Klinische Formen der Akne

Acne is a very common dermatosis with characteristic clinical features. It is a polymorphic disease. The clinical expression ranges from non-inflammatory closed and open comedones to inflammatory papules, pustules, and nodules. Most patients have a mixture of non-inflammatory and inflammatory lesions, although some have predominantly one or the other. Acne varies in severity from a very distressing, socially disabling disorder to a state that has been regarded as physiological by some authors. The most severe forms of acne are acne fulminans and acne inversa. Although acne may occur in all age groups, it is most prevalent during adolescence. It is not known why acne subsides in most patients but persists into adulthood in some. Certain medications may be associated with provocation, perpetuation, or exacerbation of pre-existing acne or with acneiform eruptions. Acne-like disorders include rosacea, pseudofolliculitis barbae, and other conditions that share clinical features with acne.     

Historie und Anwendung der Filler zur Faltenbehandlung

The development of injectable fillers for filling in depressions or wrinkles in the face is reviewed. After the hesitant interest on fillers to correct scars and depressions which started at the end of the 19th century, the development of new substances continued at a dizzying pace when public demand to treat the signs of aging increased dramatically starting in the mid 1980s. This led to a countless number of different substances. To obtain an optimal result in treating facial wrinkles or depressions the appropriate filler must be injected with a technique that suits best the individual indication. Fillers are classified in resorbable and non-resorbable permanent fillers. With resorbable fillers only a temporary result can be obtained, which means that the patient has to undergo repetitive treatments. With permanent, non-resorbable fillers long lasting results can be obtained that may last for years and even decades. All fillers may have side effects like swelling, erythema, nodules right after treatment and in very rare cases years after the injection foreign body granulomas may develop that may be resistant to treatment.     

Adverse reactions to polylactic acid injections in the periorbital area

Background Correction of aging changes and contour deformities has been addressed largely by tissue augmentation agents whose volume is injected into tissues to achieve the required result. Polylactic acid (PLA) is an agent that is injected with the aim of enhancing the host's own collagen deposition. Objective We describe the development of multiple nodules and one case of a foreign‐body granuloma formation following the administration of PLA to the face for correction of rhytides and contour deformities. Methods Four case presentations, including clinical history, injection protocol, histopathology, individual treatment, and their outcomes, are discussed with pertinent literature review. Results Four patients who received injections of PLA developed nodules that were clinically similar in size, shape, and consistency. Histopathologic examination revealed the presence of a foreign‐body granulomatous inflammatory reaction in one of the patients. Conclusion Cosmetic treatment with PLA may be complicated by disfiguring nodules that may mask a granulomatous reaction. PLA‐induced nodules and foreign‐body granulomas have proven difficult to treat. Therefore, PLA should only be injected in the infraorbital area by experienced injectors who have had appropriate training. In addition to this, PLA should be injected in a “depot” method below the muscle at a significantly diluted volume. Due to the complications encountered after the use of PLA, we feel that a cautionary warning regarding the use of PLA in this area may be prudent regardless of the abovementioned precautions.     

Immunohistochemical analysis of the infiltrated cells in tinea capitis patients

Tinea capitis is a fungal infection of the skin and the hair with involvement of the hair shaft and the pilosebaceous unit. It may be the most common of all cutaneous mycoses in children. Tinea capitis can be inflammatory or noninflammatory. It is thought that humoral and cell-mediated immunities play a role in the formation of the clinical types of the disease. We studied twelve patients with acute inflammatory disease, four patients with chronic non-inflammatory disease, and one patient with a black-dot variant of tinea capitis. The composition of inflammatory infiltrates present in lesional skin was analyzed by antibodies to T cells (CD3) and B cells (CD20). Anti-CD3 revealed large numbers of T cells in twelve patients with acute, inflammatory dermatophytosis, whereas anti-CD20 revealed marked infiltrates of both B and T cells in all patients with chronic, non-inflammatory dermatophytosis. As a result, we thought that cell-mediated immunity might play a role in the acute, inflammatory type of tinea capitis and that humoral immunity might do so in the chronic, non-inflammatory type of tinea capitis.     

The 2016 International League of Dermatological Societies' revised glossary for the description of cutaneous lesions

Foreign body reactions are regularly seen as a late complication of cosmetic treatment with synthetic dermal fillers. Often this foreign body reaction is triggered by a systemic infection, but other systemic triggers are also reported. In this case report, we present a woman in her 60s who was treated with ipilimumab for metastatic melanoma. After two courses of treatment she developed painless facial nodules. A foreign body reaction to dermal fillers was suspected because the patient had received cosmetic treatment with dermal fillers 25 years previously. This reaction was confirmed by excision and histological examination. In the absence of other known triggers, this case revealed immunotherapy (ipilimumab) and subsequent activation of the adaptive immune system as potential triggers of foreign body reactions to dermal fillers. Immunotherapy is increasingly used as anticancer treatment for an increasing number of tumour types. Furthermore, synthetic dermal fillers have frequently been used in the past. Therefore, physicians should be aware of this late‐occurring complication of synthetic filler treatment in patients who develop skin lesions during immunotherapy.     

Delayed immune-mediated adverse effects related to hyaluronic acid and acrylic hydrogel dermal fillers: clinical findings, long-term follow-up and review of the literature

Introduction Implantation of dermal filler for cosmetic purposes is becoming increasingly common worldwide. It is thought that hyaluronic acid (HA) alone or combined with acrylic hydrogels (HA‐AH) does not have severe nor persistent side‐effects. However, recent evidence may show that major, local and/or systemic, immediate or delayed adverse effects may appear in relation with its use. Objective To evaluate the clinical complaints, laboratory data, treatment and follow‐up of patients with delayed adverse effects related to HA and HA‐AH implant fillers. Design Prospective, case‐series study of patients filled with HA and HA‐AH compounds. Setting The study has been done in a tertiary, teaching university hospital. Patients We report on a series of 25 patients, 15 of them in prospective manner, with severe, delayed side‐effects related to HA‐AH. Inclusion criteria have been drawn up. Patients with immediate side‐effects were excluded. Patients were submitted to a clinical follow‐up, battery of blood tests and thorax X‐ray films. Besides, a review of the literature was made. We undertook a computed‐assisted (MEDLINE), National Library of Medicine, Bethesda, MD, USA, search of the literature from 1996 up to December 2005. Main outcome Clinical evaluation of granulomas, skin manifestations and other local and systemic immune‐mediated disorders possibly related to HA and HA‐AH fillers or their cumulative interaction with previously administered fillers. Results Of 25 cases, 16 were filled with HA alone and 9 with a HA‐AH compounds. Of 15 cases analysed and with long‐term follow‐up, 10 were filled with HA alone, and the remaining five were filled with a HA‐AH. Time latency average up to beginning of symptoms was 13.7 months. Three of these 15 cases had been filled before with silicone and another one with Artecoll. Tender nodules were seen in 14 patients. Systemic manifestations appeared in three cases. Laboratory abnormalities were noted in all studied cases. After 16‐month average follow‐up, seven patients seem to be cured, and six have recurrent bouts. Two cases were lost during follow‐up. Conclusion Although in some cases, these clinical complications might have been associated with previous fillers or with other unknown foreign bodies, we feel that, although infrequently, delayed and recurrent chronic inflammatory and granulomatous reactions may complicate HA and HA‐AH implant fillers.     

Inadvertent intra‐arterial injection of deoxycholic acid: A case report and proposed protocol for treatment

Deoxycholic acid (ATX‐101) is a secondary bile acid that was approved as an injectable drug for the reduction of submental fat. Necrosis, an uncommon but serious adverse event, can occur due to inadvertent superficial injection or intra‐arterial injection of the acid. The management of the intra‐arterial injection of deoxycholic acid has not been well characterized. Here, we discuss methods to decrease the risk of such injections and draw on existing protocols for the inadvertent intra‐arterial injection of sclerotherapy solutions and dermal fillers to propose a safe, practical approach to treatment. A case report is presented of a 42‐year‐old woman who received a deoxycholic acid injection for the correction of submental fullness, which was complicated by the inadvertent intra‐arterial injection of the acid. The adaptation of published treatment protocols for the inadvertent injection of sclerosing solutions and dermal fillers allowed for a good outcome in this patient. The inadvertent intra‐arterial injection of deoxycholic acid is a rare event. The risk of such injections can be reduced with attention to injection technique and can be managed successfully following the adaptation of protocols in the literature for similar events from vascular compromise due to dermal fillers and sclerosing solutions.     

Ästhetische Dermatologie

Younger and younger patients are undergoing aesthetic procedures to achieve "wrinkle-free" aging. This has had great impact on the field of aesthetic dermatology. The rapid development of new indications and filler materials requires a critical approach to the available substances particularly concerning side effects and long-term effects. The quality of the chosen approach depends on the applied filler substance, clear indication the compliance of the patient and the experience of the physician. The growing expectations of patients require a critical analysis of the available therapy options. Botulinum toxin A is one of the preferred treatments for wrinkles secondary to facial expression. In addition there are a variety of biologically inert and completely resorbable filler materials such as collagen and hyaluronic acid and autologous materials such as fat implants or plasma gel available. This article gives an overview about the most common fillers and their use in aesthetic dermatology.     

Hyaluronic acid-based fillers in patients with autoimmune inflammatory diseases

The use of hyaluronic acid (HA)-based aesthetic therapies is growing steadily, and according to the International Society of Aesthetic Plastic Surgery, more than 4.3 million aesthetic procedures using HA were performed in 2019, an increase of 15.7% than 2018. More people are offering these types of services, often without proper training or qualifications. Therefore, there is an increasing number of reports in the literature relating to possible adverse events, with subsequent therapeutic problems and more or less serious consequences for patients. The aim of this research is to carry out a review of the literature in order to evaluate the impact of hyaluronic acid-based fillers in patients with autoimmune inflammatory diseases, in particular scleroderma and Systemic Lupus Erythematosus (SLE). Although HA plays a central role in the inflammatory process, the use of HA-based fillers in patients with autoimmune inflammatory diseases is still controversial. HA, in fact, in inflamed tissues helps to propagate the inflammatory response and, injected in the form of a dermal filler, could potentially promote reactivation of the underlying disease. For this reason, many specialists do not perform HA-based aesthetic treatments in patients with scleroderma or SLE. However, recent scientific evidence suggests that the use of HA-based fillers in patients with scleroderma can lead to improvement of skin lesions, with satisfactory results. In the literature, there are no clinical studies that contraindicate the administration of HA-based dermal fillers in patients with inflammatory disease.     

Analysis of common side effects of isotretinoin

Patients with severe recalcitrant nodular acne that is unresponsive to conventional therapy (including topical and systemic antibiotics) have few alternative effective treatment modalities other than the use of oral isotretinoin (Accutane). The cause of acne vulgaris is multifactorial, but the pathogenesis of this disorder of the pilosebaceous follicles arises mainly from endogenous factors. It is usually, but not always, associated with the onset of puberty. Severe acne, defined by the prevalence of facial and truncal inflammatory lesions, is a disfiguring disease that can often result in significant permanent scarring after the healing of deep inflammatory lesions and other disorders, such as systemic bacterial infections. Topical treatments are considered as the first line of therapy for less severe forms of acne, although systemic treatments such as antibiotics or antiandrogen agents are effective for either mild or moderate forms and sometimes effective for severe acne. However, in many patients with large numbers of nodules, longer treatment periods with these agents are required to reduce the count of inflammatory lesions. It has become increasingly evident that (because topical agents and antibiotic or antiandrogenic therapy have a slow onset of action) even mild or moderate acne that is treated in this way can result in scarring. In addition, the excessive use of systemic antibiotics has led to the detection of increasing numbers of antibiotic-resistant bacteria on the skin of patients with acne.(1) Therefore, because of its relatively rapid onset of action and its high efficacy with reducing more than 90% of the most severe inflammatory lesions, Accutane has a role as an effective treatment in patients with severe acne that is recalcitrant to other therapies.     

Current therapeutic approach to acne scars

The occurrence and incidence of acne scarring is different. Lasting for years, acne can cause both physical and psychological scarring. Scarring frequently results from severe inflammatory nodulocystic acne but may also result from more superficial inflamed lesions or from self-manipulation. There are two general types of acne scars: hypertrophic (keloid) scars, and atrophic (icepick, rolling and boxcar) scars. The management of acne scarring includes various types of resurfacing (chemical peels, lasers, lights, cryotherapy), use of dermal fillers, and surgical methods such as dermabrasion, subcision or punch excision. Individual scar characteristics, including color, texture and morphology, determine the treatment choice. Combining treatment methods may provide additional improvement compared with one method alone. It should be noted that none of the currently available treatments can achieve complete resolution of the scar. The best method of preventing or limiting scarring is to treat acne early enough to minimize the extent and duration of inflammation.     

Erythema nodosum

Erythema nodosum is the most common and, in its classic form, the most easily recognized cause of inflammatory nodules on the legs. It is characterized by inflammatory, tender, nonulcerating, nonscarring nodules that are typically multiple and bilateral. The rather characteristic clinical presentation can be attributable to one of many causes or associated with a wide spectrum of systemic diseases. Diagnosis, evaluation, and treatment are discussed.     

Secondary follicular mucinosis associated with systemic lupus erythematosus

A 61-year-old woman presented with a five-month history of an intermittent eruption of papules and nodules on her face and neck. Past medical history included systemic lupus erythematosus. Histopathologic examination was consistent with secondary follicular mucinosis in association with systemic lupus erythematosus. This rare entity has been described in one prior report as a precursor to the clinical onset of systemic lupus erythematosus. Follicular mucinosis occurs as either a primary idiopathic form or a secondary form associated with either benign inflammatory processes or malignant conditions, such as cutaneous T-cell lymphoma. Numerous treatments for primary follicular mucinosis have been described, which include isotretinoin and glucocorticoids, whereas treatment of the underlying disease is necessary in the secondary form. The association with lymphoma mandates long-term clinical monitoring of patients with particularly recalcitrant, widespread, or chronic follicular mucinosis.     

Foreign body granuloma formation secondary to silicone injection

Injectable silicone has been used extensively over the last 40 years for soft tissue augmentation. Although considered biologically inert, this material has been implicated in a variety of adverse reactions including granulomas, disfiguring nodules, and lymphedema, sometimes with latent periods of decades. Often these complications are a result of the use of industrial grade products injected by unlicensed or unskilled practitioners. Here we report a case of foreign body granuloma in the thigh secondary to silicone injection in the buttocks. Initially the patient did not disclose a cosmetic contouring procedure administered by a nonprofessional nine months earlier, making diagnosis difficult. We remind clinicians to include foreign body granulomas in the differential diagnosis of apparent cellulitis and to question patients about the use of injectable fillers.     

Topical Retinoids in Acne Vulgaris

Topical retinoids represent a mainstay of acne treatment because they expel mature comedones, reduce microcomedone formation, and exert anti-inflammatory effects. The first-generation retinoid tretinoin (all-trans retinoic acid) and the synthetic third-generation polyaromatics adapalene and tazarotene are approved for acne treatment by the US FDA, whereas topical tretinoin, isotretinoin (13-cis retinoic acid), and adapalene are accredited in Canada and Europe. Topical retinoids have a favorable safety profile distinct from the toxicity of their systemic counterparts. Local adverse effects, including erythema, dryness, itching, and stinging, occur frequently during the early treatment phase. Their impact varies with the vehicle formation, skin type, frequency and mode of application, use of moisturizers, and environmental factors such as sun exposure or temperature. The broad anti-acne activity and safety profile of topical retinoids justifies their use as first-line treatment in most types of non-inflammatory and inflammatory acne. They are also suitable as long-term medications, with no risk of inducing bacterial resistance, for maintenance of remission after cessation of initial combination therapy.     

Increased risk of late‐onset,immune‐mediated,adverse reactions related to dermal fillers in patients bearing HLA‐B*08 and DRB1*03 haplotypes

Even though manufacturers claim that the dermal fillers are nontoxic and nonimmunogenic, adverse events may occur. Clinically and histologically, most of the late onset adverse events present as an inflammatory response. To assess whether HLA polymorphisms are associated with late‐onset inflammatory adverse events related to dermal fillers. A total of 211 patients were included, of whom 129 experienced late‐onset inflammatory adverse events to different fillers (Inflammation group) and 82 who did not (Reference group). Patients completed a standardized questionnaire and provided a blood sample or oral swap for HLA testing. The study population consisted of 188 (89%) women and 23 (11%) men. The two study groups were similar in the distributions of filler type, location of injecting, allergy, autoimmune disease, gender, age, ethnicity, and smoking status. Of the 211 patients in the sample, 25 had the combination of HLA subtype‐B*08 and HLA subtype‐DRB1*03. This was 16.3% of the inflammatory group and 4.9% of the reference group. This combination of HLA subtypes was associated with an almost 4‐fold increase in the odds of developing immune mediated adverse events (odds ratio = 3.79, 95% CI 1.25‐11.48). Genetic polymorphisms such as HLA combinations may identify patients at risk of developing late onset immune mediated adverse events to dermal fillers.     

Erythema nodosum

Erythema nodosum is the most frequent clinico-pathological variant of the panniculitides. The disorder is a cutaneous reaction consisting of inflammatory, tender, nodular lesions, usually located on the anterior aspects of the lower extremities. The process may be associated with a wide variety of diseases, being infections, sarcoidosis, rheumatologic diseases, inflammatory bowel diseases, medications, autoimmune disorders, pregnancy, and malignancies the most common associated conditions. The typical eruption consists of a sudden onset of symmetrical, tender, erythematous, warm nodules and raised plaques usually located on the shins, ankles and knees. Often the lesions are bilaterally distributed. At first, the nodules show a bright red color, but within a few days they become livid red or purplish, and finally they exhibit a yellow or greenish appearance taking on the look of a deep bruise. Ulceration is never seen and the nodules heal without atrophy or scarring. Some clinical variants of erythema nodosum have been described under different names, including erythema nodosum migrans, subacute nodular migratory panniculitis, and chronic erythema nodosum, but probably they are just clinical variants which may all be included within the spectrum of erythema nodosum. Histopathologically, erythema nodosum is the stereotypical example of a mostly septal panniculitis with no vasculitis. The septa of subcutaneous fat are always thickened and variously infiltrated by inflammatory cells that extend to the periseptal areas of the fat lobules. The composition of the inflammatory infiltrate in the septa varies with age of the lesion. In early lesions edema, hemorrhage, and neutrophils are responsible for the septal thickening, whereas fibrosis, periseptal granulation tissue, lymphocytes, and multinucleated giant cells are the main findings in late stage lesions of erythema nodosum. A histopathologic hallmark of erythema nodosum is the presence of the so-called Miescher's radial granulomas, which consist of small, well-defined nodular aggregations of small histiocytes arranged radially around a central cleft of variable shape. Treatment of erythema nodosum should be directed to the underlying associated condition, if identified. Usually, nodules of erythema nodosum regress spontaneously within a few weeks, and bed rest is often sufficient treatment. Aspirin, nonsteroidal anti-inflammatory drugs, such as oxyphenbutazone, indomethacin or naproxen, and potassium iodide may be helpful drugs to enhance analgesia and resolution. Systemic corticosteroids are rarely indicated in erythema nodosum and before these drugs are administered an underlying infection should be ruled out.     

Polymethylmethacrylate‐induced nodules of the lips: Clinical presentation and management by intralesional neodymium:YAG laser therapy

The lips are essential part of the beauty and attractiveness of the human face. Lip augmentation has become an increasingly used method to improve appearance. Soft tissue fillers are the most commonly used tools. Permanent fillers, however, have been associated with unwanted side effects after lip augmentation. In the present article the present authors will focus on permanent fillers based on polymethylmethacrylate (PMMA). The present authors provide a short review on PMMA fillers and known associated adverse events. The present authors provide a critical review of treatment options. Illustrated by clinical cases The present authors report our preferred treatment of PMMA nodules on lips by intralesional neodymium:YAG laser and blunt suction cannula with or without minor surgery.     

Cutaneous pseudolymphoma, lymphomatoid contact dermatitis type, as an unusual cause of symmetrical upper eyelid nodules

We describe a 74-year-old woman who rapidly developed bilateral voluminous nodules on the upper eyelids, following 4 months' treatment for chalazion. Histological and immunohistochemical findings were suggestive of cutaneous pseudolymphoma (CPL), and extensive screening for malignant lymphoma (ML) remained negative. Cutaneous pseudolymphomas are inflammatory diseases that can simulate ML either clinically, histopathologically, or both. They are a rare cause of nodules of the upper eyelids, usually characterized by a benign evolution, that can be secondary to ultraviolet sensitivity, adverse reactions to systemic medications and contact sensitization, among others. In our case, epicutaneous patch tests were strongly positive for a series of allergens contained in the ophthalmological preparations used; therefore, they were suggestive that the patient had CPL, lymphomatoid contact dermatitis type. In addition, the patient had been treated previously with several drugs, known to cause CPL and immune dysregulation. Complete regression of the lesions required treatment with systemic steroids and chlorambucil. No relapse occurred within a 5-year follow-up period.