin for Pre-Adolescent Acne
Topical tretinoin 0.04% microsphere gel (TMG) pump appears to be safe and effective for pre-adolescent acne, according to a study in Pediatrics (125(6):e1316-23). The open-label study involved 40 patients eight to 12 years of age (with a mean age of 10.7 years) with mild/moderate acne, defined by the Evaluator's Global Severity Score (EGSS) values between 2 and 3. The patients were given 0.04% TMG for 12 weeks and were evaluated at baseline and weeks 3, 6, and 12.

By week 12, mean EGSS value had decreased significantly from baseline (2.6 vs 2.1; P < .001). At week 12, 75 percent of cases were graded as almost clear or mild. The mean Alternative Evaluator's Global Severity Score value declined from 3.1 to 2.4 during the 12-week period (P < .001). The mean Investigator's Global Evaluation score was 3.39 at week 12, demonstrating moderate improvement of acne. Treatment was generally well tolerated.

Etanercept Safe for Pediatric Psoriasis
Etanercept provides “significant, sustained improvement in disease severity and is well tolerated tolerated in children eight years and younger with severe plaque psoriasis,” according to a retrospective analysis of previous data that was published in the European Journal of Dermatology (125(6):e1316- 23). The sub-analysis looked at patients aged eight to 17 years who received once-weekly subcutaneous etanercept 0.8mg/kg (≤50mg) or placebo in double-blind fashion for 12 weeks, followed by 24 weeks of open-label etanercept. At baseline, subjects, 95 of whom were randomized entanercept while 97 received placebo, had 10 percent body surface area and Psoriasis Area and Severity Index (PASI) 12.

Researchers found that at week 12, “54.7 percent of subjects receiving etanercept versus 11.3 percent receiving placebo achieved 75 percent or greater improvement in PASI (PASI 75) compared with baseline (P < 0.001). PASI 50, PASI 90, and static Physician Global Assessment of psoriasis followed a similar pattern (P < 0.001).” Efficacy was sustained through Week 36 during the open-label phase. Etanercept, marketed as Enbrel (Amgen/Pfizer), is approved for moderate to severe plaque psoriasis in individuals 18 years of age and older who are candidates for systemic therapy or phototherapy. Its lone pediatric indication is polyarticular Juvenile Idiopathic Arthritis in patients two and older.

Protective Creams Benefit Some ICD Patients
Treatments designed to prevent occupational irritant hand dermatitis (OIHD) appear to provide some benefit according to a recent Cochrane review (Schmitt, et al. The Cochrane Collaboration). Data came from four randomized controlled trials involving 894 subjects from different occupations. Although “generally positive,” results did not reach statistical significance, the authors say. They encourage additional large, well-designed trials to determine the benefit of barrier protection creams.

Negative Barrier Effects from TCIs?
New data suggest that topical calcineuron inhibitors may disrupt the epidermal permeability barrier and antimicrobial function (Journal of the European Academy of Dermatology, 24;(7)). Investigators examined the effects of TCI treatment for four days in hairless mice, finding that there were decreases in epidermal lipid content, lamellar body number and secretion, and lipid synthesisrelated enzymes such as 3-hydroxy-3-methylglutaryl- CoA reductase, serine-palmitoyl transferase and fatty acid synthase, implying decreased lipid synthesis. TCIs also suppressed expression of IL-1a and antimicrobial peptides. Given that TCIs can have negative effects on the skin barrier, the researchers suggest co-treatment with a physiologic lipid mixture, which helps to normalize barrier homeostasis.

Rapid-Fire Combo
Topical calcipotriol/betamethasone in combination with adalimumab may result in rapid early results, but brings little added benefit after the first four weeks of psoriasis treatment, according to the results of a new study published in the British Journal of Dermatology. Investigators conducted a 16-week, randomized, vehicle-controlled trial in patients with moderate to severe psoriasis and previous failure, intolerance, or contraindications to two or more systemic treatments. All patients receivbed adalimumab 80mg at week zero and 40mg every other week for 15 weeks, in addition to topical calcipotriol/betamethasone or drug-free vehicle applied once daily for four weeks and as needed thereafter. PASI 75 response was initially higher with the combination therapy as opposed to adalimumab monotherapy at weeks two (14.8 percent vs. 5.8 percent) and four (40.7 percent vs. 32.4 percent), but after week four the trend was toward a higher response with adalimumab monotherapy.

Data on Antibodies to Infliximab
Researchers recently shed light on the presence of antibodies to infliximab in psoriatic patients (The Journal of Dermatology, June 14 online). Fifteen patients with psoriasis were treated with infliximab (5mg/kg) every eight weeks after an initial three-dose induction regimen. Researchers used an enzyme linked immunosorbent assay kit for analyzing the presence of ATI in the sera, and found that five patients developed ATI. They suggested that monitoring for the induction of ATI and rescue strategies should be developed to avoid or to maintain a delay in ATI development.

More Evidence Suggests Tanning Addiction
Studies in recent years have indicated that those who tan indoors often exhibit traits of addiction. The newest publication to support this notion, published in Clinical and Experimental Dermatology (online June 7), found that a staggering 41 percent of individuals who were surveyed and tan regularly met criteria consistent with “tanning addictive disorder,” with an additional 33 percent meeting criteria for problematic tanning behavior.

Clarification
The June 2010 cover feature, “Mohs Micrographic Surgery: An Update for the Clinician” (vol. 7, no. 6), neglected to mention the American Society for Mohs Surgery (ASMS, www.mohssurgery.org), a professional society of board certified dermatologists who perform Mohs surgery. Most ASMS Fellows receive training in Mohs surgery during a three year Dermatology residency. ASMS Fellows may or may not have completed an extra year of fellowship training in Mohs surgery. The Society currently has 925 physician members.

The Society's stated mission is to improve physician performance and patient health through regular medical education courses with an emphasis on skin cancer, dermatologic surgery, and Mohs surgery. ASMS also provides political and professional advocacy for Mohs surgeons from a variety of Mohs training backgrounds, supports its members in the area of third-party reimbursement, professional credentialing, and other practice issues, and offers a range of ancillary products and services to assist members in establishing and maintaining their Mohs practices.