#religion & #medicine - spiritual practice into health care (esp. in terminal disease).

After asking a patient if she would like to be prayed for, Caroline Petrie, a community nurse working in the United Kingdom, was suspended from her job.

Petrie faced disciplinary action and the possible loss of her job. At the time of the incident, she was told that she had to "demonstrate a personal and professional commitment to equality and diversity" and that she could not use her "professional status to promote causes that are not related to health."

Petrie insisted that she never tried to force her religious beliefs on any of her patients, but simply asked if the patient wanted her to pray for her.

Although she was reinstated, the incident highlights the "line in the sand" that is often drawn when it comes to mixing religion and medicine. The intersection between faith, science, and healing is still hazy for many practitioners, and some are uncomfortable bringing spiritual practice into the care paradigm. But in this era of increasingly holistic care, it has become clear that religious and spiritual beliefs and practices are important to many patients. This can be particularly pronounced in people facing a potentially terminal disease, such as cancer, where one's own mortality suddenly becomes very real.

Polls and surveys show that more than 90% of Americans believe in God or a universal spirit, but the spiritual needs of patients and their families are not always obvious to healthcare professionals, said Stephen King, PhD, manager of chaplaincy at the Seattle Cancer Care Alliance. Unfortunately, the spiritual needs of patients might not be addressed until the disease reaches an advanced stage, or might not be addressed at all. While chaplains have an important role, everyone involved in the patient's care has a role to play in addressing the spiritual needs of cancer patients.

Awareness Needed

Spirituality and religion are different concepts, although they often overlap. Aligning with a specific religion indicates adherence to certain beliefs and dogma, whereas spirituality has been described as an awareness of something greater than the individual self. People can express their spirituality through religion and prayer or through other paths of spiritual pursuit and expression.

The spiritual component of care is one that patients are asking for, noted Robert Klitzman, MD, professor of clinical psychiatry and director of the masters of bioethics program at Columbia University in New York City. It is extremely important to many patients with cancer and other chronic illnesses, and doctors need to be aware of that.

In the late-19th century, medicine distanced itself from what is now considered holistic treatment. Medicine wanted to become very scientific and rejected anything that wasn't scientific. But the reality is very different for the patient: someone experiencing cancer and possibly facing the end of life doesn't think of science as one thing and spiritual issues as something else — they are seen as one and the same.

#antioxidant #vitaminC - treatment & prevention against aging & sun damage.

SkinCeuticals was founded in 1997 by Dr Sheldon Pinnel, dermatologist, chemist, scientist and expert on skin care; he changed the concept of antioxidants with his pioneering research on pure vitamin C (L-ascorbic acid) for topical use, in high concentrations and serum texture. In addition to vitamin C, these serums associate other antioxidants, such as ferulic acid and vitamin E. They have a pleasant cosmetic and are quickly absorbed, leaving no oily or shiny skin. Ideal to be uses on the clean face in the morning before the sunscreen. 

SkinCeuticals antioxidant benefits: 

1. Protect the skin against free radicals formation induced by infrared and ultraviolet radiation (sun damage); 
2. Prevent fine lines and wrinkles; 
3. Stimulate the production of collagen, improving the firmness and elasticity of the skin; 
4. Unify skin tone. 

Start using your favorite as soon as possible! So you keep your skin young, healthy and prevent photoaging. And remember: sunscreen every day, rainy or sunny... It is our greatest ally!

#amphetamines #ecstasy #methamphetamines, dangerous synthetic drugs: risks for health and acute overdose.

Amphetamines are a class of compounds increasingly abused in regions of the world such as the western United States, Australasia, and Europe. Synthetic amphetamine compounds (ecstasy, metamphetamines) commonly are produced in clandestine laboratories and vary in purity and potency. Other potentials for amphetamine abuse include prescription medications and various over-the-counter diet pills.

Acute overdose of amphetamines produces seizures, hypertension, tachycardia, hyperthermia, psychosis, hallucinosis, stroke, and fatality.

One study at San Francisco General Hospital from 1975-1987 determined that approximately 25% of seizures were secondary to amphetamine use. In a few patients, amphetamine use produces long-term toxic paranoid schizophrenia: hallucinations, delusions, and bizarre violent behavior are common. Severe psychological depression and prolonged sleep follow chronic use and binges. 

Amphetamine use was associated with an increased risk of myocardial infarctions in 15-45 year olds in Texas.

In the United States, amphetamine use characteristically occurs among single white men aged 20-35 years who are typically unemployed. However, amphetamine use is becoming more common among women and other ethnic groups. Data from rural populations reveal that Caucasians use amphetamines significantly more than African Americans.

A recent study suggests that the action of estrogen within the central nervous system might explain why fewer women than men use amphetamines. Women in their late follicular phase (when estrogen levels are high and progesterone levels are low) were more likely to report "unpleasant stimulation" when exposed to amphetamine. This effect was not observed in the early follicular phase, when both hormone levels are low.

#vitaminD and #mortality

Vitamin D and Mortality -- Are They Linked?

Vitamin D, "the sunshine vitamin," is rarely out of the news nowadays, with reports of new studies contributing regularly to the ongoing debate about optimal levels of the hormone, indications for testing, and need for supplementation. Traditionally associated with skeletal disease including osteoporosis and fractures, low levels of serum 25-hydroxyvitamin D (25[OH]D), the metabolite usually measured as a mark of vitamin D status, more recently have been linked to a wide range of nonskeletal diseases, including some cancers and autoimmune, cardiometabolic, and neurologic diseases.

A number of studies also have reported an inverse association between vitamin D concentration and all-cause mortality. However, most of the evidence for (and against) this association has come from observational studies and has yet to be confirmed in clinical trials. Meta-analyses have almost all concluded that lower vitamin D levels are associated with a significantly increased mortality risk.

To explore this association more, Medscape reached out to Dr. Cedric Garland, a well-known expert on vitamin D. His research has focused on vitamin D status in health and the association between vitamin D deficiency and increased risk for disease, including some common cancers (breast cancer, colon cancer, leukemia, and melanoma) and diabetes. He is active in seeking to reduce the risk for cancer and diabetes by improving vitamin D status among the US population.

To examine the relation between serum vitamin D and mortality, Dr. Garland and colleagues at the University of California San Diego and others in the United States pooled data from 32 studies published between 1966 and 2013. They found an overall relative risk of 1.8 comparing the lowest (0-9 ng/mL) with the highest (>30 ng/mL) category of vitamin D for all-cause mortality. It means that individuals with low levels of vitamin D have a mortality rate 1.8x higher than those with normal levels (serum vitamin D concentrations ≤30 ng/mL were associated with higher all-cause mortality than concentrations >30 ng/mL).

The investigators noted that these findings confirmed observations from the Institute of Medicine (IOM) that vitamin D levels of <20 ng/mL are too low for safety, but they suggested a cut-off point of >30 ng/mL rather than >20 ng/mL for all-cause mortality reduction. This level could be achieved in most individuals by intake of 1000 IU per day of vitamin D3, noting that this is described as a safe dose in almost all adults by both the IOM and Endocrine Society clinical guidelines on dietary intake of vitamin D.

#publichealth - the risks of microwave radiation emitted by #wireless devices (scientific review).

The potential harm from microwave radiation (MWR) emitted by wireless devices, particularly for children and unborn babies, is the highlight of a new review. Although the data are conflicting, associations between MWR and cancer have been observed.

The review, by L. Lloyd Morgan, senior science fellow at Environmental Health Trust, and colleagues, was published online July 15 in the Journal of Microscopy and Ultrastructure. The authors reviewed the current literature showing that children face a higher health risk than adults. They evaluated peer-reviewed cell phone exposure epidemiology from 2009 to 2014, along with cell phone dosimetry data, government documents, manufacturers' manuals, and similar publications.

Children and unborn babies face the highest risk for neurologic and biologic damage that results from MWR emitted by wireless devices, according to Morgan and colleagues. The rate of absorption is higher in children than adults because their brain tissues are more absorbent, their skulls are thinner, and their relative size is smaller. The fetus is particularly vulnerable because MWR exposure can result in degeneration of the protective myelin sheath that surrounds brain neurons.

Multiple studies have shown that children absorb more MWR than adults. One found that that the brain tissue of children absorbed about 2 times more MWR than that of adults, and other studies have reported that the bone marrow of children absorbs 10 times more MWR than that of adults.

Belgium, France, India, and other technologically sophisticated governments are passing laws and/or issuing warnings about children's use of wireless device. Smartphone manufacturers specify the minimum distance from the body that their products must be kept so that legal limits for exposure to MWR are not exceeded. For laptop computers and tablets, the minimum distance from the body is 20 cm.

There is an erroneous assumption that tissue damage from overheating is the only potential danger of wireless devices. However, extensive scientific reports have documented nonthermal biologic effects from chronic (long-term) exposure. Although government warnings have been issued worldwide, most of the public is unaware of such warnings.

#smoking and the #skin

Smoking is a major problem particularly in young people. In the past years, increased smoking has been observed in young women. Smoking is responsible for at least a quarter of all deaths, because of cardiovascular diseases and lung cancer.

On the skin, smoking is responsible for the following changes:

1. Premature Aging: the skin becomes very wrinkled, thickened with a yellowish aspect. Sun exposure adds negative effects (solar elastosis).
2. Yellow discoloration of the tip of the fingers and nails.
3. Poor wound healing: this can be explained by a reduced synthesis of collagen and a reduced blood supply of nutrients and oxygen.

Some skin diseases are associated with smoking:

• Strong associations:

1. Palmoplantar pustulosis and palmoplantar psoriasis
2. Hidradentitis Suppurativa (Verneuil’s Disease)
3. Squamous Cell Carcinoma (SCC) of the lips and of the oral mucosa.
4. Genital Warts (Condyloma Accuminata) and Carcinoma of the Cervix.

• Possible associations:

1. Atopic Dermatitis (including the form through passive smoking from the parents).
2. Malignant Melanoma: smokers have a worse prognosis.
3. Lupus Erythematosus: smokers present worse responses to the treatment with antimalarials.

Moreover, topical medication containing alcohol base should never be prescribed to smokers as these are highly inflammable.

#insomnia #FDA - new approved medication. Font: FDA.

The U.S. Food and Drug Administration has just approved Belsomra (suvorexant) tablets for use as needed to treat difficulty in falling and staying asleep (insomnia).

Belsomra is an orexin receptor antagonist and is the first approved drug of this type. Orexins are chemicals that are involved in regulating the sleep-wake cycle and play a role in keeping people awake. Belsomra alters the signaling (action) of orexin in the brain.

Insomnia is a common condition in which a person has trouble falling or staying asleep. It can range from mild to severe, depending on how often it occurs and for how long. Insomnia can cause daytime sleepiness and lack of energy. It also can make a person feel anxious, depressed, or irritable. People with insomnia may have trouble with attentiveness, learning, and memory.

To assist health care professionals and patients in finding the best dose to treat each individual patient’s sleeplessness, the FDA has approved Belsomra in four different strengths – 5, 10, 15, and 20 milligrams. Using the lowest effective dose can reduce the risk of side effects, such as next-morning drowsiness.

Belsomra should be taken no more than once per night, within 30 minutes of going to bed, with at least seven hours remaining before the planned time of waking. The total dose should not exceed 20 mg once daily.

The most commonly reported adverse reaction reported by clinical trial participants taking Belsomra was drowsiness. Medications that treat insomnia can cause next-day drowsiness and impair driving and other activities that require alertness. People can be impaired even when they feel fully awake.

The effectiveness of Belsomra was studied in three clinical trials involving more than 500 participants. In the studies, patients taking the drug fell asleep faster and spent less time awake during the remainder of the night compared to people taking an inactive pill (placebo). Belsomra was not compared to other drugs approved to treat insomnia, so it is not known if there are differences in safety or effectiveness between Belsomra and other insomnia medications.

Like other sleep medicines, there is a risk from Belsomra of sleep-driving and other complex behaviors while not being fully awake, such as preparing and eating food, making phone calls, or having sex. Chances of such activity increase if a person has consumed alcohol or taken other medicines that make them sleepy. Patients or their families should call the prescribing health care professional if this type of activity occurs. Belsomra is a controlled substance (Schedule-IV) because it can be abused or lead to dependence. Belsomra is made by Merck, Sharpe & Dohme Corp. of Whitehouse Station, N.J.

#laser #tattoo removal treatment

Q-Switched Nd: YAG Laser

The Q-Switched Nd: YAG Laser is a type of laser developed to remove blue, brown, black and possibly other colours of tattoo pigments and certain brown pigment patches and birthmarks from the skin. Although laser sugery is effective in most cases, no guarantee can be made that a specific patient will benefit from the treatment.

Treatment is done in stages. Initially a test dose may be done to determine the energy settings of the laser. Once this dose is determined, the entire tattoo or pigmentation will be treated. The tattoo or pigmentation will be re-examined and re-treated if necessary in two months or longer intervals until either the entire pigment is removed. In some unpredictable cases, laser will not be efficient to remove the pigment.

The number of sessions varies depending on the lesion, size, location, colour, patient's age and duration of the tattoo. Most likely a total of 3-7 visits or more will be necessary.

Instructions for Skin Care after Q-Switched Nd: YAG Laser Treatment

1. Keep the treated area dry for 24 hours following the Q-Switched Nd: YAG Laser treatment.
2. Remove the dressing after 24 hours.
3. If it is difficult to remove the dressing, soak it in saline solution (salt water) to loosen.
4. Clean the wound and the edges with cotton balls with a cleansing solution.
5. Dry the wound carefully.
6. Apply antibiotic ointment with cotton applicators. 
7. Cover the wound with non-stick dressing (eg. Melolin). This will prevent the dressing from sticking in the wound. Hold the dressing with tape.
8. Apply antibiotic ointment to the treated area twice a day for 7 days or until the surface is totally healed.
9. Showers are allowed but do not rub the area with towels because the area is extremely delicate while any crusting is present.
10. You may experience some discomfort after the Q-Switched Nd: YAG Laser treatment. For adults take two tablets of paracetamol (eg. Panadol) every six hours when needed for pain (if you are not allergic to it).
11. If swelling occurs, an ice pack wrapped in a soft cloth can be applied.

Precautions to take following your Laser Treatment

1. Avoid direct exposure to the sun. Use a sunblock.
2. Do not rub, scratch or pick at the treated area. A protective dressing should be applied if the area is irritated by clothing or jewellery.
3. Do not apply make-up until the crusts disappear. (Usually 4 to 10 days)
4. Avoid swimming and contact sports while crusts are present.
5. If the treated area shows signs of infection (tenderness, redness, swelling or pus), notify your doctor immediately.

What are the Side Effects and Possible Complications of Laser Surgery?

• Pain: prevented with the correct use of a topical anesthetic cream before the procedure.

• Healing Wound: laser surgery may cause a superficial burn on the surface of the skin which takes several days to heal. This may result in swelling, weeping and crusting of the treated area. This usually takes 4 to 10 days to heal.

• Pigmentary Changes: in most patients the treated area loses pigmentation (hypopigmentation) and becomes lighter in colour than the surrounding skin temporarily. This type of reaction tends to gradually fade away and return to normal over a period of 2-4 weeks. With repeated treatments the pigment loss may become more persistent and take time to heal, up to 6 to 8 months. There is some risk of permanent loss of pigmentation in the area of treatment, leaving a white shape similar to the original tattoo or pigment lesion being treated, but this is rare and usually avoidable by an adequate healing care. There is also a risk of increased pigmentation (post-inflammatory hyperpigmentation) as a healing reaction. However, this type of change is very rare. In such cases, the increased pigment usually fades away over a 2-6 month period.

• Scarring: to minimize the chances of scarring, it is important that the patient follows the post-laser instructions carefully.

• Persistence of Tattoo or Pigment: some tattoo inks are located too deep in the skin to be removed completely in spite of repeated treatments and may leave vague spots of colour remaining after treatment. Green tattoos don't respond to this treatment. In all cases, it may not be possible to completely remove the tattoo entirely.

#hydration - What happens to your body without enough water. Font: Harpers Bazaar.

1. You're more likely to have health problems. Higher water intake has been linked to decreased chances of kidney stones, urinary and colon cancer, and heart attacks.

2. No water, NO metabolism revving. In independent studies for his 2010 book The Water Secret, Dr Howard Murad found that a person's basal metabolic rate (the calories burned while at rest) speeds as the body becomes more positively hydrated and efficient. 

3. You'll have to think harder to complete the same tasks. At the Institute of Psychiatry at King's College London in 2011, scientists found that the brain's of dehydrated teenagers had shrunk away from their skulls, and that when asked to play a problem solving game, they performed just as well as those who drank enough, but engaged more of their brains to do so. Drinking water restores the brain to its normal size.

4. You eat more. A 2010 study of 45 adults funded by the Institute for Public Health and Water Research found that those who drank two eight-ounce glasses of water before each meal consumed 75 to 90 fewer calories while eating. Over three months, water-drinkers lost an average of five pounds more than the dieters who were parched. 

5. You look more wrinkled. In researching his book, Murad also found that water plumps skin, fills in fine lines and wrinkles, and enlivens a dull complexion. 

6. You're in a bad mood. In 2009, researchers at Tufts asked members of the men and women's crew teams to engage in 60 to 75 minutes of high-impact aerobic exercise without drinking enough water first. Others were properly hydrated. The dehydrated group was more likely to report feeling fatigued, confused, angry, depressed or tense.

#acne of the adult females: the benefits of oral spironolactone.

Acne Vulgaris is often managed with topical medications and, in the most severe cases, with oral isotretinoin. However, the latter can have serious adverse effects especially the bad consequences on pregnancies, thus requiring frequent blood monitoring.

To test the effects of oral spironolactone, researchers evaluated 14 women who had failed on responding to zinc topic treatment, oral isotretinoin and antibiotics. They used oral spironolactone in doses ranging from 75 to 150mg per day in combination with an adjuvant topical treatment.

Results showed clinical improvement (reduced acne eruptions) in 6 patients with inflammatory lesions. Side effects were observed in 3 patients: asthenia (2 patients) and epigastric pain (one patient).

Another interesting poster presented at an Asian Congress of Dermatology (RCD 2012) showed improvement of adult onset acne in females over 20 with lesions confined to the cheeks and/or the jawline. Lower doses were used in this study, ranging from 25 to 50mg. The noted side effects included menstrual abnormalities and breast tenderness (not seen at the lower doses of 25mg).

Considering these scientific results, we can conclude that spironolactone is an interesting treatment of adult onset acne in women. We must remember, however, that blood monitoring is needed for such patients.

#psoriasis - new guidelines for management.

Psoriasis is a frequent inflammatory dermatosis which affects 1 to 2% of the global population. It is more frequent in Europe, especially Scandinavia. It is less frequent in blacks and chineses and is a rarity in Ethnic American-Indian population. Its causes are both genetic (PSOR1 gene on chromosome 6) and environmental (guttate psoriasis for example has a specific infectious etiology (streptococcal pharyngitis).

Management Algorythm: 

Limited psoriasis (less than 20% of the body surface area)

• topical steroids +/- vitamin D analogues (calcipotriene or calcitriol). No more than 100g per week of the latter because of hypercalcaemia induction;
• intralesional steroids;
• coal tar: these can be used in combination with topical corticosteroids. There is no conclusive study regarding the theoretical increased risk of skin cancer related to this agent;
• anthralin: it is derived from chrysarobine. It is often useful when applied daily for short periods. It is nevertheless irritant and can stain clothes and tiles. It can be combined with phototherapy (Ingram regimen);
• retinoids: tazarotene.

Phototherapy

• Narrow Band UVB (311nm): start at 70% of the minimal erythemal dose. Increase weekly 10-30%. 3 to 5 sessions per week. Remission is usually achieved after 30-45 days.
• PUVA or topical PUVA: after oral intake or topical application of a psoralen. Dosage varies according to the phototype.
• Multiclear (localised UVA and UVB treatment).

“Classical” systemic treatments

• retinoids (acitretin);
• methotrexate (7.5-25mg per week) with folic acid (1mg/d);
• ciclosporine (3-5mg/Kg/d);
• fumaric acid.

“Biologic” systemic treatments

Indications:

1. no response to classical systemic treatments or contraindications to them;
2. PASI (Psoriasis Area Severity Index) more or equal 15.

Short term response rates

-Adalimumab:

1. 70% of treated individuals achieve an improvement of PASI 70
2. 45% of treated individuals achieve an improvement of PASI 90
3. in both cases, the dosage is of 40mg every 2 weeks, after an induction dosa of 80mg

-Etanercept:

1. 35% of treated individuals achieve an improvement of PASI 70 and 10% have an improvement of PASI 90 after a dosage of 2 times 25mg per week.
2. 50% of treated individuals achieve an improvement of PASI 70 and 20% have an improvemnet of PASI 90 after a dosage of 2 times 50mg per week.

-Infliximab: for a dosage of 0.5mg/Kg at weeks 2, 4 and 6

1. 80% of treated individuals achieve an improvement of PASI 70.
2. 40% of treated individuals achieve an improvement of PASI 90.

-Ustekimumab: for a dosage of 45mg every three months:

1. 70% of treated individuals achieve an improvement of PASI 70.
2. 40% of treated individuals achieve an improvement of PASI 90.

To summarize:

Infliximab achieves the fastest results but it requires an intravenous infusion every 6 weeks;

With ustekimumab, the improvement of PASI 90 is maintained 76 weeks after initiation of treatment in 63% of patients at a dosage of 90mg and in 45% of patients at a dosage of 45mg;

Adalimumab remains efficient 2 years after initiation of treatment.

How to start a biologic?

1. it must have no response to other systemic agents, the severity of PASI must be at least 15;
2. which one to chose: adalimumab (anti-TNF), infliximab (anti-TNF), etanercept (anti-TNF)m, ustekimumab (anti IL-12): no real guidelines exist. Personal experience is therefore a must.

Topical agents to relieve symptoms

1. keratolytics for hyperkeratosis
2. 2-5% salicylic acid (up to 20% concentration in palmar and plantar locations)
3. emollients for parakeratosis
4. anthralin, topical steroids, vitamin D analogues and phototherapy for psoriasiform hyperplasia.

#hyperpigmentation - why do some people present dark skin blemishes after healing?

 


What is post-infammatory hyperpigmentation?

It is a hyperpigmented discolouration that is left on the skin after an underlying skin disease has healed. The underlying skin diseases include:

• trauma, 
• skin infections, 
• eczema (dermatitis), 
• acne, 
• photosensitizing plants 
• drug reactions.

In dark-skinned people, the hyperpigmentation (dark coloured patches) tends to be more intense and persists for a longer period. Finally, it tends to fade slowly with time, although in some cases it can last a lifetime.

How is post-inflammatory hyperpigmentation treated ?

Usually, normal skin colour will return slowly over a period of months. The patients should avoid further trauma in the area, e.g. frequent rubbing and sunlight exposure.

Treatment options include bleaching agents such as those containing hydroquinone, although clinical practice shows that these medications are not more rapidly effective than if no treatment is given. Azelaic acid 20% cream can also be tried, twice daily, with beneficial results.

Creams containing derivatives of vitamin A (retinol, tretinoin, retinoic acid) are not recommended as they induce an inflammation which worsens the problem.

#keloid - how to treat?

Keloids represent a type of scar caused by an abnormal reaction to trauma with an excessive tissue response and production of collagen with fibrosis. 

Keloids are firm, rubbery lesions or shiny, fibrous nodules, and can vary from pink to fleshy, red or dark brown in colour. A keloid scar is benign and not contagious, but sometimes accompanied by severe itchiness, pain, and changes in texture. In severe cases, it can affect movement of skin. Genetics plays an important role on keloids predisposition. Keloid scars are seen 15 times more frequently in highly pigmented ethnic groups than in Caucasians 

Unfortunately, treatment options are limited and results may not be satisfactory. They include:

1. first line: cryotherapy, intralesional injections of steroids, silicone ointments under compression and radiotherapy (in trained hands).
2. second line: excision followed by compression therapy and monthly injections of triamcinolone.
3. Vascular pulsed dye lasers might decrease redness (at least in theory), but all lasers, even the non ablative ones, involve energy delivered to the dermis. Energy is converted to heat and carries a risk of scarring, and thus keloids. Therefore, although described as a therapeutic option, lasers can be risky and must be used very carefully for such purpose.

#atopicdermatitis - the role of a non-steroid drug (pimecrolimus) on the treatmentn & prevention of relapses.

 

This article demonstrates that a once daily application of a calcineurin inhibitor pimecrolimus in this study) is enough to prevent the flare-ups of atopic dermatitis. At the same time it reduces the side effects, thus enhancing the compliance in the treatment of this chronic condition. In this study, comparison of twice-daily and once-daily applications of pimecrolimus cream 1% is done for prevention of atopic dermatitis relapses in pediatric patients. The abstract is shown below.

METHODS: This multicenter trial recruited  300 outpatients aged from 2 to 17 years of age, with mild-to-severe AD. The patients were initially treated with twice-daily topical pimecrolimus until complete clearance or for up to 6 weeks (open-label period). Those who achieved a decrease of at least 1 point in the Investigator’s Global Assessment (IGA) score were then randomized to double-blind treatment with pimecrolimus cream 1% either twice daily or once daily for up to 16 weeks. 

RESULTS: Out of the 300 patients enrolled in the study, 268 were randomized to treatment with pimecrolimus cream 1% either twice daily or once daily (n = 134 in each group). The relapse rate was lower in the twice-daily dose group (9.9%) than that in the once-daily dose group (14.7%), but analysis of the time to disease relapse did not show a statistically significant difference between treatment arms.

CONCLUSION: Treatment of active atopic dermatitis lesions with pimecrolimus cream 1% twice daily, followed by the once-daily dosing regimen, was adequate to prevent subsequent relapses over 16 weeks in pediatric patients.

#seborrheic dermatitis - an overview of the conventional and more aggressive treatments.

 

Seborrheic dermatitis is a common inflammatory disorder that affects:

1. the scalp where it causes scales, what is also known as dandruff (Pityriasis capitis).
2. the face where it causes erythema (redness) and scaling usually located in the nasogenial folds and eyebrows.

Its cause is unknown but its severity is highly associated with the presence of the yeast of Malassezia species. Because of this, its main treatment consists of applying a topical antifungal cream twice a day. Other treatments consist of applying creams with anti-redness properties (mostly for their moisturizing and anti-irritating properties).

However, these efforts are sometimes not enough and an oral treatment can be proposed (although no cure has been found to this date). This review article summarizes them:

• antifungals: some evidence, but a limitation is that monitoring of yeast count/density was not performed in half of the studies. 
  • Itraconzole: 200mg daily for the first week of the month then 200mg for the first two days of the remaining months for up to a year.
  • Terbinafine: 250mg daily  for 4 to 6 weeks then 250mg 12 days per month for 3 months. Comment: terbinafine is not usually effective against yeasts and there is probably an alternative mechanism to its mode of action.
  • Fluconazole: 50mg daily for 2 weeks or 200-300mg weekly for up to 4 weeks. 
  • Ketoconazole: 200mg daily for 4 weeks.
  • Pramiconazole: 200mg as a single dose.

• oral prednisone: one case report. 0.5mg/Kg for 15 days with progressive tapering.
• oral isotretinoin: one case report. 20mg daily in combination with topical ketoconazole.
• homeopathic preparation of potassium bromide, sodium bromide, nickel sulfate and sodium chloride. Here, effects take longer to be appreciated.

#rosacea (red face) - topical vasconstrictor introduced as a new therapeutic option.

 

Rosacea is a common dermatological condition that affects 0,5 – 1 % of the general population. It can be classified in stages 1 (redness and microvessels), 2 (lumps) and 3 (deformities in the nose, the so-called "rhinophyma").

Rosacea is an important cause of distress and social withdrawal. Around 60% of individuals with stage 1 and 85% of those with stage 3 report bad influences of the disease in their social life – refusal of spicy/hot food and alcoholic/caffeinated beverages is quite common (as they trigger flare-ups).

Treatment is symptomatic, not curative. Conventional treatments include topical antibiotics (metronidazole), topical azelaic acid and oral antibiotics (tetracyclines and erythromycin).

Recent studies are introducing BRIMONIDINE TARTRATE as a new promising therapeutic option: it is a vasoconstrictor that acts selectively on the alpha2 adrenergic receptor. This drug is used topically once daily, at a concentration of 0,5%. Reduction of redness can already be seen 30 minutes after the application; studies suggest a maximum effect somewhere between 6 and 12 hours later. Another vasoconstrictor, called OXYMETAZOLINE, is also currently being investigated for this same purpose.

#hairloss - approach to a new promising treatment.

Hair loss is most commonly due to the so-called androgenetic alopecia, which is related to the excess of circulating androgens (males hormones).Treatment options are quite limited and include oral vitamin H (Biotin), topical minoxidil, and oral finasteride. When clinical treatments fail, the use of wigs or surgical hair transplantation may be required.

But good news are coming for those who suffer with androgenetic alopecia: a new drug, called LATANOPROST, has just entered in the therapeutic tools. Pharmacologically, latanoprost is a prostaglandin analogue which acts by dilating blood vessels. It is used as eye drops in the treatment of glaucoma. Surprisingly, it was noted that patients who were using the drops presented regrowth and thickening of the eyelashes.

Naturally it was questioned if this drug could also be used to promote hair regrowth in the scalp. A study was performed including 16 men with mild androgenic alopecia (Hamilton II and III). Latanoprost 0.1% was topically applied daily for 24 weeks on small areas of the scalp. Measurements of hair growth, density, diameter and anagen/telogen ratio were done.

The authors found promising results with statiscally significant increase in hair density in all treated subjects, when compared with their baselines. However, limitations must be considered: this research included only young individuals with mild baldness. 

Concluding and generally speaking, it is always a good idea to start treating androgenetic alopecia as early as possible, thus improving the prognosis.

#HPV - Advices on genital viral warts (condyloma acuminata).

What are genital warts?

It is a sexually transmitted infection located in the genital/anal area. It  is caused by an infection with the Human Papillomavirus (HPV). Warts located on the hands, feet and fingers are not sexually transmitted and are caused by other subtypes of HPV than the ones causing genital warts.

How are genital warts transmited?

• Unprotected sexual intercourse with an infected individual.
• Mother to child transmission during normal delivery (through the birth canal).
• Self inoculation from the hands and fingers is also possible.

What are the signs and symptoms of genital warts?

The lesions appear as fleshy masses on the skin, which can be big or small, single or multiple. They can be slightly itchy.

In women, the lesions tend to be located in the cervix, vagina or vulva. In men, the lesions affect the penis and urethra. In both males and females, the lesions can be present in the anal and perianal areas.

If not treated, the warts persist and grow slowly. During pregnancy, the lesions can grow faster.

Are genital warts dangerous?

Certain types of genital warts can change into cancers (malignant change). Untreated lesions can be transmitted to other sexual partners.

How are genital warts diagnosed?

These lesions have a characteristic clinical appearance. Warts in the cervix and vagina have to be demonstrated by a gynecologic examination with the speculum. Blood tests are not useful in the diagnosis of this condition.

How are genital warts treated?

1. Chemical agents such as podophyllin, podophyllotoxin, silver nitrate and trichloroacetic acid;
2. Liquid nitrogen;
3. Imiquimod cream;
4. Surgery with lasers, electrosurgery or scalpel excision.

Some kinds of treatment can be combined; repeated treatments may be necessary.

Inform your doctor if you are pregnant (podophyllin can't be used as it can cause fetal anomalies). Do not self-medicate. Women should consult a gynecologist to ascertain the usefulness of regular cervical swabs (Papanicolaou) to screen for cervical cancer.

For a safer sexual attitude, use condoms (male or female available) for each sexual intercourse. Do not consume alcohol before or during the sex act as it may impair conscience and judgement.

#Acne Treatment: the combination of isotretinoin (Accutane) with antihistamine improves the results and reduces side-effects.

Isotretinoin remains the gold standard in the treatment of Acne Vulgaris especially because nowadays we focus on lower and more tolerable doses. However, even so, patients can have difficulties to tolerate it because of the occurrence of side effects such as xerosis (very dry skin and mucousae). Besides, isotretinoin can have adverse effects on liver function and lipid metabolism.

To avoid this, researchers studied forty patients, 20 taking oral isotretinoin alone, and 20 with additional desloratadine (antihistamine, selective anti-H1 receptor antagonist). Results show that after 20 weeks of treatment, patients taking isotretinoin + antihistamine had a significant decrease in acne lesions counts, sebum and erythema. Also the occurrence of flare-ups was significantly reduced: it was described in only one subject taking the combined therapy (vs. 6 in the isotretinoin treated group). 

Comment: the beneficial effects of anthistamines (here desloratine) seem too be warranted in the treatment of severe acne with isotretinoin. The lack of long term follow-up limits the scope of this study.

#fillers - Cosmetic facial fillers linked to permanent blindness.

Improper use of dermal fillers to treat frown and laugh lines can cause retinal artery occlusion and permanent blindness, according to a South Korean study published in the American Journal of Ophthalmology (2012). The findings may be eye-opening for the rising number of young, healthy women who undergo soft-tissue augmentation in the glabella or nasolabial folds, viewing this procedure as a safe method of achieving cosmetic goals.

In reviewing the medical records of 12 patients with sudden vision loss after filler injections, researchers found that ophthalmic retinal artery occlusion with choroidal ischemia was most prevalent and led to permanent blindness with no light perception. In 4 of the 7 patients with ophthalmic artery occlusion, blindness followed autologous fat injections in the glabellar region; 2 patients received autologous fat in the nasolabial fold, and 1 was injected with hyaluronic acid in both regions.

Use of autologous fat yielded significantly worse outcomes than hyaluronic acid and collagen injections, potentially because of the variable particle size, which can lead to blockage of different-sized arteries. Two patients who had received fat injections in the glabella sustained a cerebral fat embolism leading to brain infarction.

Therefore, patients should be aware of the possibility of development of retinal/ophthalmic artery occlusion and blindness, with poor prognosis.

#acne - can make-up trigger flare-ups? Font: Nature Health.

There is a popular myth that has always been associated with acne and, that is, acne in women is often “caused” due to excessive make up. In reality, however, this myth is not scientifically proven. However, what has been clinically proven is the fact that while wearing makeup on regular basis does not “cause” acne, it actually triggers or “aggravates” the already existing acne conditions.

How wearing make-up can trigger acne flare-ups?

There are a number of factors that can make acne flare up or lead to "breakouts", although triggers can vary from person to person and depend on a number of other factors such as age, gender, weather, hormones and stress related conditions. 

The following two make-up related factors have been thought to be important in the “triggering” of acne attacks. 

Cosmetics: Some specific cosmetics, oils, gels, cleansing lotions and facial masks are oil-based or oil-friendly. These make-up and hair care products can easily clog skin pores. Therefore, before buying any of such stuff, you should specifically look for the following terms on product labels: "oil-free", "non-comedogenic" or "non-acnegenic".

Over washing: Actions like cleaning or washing your skin more often, scrubbing/exfoliating, or using strong cleansers or astringent products can actually strip the skin and irritate it. This can lead to more severe acne.

Make up tips in acne:

• If you wear make-up, you should ideally use dry powder or hypoallergenic, water-base make-up
• Using skin care products labeled “nonacnegenic,” “noncomedogenic,” “oil free,” or “will not clog pores” can help.
• If you tend to have oily hair or dandruff you might benefit from an anti-dandruff shampoo. 
• Also avoid unauthentic face creams or oils and oil-based hair tonics.
• Wash your face twice daily (yes, just twice and not more) with mild soap and water. Don’t be too rough while washing and avoid astringents and abrasives as they can cause skin irritation and in general do not help improve acne.

• Prefer to use a clean wash cloth and towel every time you wash your face to prevent acne flare-ups. You should also clean makeup brushes, applicators and sponges after every use to avoid pimples. Bacteria build up on these materials and may contribute to acne flare-ups.
• Avoid unnecessary exposure to sunlight. Wear a sunscreen under your makeup or select moisturizers or foundations with an SPF protection level of at least 15.