Showing papers in "Dermatologic Therapy in 2006"

Hyaluronic acid fillers

Abstract: Although hyaluronic acids are a relatively new treatment for facial lines and wrinkles, they have provided numerous advances in the area of cosmetic surgery. This article discusses the inherent properties of hyaluronic acid fillers that make them ideal for treatment of facial lines. It encompasses a review of the current literature on U.S. Food and Drug Administration-approved hyaluronic acid fillers and the role that each of these fillers currently has in facial cosmetics. This article also discusses the potential pitfalls and adverse effects that can be associated with using hyaluronic acids for filling facial lines. Finally, it serves as an overview of current techniques for clinical assessment of patients as well as administration and treatment of facial lines and wrinkles.

Distinguishing melanocytic nevi from melanoma by DNA copy number changes: comparative genomic hybridization as a research and diagnostic tool.

Abstract: Cancer typically results in loosened control over genomic integrity, resulting in alterations of the genome of cancer cells. Comparative genomic hybridization (CGH) is a method that can be used on DNA extracted from routinely fixed tissue to assess the entire genome for the presence of changes in DNA copy number. CGH analysis has revealed that melanoma differs from melanocytic nevi by the presence of frequent chromosomal aberrations. In contrast, melanocytic nevi typically show no chromosomal aberrations, or have a restricted set of alterations with basically no overlap to melanoma. These marked differences between aberration patterns in melanomas and melanocytic nevi can be exploited diagnostically to classify melanocytic tumors that are ambiguous based on histopathologic assessment. In addition to potential diagnostic applications, detailed analyses of recurrent aberrations can lead to the identification of genes relevant in melanocytic neoplasia.

Combination therapy with BOTOX™ and fillers: the new rejuvnation paradigm

Abstract: Until relatively recently, restoration of appearance by replacement of lost facial volume and muscular relaxation has been an illusory goal. With advances in the commercial availability of newer filling agents and a better understanding of the clinical esthetic effects of botulinum toxin A, remarkably sophisticated and refined results can now be achieved by using these noninvasive techniques. The combined use of BTX-A and filling agents, such as collagen and hyaluronic acid, can restore facial appearance by the dual mechanisms of reflation and relaxation. In addition, their combined use appears to increase the longevity of tissue dwell time of the filling agent. Current practices now strive to correct wrinkles by restoring volume and also relaxing the pull of muscles that create negative facial expressions such as glabellar folds, mouth frown, crow's feet, horizontal forehead lines, and perioral and cervical rhytides. As with any of the new technological innovations currently available, understanding of the differing properties of the agents used and education in optimal technique is essential to clinical and esthetic success.

Cutaneous melanoma: available therapy for metastatic disease.

Abstract: Survival of melanoma varies widely by stage, from a potentially highly curable disease when detected in early stages, to a disease with dismal prognosis when it reaches advanced inoperable stages Stage IV melanoma defines distant metastasis and continues to comprise an ominous prognosis, with a median survival of 6-9 months Currently, there is no therapeutic agent known to prolong survival in patients with metastatic melanoma Therapeutic approaches studied in metastatic melanoma include chemotherapy, biochemotherapy, nonspecific immune adjuvants, cancer-specific vaccines, cytokines, monoclonal antibodies, and specific immunostimulants Chemotherapy with single-agent dacarbazine is the only United States Food and Drug Administration (US-FDA)-approved chemotherapy agent for metastatic melanoma Immunological approaches have yielded the only newly US-FDA-approved agent for metastatic disease in 30 years, high-dose bolus IL-2, based on durable responses in some patients with metastatic melanoma, but with associated high toxicity rate and cost A number of novel therapeutic agents are undergoing active clinical investigation

Debridement and wound bed preparation.

Abstract: Debridement can play a vital role in wound bed preparation and the removal of barriers that impair wound healing. In accordance with the TIME principles, debridement can help remove nonviable tissue, control inflammation or infection, decrease excess moisture, and stimulate a nonadvancing wound edge. There are many types of debridement, each with a set of advantages and disadvantages that must be clearly understood by the healthcare team. Failure to use the correct debridement method for a given type of wound may lead to further delays in healing, increase patient suffering, and unnecessarily increase the cost of care. This review article discusses the various methods of debridement, describes currently available debriding agents, evaluates the clinical data regarding their efficacy and safety, and describes strategies for the management of problematic nonhealing wounds.

Psychological problems in the acne patient

Abstract: Acne is a ubiquitous affliction that can leave physical and emotional scars that can persist throughout the life of the affected individual. Recent studies have substantiated the psychological impact and support a causal, and at times reciprocal, link between acne and the emotional and functional status of the patient. The present article will examine the recent data substantiating the emotional and functional impact of acne on the affected individual. Criteria to identify high-risk patients are provided. High-risk patients are those at increased risk for psychological and functional impairment or self-injurious behavior.

Wound bed score and its correlation with healing of chronic wounds

Abstract: Adequate wound bed preparation is essential for healing of leg ulcers, and consists of controlling exudate and edema, decreasing the bacterial burden, promoting healthy granulation tissue, and removing necrotic tissue. Currently, there is no classification system for wound bed preparation that has predictive value. Based on past work and the authors’ experience, we have now developed and tested a new classification system that scores the following parameters: healing edges (wound edge effect), presence of eschar, greatest wound depth/granulation tissue, amount of exudate amount, edema, peri-wound dermatitis, peri-wound callus and or fibrosis, and a pink/red wound bed. Each parameter receives a score from 0 (worst score) to 2 (best score), and all the parameter scores are added for a total score. Each wound can have a maximum score of 16 (the best score possible), to a minimum score of 0 (the worst score possible). We used this wound bed score (WBS) system in a study of 177 patients with venous ulcers who had been prospectively treated with and randomized to either conventional therapy (compression alone) or a living bilayered skin construct (BSC). We evaluated serial photographs at baseline to determine whether the results would be predictive of complete wound closure and could validate the WBS. We found that wounds that ultimately achieved full closure had a statistically significant higher WBS than those that did not heal (p = 0.0012). This was also true when separating wounds by treatment modality: standard therapy (p = 0.044) and treatment with a BSC (p = 0.011). When dividing the WBS in the following quartile groups: scores 4–10, 10–12, 12–13, and 13–16, the percentage of healed wounds correlated with the WBS (p = 0.0008). For all wounds, a one unit increase in total WBS resulted on average in a 22.8% increase in odds of healing (OR = 1.228). This WBS seems to have validity in predicting complete wound closure in wounds treated with either standard therapy or advanced modalities, such as BSC. If confirmed and widely adopted in this and other types of wounds, it could be a useful tool in both the clinical and research setting.

Diagnosis and management of the dermatologic manifestations of the polycystic ovary syndrome

Abstract: Polycystic ovary syndrome (PCOS) is a complex phenotypic spectrum of primarily hyperandrogenic signs and symptoms. PCOS is the most common endocrine disturbance to affect women of reproductive years. Although patients affected are often very disturbed by the cutaneous manifestations, including acne, hirsutism, alopecia, obesity, and acanthosis nigricans, the clinical manifestations of PCOS ramify far beyond the skin. PCOS frequently causes menstrual abnormalities and infertility. Insulin resistance is both pathogenic and a cause of numerous serious health consequences. The accurate diagnosis and recognition of cutaneous hyperandrogenism in PCOS are discussed. The differential diagnosis is reviewed. The work-up and approach to evaluation of patients with PCOS is presented. Although no uniform treatment approach for the management of the cutaneous manifestations of PCOS has been agreed upon, the data on various treatment options and the author's treatment approach to these patients are presented.

The psychosocial burden of childhood atopic dermatitis.

Abstract: Atopic dermatitis is an extremely common childhood disease of increasing prevalence that greatly affects the quality of life of afflicted children and of their families. The disease alters the emotional and social functioning of the affected child and their family. The complex multidimensional effects of atopic dermatitis in children and families have been described qualitatively and measured quantitatively with quality of life instruments. Emotional effects on both the child and parents are predominant. The burden of atopic dermatitis can be improved by targeting parents and caregivers with education, psychosocial support, and specialty care.

Retinoids in cosmeceuticals.

Abstract: Retinoids are natural and synthetic vitamin A derivatives. They are lipophilic molecules and easily penetrate the epidermis. Their biologically active forms can modulate the expression of genes involved in cellular differentiation and proliferation. Retinoic acid (tretinoin), its 13-cis isomer isotretinoin, as well as various synthetic retinoids are used for therapeutic purposes, whereas retinaldehyde, retinol, and retinyl esters, because of their controlled conversion to retinoic acid or their direct receptor-independent biologic action, can be used as cosmeceuticals. These natural retinoic acid precursors are thus expected to be helpful in (i) renewing epidermal cells, (ii) acting as UV filters, (iii) preventing oxidative stress, (iv) controlling cutaneous bacterial flora, and (v) improving skin aging and photoaging. Retinol and retinyl esters are not irritant, whereas demonstrating only a modest clinical efficiency. On the other hand, retinaldehyde, which is fairly well tolerated, seems to be the most efficient cosmeceutical retinoid; it has significant efficiency toward oxidative stress, cutaneous bacterial flora, epidermis renewing, and photoaging.

Prevention and management of pressure ulcers

Abstract: Pressure ulcers represent a major health problem causing a considerable amount of suffering for patients and a high financial burden for healthcare systems. The geriatric population with an increased risk of pressure ulcer development is rising constantly as a result of chronic degenerative diseases that can lead to prolonged immobilization and poor nutrition. Evidence clearly indicates that preventive measures are essential to reduce the prevalence rates of pressure ulcers; therefore healthcare professionals must be able to identify the appropriate strategies to adopt, in order to meet the individual patient's requirements. Important advances have taken place in the world of pressure ulcer treatment during the past decade. These advances are reflected in the high rate of cures being obtained. This, together with the implementation of prevention guidelines, the excellent cost/effectiveness relationship of the techniques described, and other factors, means that the field of pressure ulcers management is no more an isolated and self-administered issue in medical practice. The areas discussed here are those in which there will be linear or, in some cases, exponential growth in the decades to come.

Retinoid therapy of pigmentary disorders.

Abstract: Topical retinoids such as all-trans-retinoic acid (RA), 13-cis-retinoic acid (isotretinoin), retinol, retinaldehyde, tazarotene, and adapalene have been shown to improve dyspigmentation of photodamaged skin including mottling and actinic lentigines. RA monotherapy has also been demonstrated to improve melasma and postinflammatory hypermelanosis. Furthermore, RA in combination with hydroquinone or 4-hydroxyanisole, or azelaic acid increases the potency of depigmenting agents for the treatment of melasma, actinic lentigines, and postinflammatory hypermelanosis. The basic mechanisms underlying these effects are not completely identified. Topical retinoids stimulate the cell turn-over of epidermal keratinocytes and promote a decrease in melanosome transfer and a rapid loss of melanins via epidermopoiesis. Topical retinoids are also involved in the control of cell differentiation. Retinoid-induced changes in the stratum corneum and the permeability barrier may also facilitate the penetration of depigmenting agents in the epidermis and increase their bioavailability, leading to increased depigmentation. In addition, several in vitro studies demonstrate that cis and trans-retinoic acid inhibit UV-B stimulated melanogenesis in term of tyrosinase activity and melanin synthesis. It is likely that topical retinoids modulate epidermal melanin count via a direct action on melanocytes and epidermal keratinocytes.

Update on retinoid therapy of psoriasis in: an update on the use of retinoids in dermatology.

Abstract: Both in the topical and systemic treatment of psoriasis, retinoids are mainstays. In this chapter the history and modes of actions of retinoids are presented. Tazarotene and acitretin are the only retinoids that are available in both topical and systemic formulations. A more extensive description of their pharmacology, modes of action, indications and contraindications, clinical results, and treatment strategies will be presented. Finally, retinoid X receptor ligands and retinoic acid metabolism blocking agents will be introduced as potential future retinoid mimetics in psoriasis.

Treatment of cutaneous T‐cell lymphoma with retinoids

Abstract: Retinoids are biologic regulators of differentiation, proliferation, apoptosis, and immune response. Retinoids (all-trans retinoic acid, 13-cis-retinoic acid, and the synthetic analogs isotretinoin, etretinate, and acitretin) have been used for years as monotherapy and/or in combination for treatment of cutaneous T-cell lymphomas (CTCL). Orally administered bexarotene, the first synthetic highly selective retinoid X receptor retinoid to be approved by the Food and Drug Administration for CTCL, was shown to be active against the cutaneous manifestations of all stages of CTCL. The topical gel formulation was also effective for early cutaneous manifestations of CTCL or as an adjunct to systemic or phototherapy. Use of retinoids in future long-term clinical trials and their eventual application in CTCL regiments will require strategies to decrease the side effects of existing retinoids, identify novel receptor subtype-selective retinoids with better therapeutic index, and explore biologically based synergistic combination therapies with other active agents.

Update in retinoid therapy of acne

Abstract: The pathogenesis of acne, the most common skin disease, is complex and multifactorial. Clinical experience has demonstrated that parallel targeting of various pathogenetic factors, achieved either by mono- or combination therapy with appropriate drugs, represents the most effective approach to treating acne. Topical retinoids have been shown to expulse mature comedones, reduce microcomedone formation, and exert immunomodulatory effects. They have broad anti-acne activity without the risk of inducing bacterial resistance, which justifies their use as first-line treatment in most types of noninflammatory and inflammatory acne and makes them uniquely suitable as long-term medication to maintain remission after cessation of initial combination therapy. Systemic isotretinoin as a monotherapeutic agent strongly affects all four major pathogenetic factors and has been, in the hand of experienced dermatologists, a potent and safe agent for the treatment of severe and recalcitrant acne forms for more that 20 years. However, patient counseling, careful monitoring, and evaluation and management of adverse events are necessary. The use of isotretinoin has experienced a drawback now that its indication has been lowered from a first-line to a second-line medication.

Liquid injectable silicone for soft tissue augmentation

Abstract: Liquid injectable silicone is a unique soft tissue augmenting agent that may be effectively utilized for the correction of specific cutaneous and subcutaneous atrophies. Although historical complications have occurred, resulting likely from the presence of adulterants and impurities, modern purified silicone products approved by the Food and Drug Administration for injection into the human body may be employed with minimal complications when strict protocol is followed. In this article the present authors review the history and controversy regarding silicone as well as describe the appropriate indications, patient selection, instrumentation, treatment protocol, and anticipated complications involved with the use of liquid injectable silicone for soft tissue augmentation. Although its use is controversial, the present authors maintain that liquid injectable silicone is an important and effective augmenting agent for the long-term correction of scars and facial contour defects such as HIV facial lipoatrophy. Furthermore, it is a treatment modality deserving of continued investigation.

Tricks for improving compliance with acne therapy.

Abstract: Adherence to a medical regimen is the most important aspect of therapeutic efficacy. It goes without saying that a drug that is not used will not be effective. Reasons for noncompliance can be related to the specific disease state, to characteristics of the drugs chosen, to patient personality traits, and to effectiveness of the clinician in dealing with the individual patient. Recognizing, confronting, and improving noncompliant behavior are all part of an effective doctor-patient relationship.

Cutaneous melanoma: public health approach to early detection.

Abstract: Melanoma is a major public health problem. There will be a projected 60,000 cases of invasive melanoma diagnosed in 2005, and that number is increasing each year. Fortunately, the prognosis is improving as well, but we still have approximately 8000 deaths per year related to this tumor. To reduce this number of deaths, we need to look at the skin--inspect--and see--recognize potential early melanomas when we look at them. Most of the population does not see a dermatologist regularly, and there are many barriers to general clinicians inspecting the skin, including inadequacy of dermatologic skills. Patients are ultimately responsible for their own skin, but only a small proportion of people actually perform thorough skin self-examination on a recommended monthly basis. There are various tools used by some dermatologists to facilitate early detection, including total body and lesional photography and epiluminescence microscopy (dermoscopy) of lesions. A basic skin cancer triage algorithm has been developed and tested in primary care, with promising results for improving practice. The general population also needs better guidance on early melanoma detection. Hence, instead of relying on the "ABCDs" for a morphologic diagnosis, the message of "a new or changing skin lesion" is being promoted to facilitate early diagnosis of thin, curable tumors. Together, patients and clinicians can improve early detection to reduce melanoma-related mortality.

Does food allergy cause atopic dermatitis? Food challenge testing to dissociate eczematous from immediate reactions.

Abstract: The objective is to evaluate and diagnose, in a controlled setting, suspected food allergy causation in patients hospitalized for management of severe, unremitting atopic dermatitis (AD). Nineteen children were hospitalized at Oregon Health and Science University with atopic dermatitis from 1986 to 2003 for food restriction, then challenge, following standard recommendations. Challenges were prioritized by categories of (a) critical foods (e.g., milk, wheat, egg, soy); (b) important foods; and (c) other suspected foods. Patients were closely observed for evidence of pruritus, eczematous responses, or IgE-mediated reactions. If results were inconsistent, double-blind, placebo-controlled food challenge was performed. A total of 17 children with atopic dermatitis were assessed. Two could not be fully evaluated, thus were excluded from data tabulations. Only one positive eczematous food response was observed of 58 challenges. Three children had well-documented histories of food-induced IgE-mediated anaphylactoid or urticaria reactions to seafood and/or nuts and were not challenged with those foods. Atopic dermatitis, even in the highest-risk patients, is rarely induced by foods. Undocumented assumptions of food causation detract from proper anti-inflammatory management and should be discouraged. Immediate IgE-mediated food reactions are common in atopic dermatitis patients; such reactions are rapid onset, typically detected outside the clinic, and must be distinguished from eczematous reactions. Diagnosis of food-induced eczema cannot be made without food challenge testing. Such tests can be practical and useful for dispelling unrealistic assumptions about food allergy causation of atopic dermatitis.

Skin cancer chemoprevention with systemic retinoids: an adjunct in the management of selected high‐risk patients

Abstract: Systemic retinoids (isotretinoin, etretinate, and acitretin) have been shown to be effective chemotherapeutic agents in studies of patients with xeroderma pigmentosum, the nevoid basal cell carcinoma syndrome, and recipients of organ or bone marrow transplantation. In addition, patients who do not have these disorders but who are actively developing large numbers of new skin cancers may also benefit from this approach. All patients developing large numbers of skin cancers need rigorous UV protection and frequent dermatologic examinations. Although isotretinoin and acitretin share overlapping toxicities, there are differences that may affect drug choice. Because low doses may be effective, there are advantages to beginning treatment at a low dose, and subsequently, increasing dose if necessary, based on patient response. Laboratory monitoring including pregnancy testing should be performed before and during treatment. Long-term toxicity, primarily involving the skeletal system, can be monitored with imaging studies.

Cutaneous melanoma: making a clinical diagnosis, present and future.

Abstract: The minimum requirement for the general dermatologist for clinically assessing pigmented skin lesions is dermoscopy. In expert hands, this technique has been shown to improve both the sensitivity and specificity for the diagnosis of melanoma. This is also reflected by lower benign melanoma excision ratios and decreased excision rates. Evidence is mounting for the routine use of total body skin photography for patients with a very high risk of developing cutaneous melanoma. Both long-term (12 months) and short-term (3 months) digital dermoscopy monitoring has been shown to allow the detection of dermoscopically featureless melanoma and is central for the clinical assessment of melanocytic lesions at the Sydney Melanoma Diagnostic Center. The use of automated instruments for the diagnosis of cutaneous melanoma is still in an experimental phase, and its utility is dependent on the evidence that such instruments give a clinically useful expert second opinion. Currently, other noninvasive diagnostic techniques, such as in vivo confocal scanning laser microscopy, are reserved for clinical research settings.

Poly-L-lactic acid: a new dimension in soft tissue augmentation.

Abstract: Poly-L-lactic acid (PLLA) is a biodegradable, synthetic polymer of L-lactic acid that has been used in a variety of human medical applications for over 40 years. It has recently been approved in the United States for the treatment of HIV-associated facial lipoatrophy. This indication, combined with a European experience that indicates a clinical benefit persisting for up to 2 years, has made PLLA an increasingly popular injectable soft tissue filler in healthy patients. However, controlled clinical studies are necessary to determine whether PLLA benefits healthy patients seeking contour restoration as much as patients seeking treatment for HIV facial lipoatrophy. The present authors reviewed the background and clinical applications of PLLA as treatment for HIV-associated facial lipoatrophy and age-related facial volume loss.

Soft tissue augmentation 2006: filler fantasy.

Abstract: As an increasing number of patients seek esthetic improvement through minimally invasive procedures, interest in soft tissue augmentation and filling agents is at an all-time high. One reason for this interest is the availability of botulinum toxin type A, which works superbly in the upper face. The rejuvenation of the upper face has created much interest in injectable filling agents and implant techniques that work equally well in the restoration of the lower face. One of the central tenets of soft tissue augmentation is the concept of the three-dimensional face. The youthful face has a soft, full appearance, as opposed to the flat, pulled, two-dimensional look often achieved by more traditional surgical approaches. Injectable filling agents can augment and even at times, replace pulling. Additionally, with the lip as the focal center of the lower face, subtle lip enhancement is here to stay, and is in fact, the number one indication for injectable fillers. Moreover, minimally invasive soft tissue augmentation offers cosmetic enhancement without the cost and recovery time associated with more invasive procedures. As more and more physicians take interest in minimally invasive surgery, courses in cosmetic surgery techniques are becoming increasingly popular at the medical meetings of many specialties. Today, physicians have a much larger armamentarium of techniques and materials with which to improve facial contours, ameliorate wrinkles, and provide esthetic rejuvenation to the face. For a substance or device to be amenable for soft tissue augmentation in the medical community, it must meet certain criteria. It must have both a high "use" potential, producing cosmetically pleasing results with a minimum undesirable reactions, and have a low abuse potential in that widespread or incorrect or indiscriminate use would not result in significant morbidity. It must be nonteratogenic, noncarcinogenic, and nonmigratory. In addition, the agent must provide predictable, persistent correction through reproducible implantation techniques. Finally, the substance, agent or device must be approved by the U.S. Food and Drug Administration, which assures purity, safety, and accessibility, as well as much-needed information regarding use. Having a thorough understanding of the filling agents available, their indications and contraindications, as well as having thorough knowledge of implant technique are vital in providing the patient with an esthetically pleasing result.

The use of retinoids in the treatment of photoaging

Abstract: Photoaging describes the clinical and histologic consequences of chronic sun exposure, the key features of which--wrinkles and mottled hyperpigmentation--are frequently and erroneously attributed to the aging process. Although a number of surgical procedures can improve the clinical appearance of photoaged skin, the only medical therapy with proved benefit derived from randomized clinical trial evidence is the use of topical retinoids, particularly tretinoin, isotretinoin, and tazarotene. Retinoids are capable not only of repairing photoaged skin at both the clinical and biochemical levels but their use may prevent photoaging. There is in addition emerging evidence that topical retinoids could be beneficial in the treatment of intrinsically aged skin.

The use of systemic antibiotics in the treatment of chronic wounds.

Abstract: The role of microorganisms in the etiology and persistence of chronic wounds remains poorly understood. The chronic wound bed houses a complex microenvironment that typically includes more than one bacterial species. Difficulty lies in determining when the presence of bacteria impedes wound healing, thereby warranting intervention. Indications for antibiotic therapy and optimal treatment regimens are ill defined. The goal of this article is to describe the appropriate role of systemic antibiotics in the management of chronic wounds. A common sense approach will be offered based on six clinically pertinent questions: • Is infection present? • Are systemic antibiotics necessary? • Should treatment be enteral or parenteral? • What antibiotic or combination of antibiotics should be used? • What should be the duration of therapy? • What special circumstances are present (i.e., concomitant illnesses, potential drug–drug interactions) that can impact therapy?

The differential diagnosis of atopic dermatitis in childhood.

Abstract: Atopic is the most common of the dermatitides seen in infancy and childhood, but there are numerous other diseases that can mimic the skin findings These include seborrheic dermatitis, immunodeficiency, and psoriasis in infancy; scabies, tinea corporis infection, perioral, nummular, contact, and molluscum dermatitis in childhood It is sometimes extremely difficult to differentiate between ichthyosis and AD, and it is also important to differentiate AD from erythrodermic conditions including acrodermatitis enteropathica, biotin deficiency, and Netherton syndrome A rare condition in children that may mimic AD is mycosis fungoides

Childhood acne: evaluation and management.

Abstract: Acne is a disease that can be seen in the first year of life, early childhood, prepubertal age, and puberty. The purpose of this article is to review the clinical presentation and pathogenesis of the various forms of prepubertal acne and to propose guidelines regarding its evaluation and treatment. The early clinical recognition of the disease and prompt initiation of therapy in these age groups will help prevent the sequelae of emotional distress and severe scarring in both the child and parents.

Cutaneous melanoma and intervention strategies to reduce tumor-related mortality: what we know, what we don't know, and what we think we know that isn't so.

Abstract: The care of patients who have cutaneous melanoma (CM) has undergone a dramatic change during the past five decades. In an increasing majority of cases, CM is being discovered in a premetastatic phase of tumor progression. Most patients are being treated in the ambulatory setting with a minimum of inconvenience and economic cost, and modest re-excision margins have largely replaced the mutilating surgical exonerations that were once standard only four decades ago. Histopathologic assessment of the primary tumor is the most widely used staging procedure to determine who is most likely to develop metastatic disease. For patients who develop distant metastases, there is no therapy currently available, based on large-scale randomized trials, that will prolong patient survival. Therefore, establishing an early diagnosis in a premetastatic phase of tumor development must be the overriding goal of any intervention strategy that seeks to reduce CM-related mortality. Unfortunately, as a result of public messages that emphasize the role of ultraviolet radiation (UVR) exposure in tumor development, most general physicians and lay people believe that most if not all cases of CM are the direct result of UVR exposure. In fact, we do not know the case fraction of CM directly attributable to UVR, and the unintended consequences of current messages directly linking UVR exposure and CM development may be thwarting the primary intervention goal of reducing tumor-related mortality. More likely to have an immediate positive impact on CM-related mortality are public messages that encourage skin awareness and self-examination by patients, total skin screening examinations by physicians during routine care, and periodic lifetime surveillance of patients determined to have a high CM risk based on identifiable historic and phenotypic traits.

Cutaneous melanoma: interferon alpha adjuvant therapy for patients at high risk for recurrent disease.

Abstract: Systemic adjuvant therapy in melanoma patients is the systemic treatment that is administered with the goal of eradicating micrometastatic deposits in patients who are clinically free of disease after surgical removal of the primary melanoma, but with a high risk of systemic recurrence. Interferon-alpha (IFN-alpha) is one of the most frequently used adjuvant therapies. Several randomized trials evaluated the efficacy of IFN-alpha in melanoma patients. However, results from conducted trials are controversial. Twelve randomized IFN-alpha trials are discussed in detail. All trials, including meta-analysis, failed to demonstrate a clear impact of IFN-alpha therapy on overall survival in melanoma patients. Based on currently available evidence, IFN-alpha therapy in the adjuvant setting should not be considered standard of care for patients who have melanoma. Results from ongoing studies are awaited. Further research for this therapy is required.

Fat transplantation for treatment of the senescent face.

Abstract: For more than a century, clinicians have attempted to utilize fat for the treatment of tissue deficiencies and contour abnormalities. Autologous fat transplantation for soft tissue augmentation has become increasingly popular in recent years. This has occurred as a result of the present authors' comprehension that the aging face is not simply as a result of gravity-induced ptosis, but also as a result of volume loss secondary to the atrophy of tissues. The popularity of tumescent liposuction has brought renewed interest and accessibility of fat for transplantation. Newer techniques and approaches to augmentation have provided more predictable and reproducible results. Fat augmentation has become an effective, safe, and reliable method for restoring volume and correcting the atrophy that accompanies senescence. In this review, the present authors describe their approach and technique of fat transplantation for the aging face.