Botulinum toxin type A (BoNT/A) is commonly used for both medical and aesthetic purposes. However, approximately 3

Background: Data on the effectiveness of nail gutter method for epidermal growth factor receptor inhibitors (EGFRi)-induced nail changes, especially from a randomized study, are limited Objective: This study aimed to investigate the efficacy of nail gutter method for EGFRi-induced nail changes.

Eimpunth, Sasima MD; Pacharapakornpong, Sarun MD; Yogya, Yuri MD; Weiss, Margaret A. MD Author Information

BACKGROUND: Blue wheals and blue angioedema, the adverse reactions to blue dye injections with or without anaphylaxis, are poorly defined.OBJECTIVE: The objective is to review the characteristics (ie, sex and age at onset, interval between blue dye injection and symptom onset, clinical manifestations, duration of blue wheals or angioedema), natural courses, and treatments of blue dye adverse reactions. METHODS: A review of the articles published through July 2021 was performed per the Preferred Reporting Items for Systematic Reviews and Meta-Analysis recommendations. RESULTS: Across 523 patients (175 studies) with any adverse reactions to blue dye injections, wheals, angioedema, or both occurred in 193 patients (36.9%). Of these 193 patients, 68 patients (35.2%) developed blue wheals or angioedema, 118 (61.1%) had ordinary wheals or angioedema (nonbluish), and 7 had both (3.6%). We reviewed 169 patients with available data (99 with ordinary lesions and 70 with blue lesions). Patent blue violet had the highest rate of inducing blue wheals or angioedema (odds ratio 4.9). Almost half of the patients with blue wheals or angioedema developed systemic symptoms; and of those with systemic symptoms, all except 1 progressed to anaphylaxis. On -demand treatments with antihistamines, corticosteroids, and epinephrine were commonly used and effective.CONCLUSIONS: Using blue dyes can lead to blue wheals or angioedema and systemic reactions. In patients with a history of a severe allergic reaction to a blue dye, repeat administration of a blue dye should be used only after carefully weighing all the risks and benefits.(c) 2023 American Academy of Allergy, Asthma & Immunology

Abstract Botulinum toxin type A (BoNT/A) has been used for medical purposes for decades. Approximately 3% of long-term patients do not respond to treatment, which might result from antibody formation. This study aimed to compare the antibody levels in patients receiving intradermal and intramuscular toxin injections of several types of BoNT/A. One hundred twenty subjects were divided into groups receiving either intradermal or intramuscular injections. Each group was equally divided into 6 subgroups receiving one of the 6 types of BoNT/A (incobotulinumtoxinA, onabotulinumtoxinA, abobotulinumtoxinA, letibotulinumtoxinA1, letibotulinumtoxinA2, and prabotulinumtoxinA). Blood was drawn from each subject, and enzyme-linked immunosorbent assays (ELISA) were used to detect total human immunoglobulin G (hIgG) specific to the whole molecule of BoNT/A, hIgG against active sites and complexing proteins of BoNT/A. Intradermal injection induced higher levels of BoNT/A specific hIgG than the intramuscular injection did for every type of BoNT/A except for letibotulinumtoxinA. The level of hIgG against active sites of BoNT/A increased after the injections and peaked at day 30 before gradually decreasing. The levels of hIgG specific to complexing proteins did not change significantly over the course of the study. However, the levels of hIgG specific to either active sites or complexing proteins were lower than cut-off points in BoNT/A treatment responders. In summary, our finding suggested that intramuscular BoNT/A injections could be preferable for facial treatment, with retreatment after 90 days of treatment to minimize antibody production.

Background: The periorbital area is prone to displaying the first signs of aging. Periorbital rejuvenation strategies are optimally applied when a combination of interventions that effectively and safely "lift and fill" is utilized.

Autologous cultured fibroblast injections for soft tissue augmentation are a potential alternative to other filler materials. No studies have compared autologous fibroblast injections and hyaluronic acid (HA) fillers for treating nasolabial folds (NLFs). To compare the efficacies and safeties of autologous cultured fibroblast injections and HA fillers for treating NLFs. This prospective, evaluator-blinded, pilot study enrolled 60 Thai female adult patients diagnosed with moderate to severe NLFs. They were randomized to receive either 3 treatments of autologous fibroblasts at 2-week intervals or 1 treatment with HA fillers. The primary outcome was the clinical improvement of the NLFs graded by 2 blinded dermatologists immediately after injection and at 1-, 3-, 6-, and 12-month follow-ups. Objective measurement of the NLF volume was evaluated. Patient self-assessment scores, pain scores, and adverse reactions were recorded. Of the 60 patients, 55 (91.7%) completed the study protocol. The NLF volumes improved significantly in the autologous fibroblast group at all follow-ups relative to baseline ( P = 0.000, 0.004, 0.000, 0.000, and 0.003). The patients in the autologous fibroblast group rated more noticeable NLF improvements than those in the HA filler group (3-month follow-up, 58.41% vs. 54.67%; 6-month follow-up, 52.50% vs. 46%; 12-month follow-up, 44.55% vs. 31.33%). No serious adverse reactions were recorded. Autologous fibroblast injections are safe and effective for treating NLFs. These injections also promise sustained growth of living cells, possibly leading to a greater persistence than shown by other fillers.

Monopolar radiofrequency (MRF) is a valuable modality for tightening and contouring mild-to-moderate facial skin laxity. Few studies have evaluated new-generation MRF devices for lower facial laxity in Asians. This study aims to evaluate the efficacy and safety of MRF for treating lower facial laxity in Asians. This prospective cohort study enrolled 30 volunteers with Fitzpatrick Skin Types III–V and mild-to-moderate skin laxity. Subjects received a single MRF treatment. Self-assessments and adverse events were recorded. Two blinded dermatologists graded improvements (6-point scale) after treatment and 1, 3, and 6 months later. All subjects completed the study. Treatment energy levels ranged from 2 to 4. The average number of shots was 412 ± 49, delivered in 3–4 passes with 15–30

Hyperpigmentation of split-thickness skin grafts (STSGs) is commonly found among Asians, and it is also challenging to treat. Although the 1064-nm Q-switched Nd:YAG laser has been used as a standard treatment for skin hyperpigmented lesions, there are limited number of reports focusing on the treatment of hyperpigmentation of STSGs. We aimed to evaluate the efficacy of 1064-nm Q-switched Nd:YAG laser for treatment of hyperpigmented STSGs. Half of each STSGs was treated with the 1064-nm Q-switched Nd:YAG laser, while the remaining was left untreated as comparison. The laser was applied for 4 times with 2–4-week interval. The treatment outcomes were compared by measurement of melanin index, erythema index, and photographs of STSGs at prior to enrollment, before each treatment session, and after 1 month of treatment completion. Five patients with 11 skin graft lesions were enrolled. The melanin index was significantly improved after the 2nd session and after treatment completion in laser-treated area (p = 0.006 and p = 0.001, respectively). There was non-significant difference in erythema index. The photographic comparison showed brightened of laser-treated area after treatment completion and improved skin texture. The 1064-nm Q-switched Nd:YAG laser can significantly reduce melanin index of STSGs and can be an alternative treatment for hyperpigmentation of STSGs.

Talaromyces (formerly Penicillium) marneffei is a dimorphic fungus that causes talaromycosis (formerly penicilliosis). The condition is predominantly found in patients with HIV. Important diagnostic clues are a history of living or travelling in endemic areas, and central umbilicated skin lesions. Dermoscopy is particularly useful for providing rapid bedside information, with a round, whitish, amorphous structure being the most common finding. Immune reconstitution inflammatory syndrome (IRIS) may occur. Driven by the initiation of antiretroviral therapy, IRIS is an exaggerated response of T cells to pathogens. Although mycobacterial and cryptococcal opportunistic infections are common with IRIS, a linkage between T. marneffei and IRIS has rarely been reported. Here, we report on a literature review of patients with HIV who developed IRIS associated with talaromycosis. Dermatologists should be aware of the cutaneous and dermoscopic findings of talaromycosis as they provide important clues that enable its early diagnosis and treatment.

Laser lipolysis is a rapidly growing noninvasive body-contouring treatment in Asians. There is increasing demand for leg contouring, especially in areas where unwanted fat deposits are prominent despite diet and exercise. Medial fat knees are one of the esthetic concerns of women today and can be a challenging problem in terms of treatment. There are few noninvasive options to remove fat from these areas. This study aims to evaluate the safety and efficacy of a 1060-nm diode laser for medial knee fat reduction. Nineteen subjects with localized unwanted fat on the medial knees were enrolled into this study. All of them were treated with a single session of 1060-nm diode laser at a power setting of 1.0–1.4 W/cm2, depending on patient tolerance. Body weight, knee circumference at 3 cm above the medial epicondyle of the femur, and knee fat thickness measured by ultrasonography were recorded at baseline and 1, 3, and 6 months after treatment. Clinical photographs and ultrasound images were taken before and after treatment. Side effects were documented during follow-up visits. Subjects answered a satisfaction questionnaire at the completion of the study. All subjects were female, with mean age of 32.3 ± 5.3 years and body weight of 59.8 ± 11.6 kg. The average power setting was 1.3 ± 0.1 W/cm2 with pain score of 6.1 ± 1.0. Significant reduction in knee circumferences (p < 0.001) at 1-, 3-, and 6-month follow-up visits compared with baseline, and knee fat thickness measured by ultrasound in both axial and sagittal plane at 1 and 6 months after treatment (p = 0.036 and p < 0.001, respectively) were recorded. Side effects were mild and transient, including mild erythema and tenderness. The 1060-nm diode laser is effective and safe for knee circumference and medial knee fat layer thickness reduction. ClinicalTrials.gov identifier, TCTR20220219002. Retrospectively registered on February 19, 2022.

Background Cryotherapy is typically performed by physicians. No cost-utility studies of home-based cryotherapy have been reported. Objectives To study the cost utility of home-based cryotherapy devices and in-hospital liquid nitrogen therapy for cutaneous warts. Materials and methods This randomized, controlled, investigator-blinded trial was carried out on patients with cutaneous warts. Participants were randomly assigned to two groups: home-based cryotherapy and in-hospital liquid nitrogen therapy. Clinical examinations were conducted at baseline and monthly until cure, and outcomes (cure rate, side effects, total costs, and quality of life) were compared. A cost-utility analysis was performed. Results Nineteen of 22 patients completed the treatment and were analyzed. The efficacy of home-based cryotherapy and in-hospital therapy was 72.8% and 64.3%, respectively. Side effects (pain, redness, and burning) were observed. The mean numbers of medical visits were 2.83 for home-based therapy and 3.30 for in-hospital therapy. The total costs for home-based therapy and the in-hospital therapy were US $76.03 and $100.45, respectively. The home-based therapy had 0.2297 quality-adjusted life years, slightly higher than the corresponding value of 0.2254 for in-hospital therapy. Conclusions Home-based cryotherapy devices are a cost-saving strategy with similar efficacy to in-hospital liquid nitrogen therapy.

BACKGROUND Surgical and nonsurgical methods are used for treating basal cell carcinoma (BCC). Few randomized controlled trials exist on the effectiveness of the pulsed dye laser (PDL) on BCC treatment. OBJECTIVE We investigated the effectiveness of PDL treatment in a single session for the management of nodular and superficial BCCs on the trunk and extremities of adults using a randomized, double-blind, controlled technique. METHODS We used settings of fluence 7.5 J/cm 2 , 3-ms pulse duration, no dynamic cooling, 10-mm spot size, 10% overlap between pulses, and 2 stacked pulses on a 595-nm wavelength laser. Histopathologic clearance on excision of tumor with 4-mm margins was the primary outcome measure. RESULTS Twenty-four patients were included in the study, with 14 in the laser treatment group and 10 patients in the sham/control group. In total, 10/14 (71.4%) of the tumors in the treatment group were successfully treated with no residual tumor on excisional specimen histology, compared with 3/10 (30.0%) of the control group ( p = .045). CONCLUSION Our study shows that PDL may be an effective treatment for low-risk BCCs of the trunk and extremities, but the cure rate is lower than those of other treatments for BCC. Thus, PDL under the current settings cannot be recommended.

Liquid injectable silicone (LIS) has been used for soft tissue augmentation for more than 5 decades; however, its use remains controversial due to associated complications.1 Granulomatous reaction or siliconoma is the most commonly observed complication, and it clinically presents as recurrent cellulitis, skin induration, nodules, ulceration, and/or local lymph node involvement.2 Treatment of siliconoma remains a therapeutic challenge. Here, we present the case of a 65-year-old woman with facial siliconoma who responded well to low-dose isotretinoin.

Background. Pitted keratolysis (PK) is a superficial bacterial infection diagnosed mainly by clinical manifestations. Current data on its dermoscopic and histopathological findings, and the correlation of those findings, are limited. Objectives. To evaluate the clinical manifestations, dermoscopic, and histopathological findings of PK and to determine the correlations. Methods. Forty naval cadets with PK and five cadets with normal feet were enrolled this cohort study and provided informed consent. Dermoscopy was independently applied and evaluated by 2 dermatologists. Shave biopsies were performed on 37 patients with PK. Results. Pits were the most common dermoscopic finding (88.1%). The dermoscope had more sensitivity for the detection of PK than the naked eye examinations. Apart from the pits and the presence of bacteria, the most common histopathological finding for PK was color alteration of keratin. The presence of bacteria correlated with interrupted dermatoglyphic lines and the color alteration of keratin. Moreover, the presence of bacteria at the base of pits was related to worse treatment outcomes. Conclusions. Dermoscopy is a useful tool for PK diagnosis. Color alteration of keratin is another histopathological finding for PK. The presence of bacteria is associated with worse treatment outcomes.

A 60-year-old Thai woman developed bilateral carpal tunnel syndrome (CTS) in 2017, and was later treated for smear-negative pulmonary tuberculosis at a different hospital in May 2019. During that treatment, isoniazid, rifampicin and pyrazinamide were all discontinued due to onset of hepatitis, and the patient was switched to ethambutol and streptomycin. In July 2019, isoniazid was restarted. One week later erythematous macules developed on the limbs resulting in discontinuation of all drugs. In October 2019, the patient developed multiple bullae on her limbs, which were not associated with trauma. Skin biopsy revealed blistering with perivascular lymphocytic infiltration. Bullous drug eruption was suspected. The condition was refractory to topical treatments. The patient also lost 17 kg in weight within a period of 9 months (May 2019 to January 2020), and was referred to our centre in February 2020. Physical examination revealed pallor, macroglossia (Fig. 1) and bullous lesions on the limbs (Fig. 2a–c). Tzanck smear showed numerous eosinophils; however, ELISA for bullous pemphigoid antigen (BPAG)1 and BPAG2 was negative. Investigations showed marked anaemia (haemoglobin 4.4 g/dL; normal range 11.5– 16.5 g/dL), acute kidney injury (raised creatinine 2.76 mg/dL; 0.6–1.1 mg/dL) and hypercalcaemia (calcium 11 mg/dL; 8.5–10.2 mg/dL). Serum protein electrophoresis showed elevated serum-free j light-chain (47.8 mg/L; 3.3–19.4 mg/L), elevated serum-free k light chain (1789.8 mg/L; 5.7–26.3 mg/L) and a j/k ratio of 0.03 (0.26–1.65). Bone marrow biopsy showed plasma cell myeloma without amyloid, while immunostaining showed k light chain restriction.

This split-face, double-blind, randomized controlled study examines the efficacy of fractional thulium laser (FTL)–assisted delivery of topical tranexamic acid (TXA) compared with FTL alone as a treatment option for melasma. Forty-six adults with Fitzpatrick skin types III–V and recalcitrant melasma underwent four weekly treatments with fractional 1927-nm thulium laser on both sides of the face. Immediately after treatment, TXA was applied to one side of the face and normal saline solution (NSS) to the contralateral side as control under occlusion. Melanin index (MI), modified MASI (mMASI), and patients’ self-assessed improvement scores were measured at baseline, 1 week, 4 weeks, and 3- and 6 months after the final treatment and were examined statistically with a paired sample t test with significance set at p ≤ 0.05. The majority of the participants (95.7%, n = 44) were female with Fitzpatrick skin type IV (82.6%) and a mean age of 48.0 ± 10.0 years. Twenty-nine individuals were able to be followed up until the 6-month assessment. Significant improvement from baseline was seen in both the MI and mMASI scores for both the TXA and control sides at 3 months, with no statistically significant difference between sides. By the 6th month, significant differences in MI and mMASI scores from baseline were still noted, except in the MI for controls. The patients’ self-assessment showed similar patterns. No serious adverse events were reported for either group. A regimen of FTL-assisted delivery of TXA over a 4-week period is a safe and effective treatment option for melasma, producing significant improvement up to 3 months. Results further would suggest a repeat regimen every 3 months could be useful for treatment of recalcitrant melasma.

Background Postacne erythema (PAE) is a common sequela of inflammatory acne vulgaris, treatment of which has been challenging due to limited options available and the variability of results for each modality. Recently, a 577-nm high-power optically pumped semiconductor laser (HOPSL) initially developed for vascular lesions has shown promising results for the treatment of PAE. Aims To evaluate the efficacy and safety of 577-nm HOPSL in the treatment of postacne erythema. Methods This was a split-face, randomized controlled trial pilot study. Twenty-one patients with PAE on both sides of their face were enrolled. Each subject's face sides were randomly assigned to either receive 577-nm HOPSL treatment (QuadroStar PRO (TM), Asclepion Laser Technologies) using the scanner handpiece, 1mm spot size, 80% coverage, 12-15 J/cm(2), 30 ms, 2 passes for 3 sessions at 1-month intervals, or no treatment at all. Outcome measures such as overall improvement, the Erythema Index (EI), and Melanin Index (MI) from 3 different areas on both treatment and control sides were assessed at baseline, and 1-month follow-up after each treatment session. Side effects including pain, erythema, swelling, and crusting were also recorded. Results Upon completion of the treatment period, the mean EI was significantly decreased in both treated and nontreated sides of the face (P P = .001, respectively). The laser-treated sides already demonstrated significant reduction in the mean EI compared with nontreated sides at 1 month after the 2nd treatment (P = .007). The mean MI of both sides, however, did not show any statistically significant differences from baseline, and likewise when comparing between sides. Patients reported more improvement on laser-treated sides compared with nontreated sides. Reported side effects were limited to mild discomfort during treatment and transient facial erythema lasting approximately 30 minutes. Conclusion Patients who received treatment with the 577-nm HOPSL had better outcomes with minimal side effects at 1 month after 2 treatments as compared to those who did not receive any treatment. Therefore, the 577-nm HOPSL may be considered as an effective adjuvant treatment for PAE and early erythematous atrophic scars.

Background Recently, macro-focused ultrasound (MFU) has become a popular noninvasive esthetic treatment for facial laxity. However, there are no studies done that evaluated the use of MFU with a 2.0 mm transducer for upper facial lifting. Aims To evaluate the efficacy and safety of MFU with a 2.0 mm transducer in the treatment of upper facial laxity in Thai patients. Methods This was a prospective, evaluator-blinded pilot study with 34 Thai patients diagnosed with mild to moderate facial laxity. Patients were treated with a single session of MFU with 2.0 mm transducer at the forehead, lateral and just below the eye area. Primary outcome was the clinical improvement of upper facial laxity graded by 2 blinded dermatologists at baseline, 1-week, 1-, 3-, and 6-month follow-up. Objective measurements including eyebrow height, upper facial volume, and textural irregularities were evaluated. Patients' self-assessment scores and adverse effects were also recorded. Results Out of 34 patients, 27 (79.4%) attended all follow-ups. Clinical improvement of upper facial laxity was observed as early as 1-week follow-up. Eyebrow height elevation was significantly increased at every follow-up (P = .000) with an average of 1.22 mm at 6-month follow-up. Wrinkles improved significantly at 1-week and 6-month follow-up (P = .002 andP = .010, respectively). Skin roughness showed significant improvement at 6-month follow-up (P = .004). Majority of the patients (53.6%) reported marked improvement at 3-month follow-up. No serious adverse event was noted. Conclusion Macro-focused ultrasound is a safe and effective treatment for upper facial laxity and skin textural irregularities in patients with mild to moderate degree of laxity.