Postsurgical Use of Imiquimod 5% Cream in the Prevention of Earlobe Keloid Recurrences: Results of an Open-Label, Pilot Study

Background. Traditional surgical modalities for the management of earlobe keloids are often associated with high recurrence rates. A recent report suggests that imiquimod 5% cream can be effective in the prevention of keloid recurrences after surgical excision.
Method. To establish the safety and efficacy of imiquimod 5% cream in the prevention of recurrences of excised earlobe keloids.
Methods. Patients who attended a dermatologic surgery clinic for the treatment of earlobe keloids were recruited into the study. Earlobe keloids underwent parallel shave excision. Imiquimod 5% cream was applied daily for 8 weeks followed by an observation period of 16 weeks. In patients who presented with bilateral earlobe keloids, paired comparisons of imiquimod versus intralesional steroid injections were performed.
Results. Eight earlobes were treated with imiquimod 5% cream after parallel keloid removal. Twenty-four weeks after surgery, six (75%) remained recurrence free. Four patients underwent bilateral paired comparisons. At the end of the observation period, two patients (50%) remained recurrence free in the imiquimod-treated areas while experiencing recurrences in the intralesional steroid–treated areas. Local irritation secondary to imiquimod application required rest periods in three cases. In all cases, patients were able to resume therapy and completed the study without further complications.
Conclusion. Although small and uncontrolled, the results of this open-label, pilot study suggest that imiquimod 5% cream may prove to be a reasonably effective adjuvant therapeutic alternative for the prevention of recurrences in excised earlobe keloids.
DR. Martín-García HAS BEEN A CONSULTANT AND SPEAKER FOR 3M PHARMACEUTICALS.     

Infiltrative Trichilemmal Carcinoma Treated with 5% Imiquimod Cream

Background. Trichilemmal carcinoma (TLC) is a rare cutaneous neoplasm that occurs in the sun-exposed skin of the elderly. Although the clinical behavior of TLC appears to be relatively indolent, wide excision or Mohs micrographic surgery is the recommended treatment owing to its locally aggressive growth. Recently, imiquimod has become an important part of the armamentarium in the treatment of nonmelanoma skin cancer.
Objective. This article serves to remind dermatologists that in addition to Mohs micrographic surgery and surgical excision, imiquimod 5% cream may have a role in the treatment of TLC.
Methods. In addition to a review of the literature, we present a case of TLC successfully treated with 5% imiquimod cream.
Conclusion. Its nonsurgical approach and excellent cosmetic result make imiquimod 5% cream another promising therapeutic option for TLC, even though it is histologically infiltrative.     

Treatment of Lentigo Maligna with Imiquimod before Staged Excision

BACKGROUND Imiquimod 5% cream has demonstrated effectiveness in the treatment of lentigo maligna (LM) in several small studies. None of the studies to date have included posttreatment surgical removal to confirm negative histologic margins.
OBJECTIVE The aim of this retrospective analysis was to assess the efficacy of topical imiquimod in LM by circumferentially examining vertically oriented sections from a geometrically designed "picture frame" margin as well as bread-loafed sections of the central portion after staged excisions of imiquimod-treated lesions of LM.
METHODS Forty patients with biopsy-confirmed LM were treated five times a week for 3 months with 5% imiquimod cream before staged excision. Tazarotene 0.1% gel was added when no clinical signs of erythema developed with imiquimod alone after 1 month (10 patients). After the course of topical therapy, patients were assessed for clinical and complete histologic clearance after staged excision.
RESULTS A total of 33 of 40 patients had a complete clinical response as determined by the absence of remaining clinical lesion on physical examination. Upon histologic review, 30 of 40 patients had no evidence of LM whereas 10 of 40 harbored residual disease. One patient was found to have histologic evidence of invasion after completing the topical protocol. After a mean follow-up of 18 months (range, 12–34 months) and after complete surgical excision of the treatment site, none of the imiquimod-treated patients had evidence of recurrence.
CONCLUSIONS Imiquimod appears to be an effective adjunctive treatment for LM but does not qualify as a replacement therapy for surgery.     

Topical imiquimod therapy for lentigo maligna

Lentigo maligna (LM) presents a challenge for complete surgical excision. Imiquimod is a topical immune-response modifier that acts on the immune system. We report our experience using imiquimod 5% cream as a surgical alternative for treatment of LM. Consecutive patients between December 2004 and February 2006 with LM were treated with topical imiquimod. Data on patient and lesion characteristics, side effects of therapy, posttreatment biopsy results, and follow-up was collected. Seven patients were treated with imiquimod 5 nights/wk for 12.4 weeks. Complete histologic and clinical resolution was seen in 86% (6 of 7 patients), at 19.1 months follow-up. Side effects included erythema (86%) and crusting (71%), resulting in dose alteration in 71% of patients. Topical imiquimod therapy demonstrates a high response rate for treatment of LM, with tolerable side effects. Further investigation into its efficacy in the treatment of LM in controlled clinical trials is warranted.     

Efficacy of 1% 4-Ethoxybenzaldehyde in Reducing Facial Erythema

Background. Facial erythema is a common postsurgical and dermatologic problem. It is commonly the result of dermal inflammation arising from either a facial surgical procedure, such as laser resurfacing, dermabrasion, or a face peel, or from an underlying dermatologic condition, such as rosacea. Facial erythema is difficult for the dermatologist to treat in both settings because topical corticosteroids cannot be used long term on the thin facial skin and anti-inflammatory oral or topical antibiotics have associated side effects.
Objective. The goal of this pilot study was to evaluate the anti-inflammatory effect of 1% 4-ethoxybenzaldehyde in a rosacea model of facial erythema.
Methods. Thirty subjects with mild to moderate stable rosacea were enrolled in this 4-week, double-blind, vehicle-controlled study. Photographs, investigator assessment, and subject assessment were the efficacy criteria.
Results. There was a statistically significant reduction in facial erythema (p<.01) in those subjects who used the active for 4 weeks, as well as a statistically significant improvement in uneven skin tone (p<.01) and the overall severity of the disease (p<.01). There was no statistically significant difference in any of these three indices in the vehicle-treated group.
Conclusion. The results suggest that benzaldehyde-derived anti-inflammatory agents may be useful in reducing facial erythema in a rosacea model.
THIS STUDY WAS FUNDED BY AN EDUCATIONAL GRANT FROM CUTANIX CORPORATION. ZOE DRAELOS, MD, HAS INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS. BRYAN FULLER, PHD, IS THE INVENTOR OF THE ACTIVE, WHICH WAS LICENSED THROUGH THE OKLAHOMA HEALTH SCIENCES CENTER TO CUTANIX.     

The Use of Imiquimod 5% Cream for the Treatment of Superficial Basal Cell Carcinomas in a Basal Cell Nevus Syndrome Patient

Background. Imiquimod 5% cream has been used effectively to treat superficial basal cell carcinomas (BCCs).
Objective. The purpose of this study is to examine the effectiveness, tolerability, and desirability of imiquimod 5% cream in treating superficial non-facial basal cell carcinomas in a patient with basal cell nevus syndrome.
Methods. Three biopsy-proven nonfacial BCCs were treated for 18 weeks with once daily application of 5% imiquimod cream. The lesions were then removed to search histologically for residual tumor.
Results. The two adequately treated tumors revealed no residual BCC upon removal. Our patient reported that he tolerated the treatment but he would not desire this treatment again based on the length of treatment time and the degree of local inflammation at the treatment sites.
Conclusion. Imiquimod 5% cream appears to be effective in eradicating superficial nonfacial BCCs. The degree of local inflammatory response may affect the patients' tolerability of treatment and therefore patient compliance.     

5% Imiquimod Cream and Reflectance-Mode Confocal Microscopy as Adjunct Modalities to Mohs Micrographic Surgery for Treatment of Basal Cell Carcinoma

Background. Imiquimod is an immune response modifier that up-regulates cytokines and has been shown in clinical studies to reduce or clear basal cell carcinoma tumors when applied topically.
Objective. The objectives were to evaluate the efficacy of 5% imiquimod cream in treating basal cell carcinoma preceding excision by Mohs micrographic surgery and to determine if reflectance-mode confocal microscopy is useful to establish the need for surgical intervention after imiquimod treatment.
Methods. Subjects applied study cream to one biopsy-confirmed basal cell carcinoma tumor 5 ×/week for 2, 4, or 6 weeks in this vehicle-controlled, double-blind study. Confocal microscopy was used for the 6-week treatment group to examine the target tumor area at each interval visit and immediately before Mohs micrographic surgery. After the Mohs micrographic surgery excision, the tissue was evaluated histologically, and the excision area was measured. Confocal microscopy readings were correlated to the histologic diagnosis.
Results. Tumors cleared or the target tumor area was reduced in subjects in the 4- and 6-week dosing regimens. Confocal microscopy assessments correlated well with the histologic diagnosis.
conclusion. Imiquimod improved excision results relative to vehicle when used for treating basal cell carcinoma before Mohs micrographic surgery. Confocal microscopy assessments correlated well with tumor response to therapy, suggesting that confocal microscopy may help determine the need for surgery.     

Successful Treatment of Persistent Melanoma In Situ with 5% Imiquimod Cream

Background. Five percent imiquimod cream, a topically applied immune response modifier with potent antiviral and antitumor activity, has been reported to be effective in the management of lentigo maligna and cutaneous metastases from melanoma.
Objective. We report a case in which 5% imiquimod cream was effective in the management of a persistent melanoma in situ.
Methods. Five percent imiquimod cream was applied to the affected area twice to three times a week, as tolerated.
Results. After 4 months of treatment, repeated biopsies of the previously affected areas showed complete regression of the melanoma.
Conclusion. Treatment of melanoma in situ of sun-damaged areas with 5% imiquimod cream certainly appears warranted in selected cases where surgical procedures have failed or are not feasible owing to factors such as size and/or localization of the lesion, advanced age, or deteriorated medical status of the patient. Rigorous posttreatment follow-up is mandatory, because long-term recurrence rates after treatment of melanoma in situ with imiquimod are yet unknown.     

Experimental Nonsurgical Tattoo Removal in a Guinea Pig Model with Topical Imiquimod and Tretinoin

BACKGROUND: Tattoo removal is a common request in dermatologic surgery practices. Conventional tattoo removal modalities consist of mechanical, chemical, and thermal methods, but these interventions may result in undesirable dermal damage, disfiguring scars, and pigmentary changes. OBJECTIVE: To evaluate the efficacy of topical imiquimod and tretinoin for the removal of tattoos in a guinea pig model. METHODS: Five albino guinea pigs (A-E) were tattooed with black, red, green, and yellow. Beginning 6 hours after tattooing, A received no treatment, B was treated with petrolatum, C had imiquimod cream alternating with tretinoin gel, D had imiquimod cream alone, and E received tretinoin gel alone. The animals were treated for 7 days. Biopsies of the tattoos were taken at 6 hours, 7 days, and 28 days. RESULTS: Control guinea pig B had normal-appearing tattoos with consistent histopathology on day 28. Guinea pig D, treated with imiquimod cream clinically, had no visible tattoo, consistent with greatly diminished or no dye evident on histopathology. Guinea pig E, treated with tretinoin gel, and guinea pig C, treated with combination tretinoin gel and imiquimod cream, had faded tattoos and moderate clearance of pigment on histopathology. CONCLUSION: In the guinea pig, the use of imiquimod was successful as a nonsurgical method of acute-phase tattoo removal, but was associated with fibrosis and the loss of dermal appendages.     

NewFill for Skin Augmentation: A New Filler or Failure?

Background New injectable materials for skin augmentation that promise to be the ideal filling material are introduced every year. Recently, we treated three patients with adverse reactions to a new substance for skin augmentation: polylactic acid (NewFill, Ashford Aesthetics Inc, Belgium).
Objective To present three cases in which serious adverse reactions had occurred after skin augmentation with a new filling substance, polylactic acid (NewFill). Because an identical substance (Sculptra, Aventis Pharmaceuticals, Bridgewater, NJ, USA) was recently introduced in the United States, we want to alert future users of these substances to possible adverse events.
Materials and Methods We report three cases with serious adverse events more than 12 months after skin augmentation with polylactic acid (NewFill). They were treated with intralesional steroid therapy and topical imiquimod application.
Results Both intralesional steroid therapy and topical imiquimod application lead to moderate results. If feasible, surgical excision is the best available option.
Conclusions Great care should be taken when polylactic acid is used for intradermal injection because giant cell granulomatous reactions may be the result. Other than surgical excision, effective treatment options are lacking.     

Successful Treatment of Earlobe Keloids with Imiquimod after Tangential Shave Excision

BACKGROUND: The treatment of earlobe keloids has historically been suboptimal; characterized by discomfort, poor response, and high rates of recurrence. Keloids are characterized by increased fibroblast activity in the setting of an altered cytokine profile. OBJECTIVE: To investigate whether topical imiquimod 5% cream applied postoperatively after tangential excision can prevent recurrence of earlobe keloids. METHODS AND MATERIALS: Four patients with a total of eight large pedunculated earlobe keloids (five of which were recurrent lesions) were treated with debulking by tangential shave excision followed by daily application of imiquimod 5% cream for 6 weeks. RESULTS: At 6 and 12 months post-treatment there was an excellent cosmetic result and no evidence of recurrence in any of the lesions. Patients with keloids that were itchy and painful were completely asymptomatic at the conclusion of the study. CONCLUSION: In this pilot study, imiquimod 5% cream following tangential shave excision was efficacious for the treatment of earlobe keloids. Further study is warranted to confirm the utility of imiquimod 5% cream in the treatment of earlobe keloids, as illustrated herein.     

Eruptive Epidermoid Cysts Resulting from Treatment with Imiquimod

Background Because of its unique mechanism of action and safety profile, imiquimod, a topical immune response modifier, is used for many benign and malignant dermatologic conditions. Adverse effects are typically limited to treatment site erythema and erosion.
Objective To describe a newly recognized adverse effect of imiquimod.
Methods A 79-year-old woman being treated with imiquimod 5 days per week for a nodular basal cell developed a verrucous plaque over the treatment area after 7 weeks of therapy.
Results Scouting biopsies demonstrated multiple comedones and ruptured epidermoid cysts. There was no evidence of residual basal cell carcinoma.
Conclusions Imiquimod is a new and novel treatment option for cutaneous malignancies. We report its successful use in the treatment of a nodular basal cell carcinoma. The multiple comedones and ruptured epidermoid cysts are newly reported adverse effects of imiquimod therapy.     

Topical Imiquimod as an Adjuvant to Laser Removal of Mature Tattoos in an Animal Model

BACKGROUND: Lasers are a commonly employed method of tattoo removal; however, numerous treatments are often needed and laser treatment may fail to eliminate the tattoo completely. It has been shown in animal studies that topical application of imiquimod cream, alone, fades tattoos. It is suspected that the combination of both imiquimod and laser treatment will result in enhanced tattoo pigment clearance. OBJECTIVE: The objective was to evaluate the efficacy of topical imiquimod cream as an adjuvant to laser removal of mature tattoos. METHODS: Fourteen albino guinea pigs were tattooed with black ink, then randomly assigned into two groups: one underwent sequential laser treatments with a Q-switched alexandrite laser in conjunction with triweekly applications of 5% imiquimod cream, while the other group underwent laser therapy alone. Subjects were evaluated with clinical photographs and skin biopsies after six laser treatment sessions. RESULTS: The combination laser and imiquimod treated group was clinically and histologically rated as having less pigment than the tattoos that were treated with laser alone (p=.012 and p=.047, respectively). Adjuvant imiquimod treatment had greater inflammation (p=.002) and fibrosis (p=.002) on posttreatment skin biopsies. CONCLUSION: Imiquimod appears to be a useful adjuvant to experimental laser tattoo removal in guinea pigs.     

Adhesive strips versus subcuticular suture for mediansternotomy wound closure

Abstract Background and Aim: This prospective randomized study was undertaken to compare the use of the 3M™ Steri‐Strip™ S Surgical Skin closure system with a running absorbable subcuticular suture technique for skin closure following a mediansternotomy for cardiac surgical procedures. Methods: Thirty‐six patients undergoing a mediansternotomy for a cardiac surgical procedure were prospectively randomized to either Steri‐Strip S or subcuticular suture for wound closure. The wounds were evaluated on postoperative days 7 and 21 for erythema, edema, pain, cosmesis, and the time taken to close the incision. Results: Skin closure with Steri‐Strip S was faster (5.33 ± 1.32 minutes steri‐strips vs. 6.07 ± 0.91 sutures; p = 0.06) and resulted in significantly less erythema and edema, but no difference in pain or cosmesis after seven days. Following 21 days, there was no difference in pain, edema, or cosmesis between the groups. However, patients receiving steri‐strips continue to have less erythema. Conclusions: Both Steri‐Strip S and absorbable sutures are effective techniques for skin closure following a mediansternotomy incision for cardiac surgical procedures. Steri‐Strip S can decrease the amount of erythema, but results in no significant difference in pain, cosmesis, or edema compared to the traditional subcuticular wound closure technique. (J Card Surg 2011;26:344‐347)     

Grafts in Dermatologic Surgery: Review and Update on Full- and Split-Thickness Skin Grafts, Free Cartilage Grafts, and Composite Grafts

Background. Skin grafting has evolved in the past centuries to encompass numerous well-established reconstruction techniques that are uniquely able to restore structure, function, and cosmesis to a variety of surgical wounds.
Objective. To provide a detailed overview of the general principles of skin grafting geared for the dermatologist and the dermatologic surgeon.
Methods. Comprehensive review of the literature.
Results. A summary of the different applications and techniques of full- and split-thickness skin grafts, free cartilage grafts, and composite grafts is presented. Indications, advantages, disadvantages, techniques, and complications are discussed in depth.
Conclusion. Skin grafting is a dynamic and versatile method of cutaneous reconstruction that can be accomplished successfully with a thorough understanding of the principles and techniques of grafting.     

咪喹莫特治疗婴幼儿血管瘤

目的 探讨咪喹莫特治疗婴幼儿血管瘤( infantile hemangioma,IH)的临床适应证.方法 320例婴幼儿血管瘤,浅表型250例,深在型20例,混合型50例,年龄3～24周,隔日夜间睡前外用5％咪喹莫特乳青涂擦16周,随访至1岁.疗效评价分为6级,1级:完全消退;2级:75％≤消退≤99％;3级:50％≤消退＜75％;4级:25％≤消退＜50％;5级:消退＜25％;6级:未消退或增生.记录局部皮肤反应及全身不良反应.结果 浅表型、深在型、混合型IH的有效率分别为61.2％(153/250)、10.0％ (2/20)、60.0％( 30/50).浅表型和混合型之间比较差异无统计学意义(P=0.874),浅表型与深在型之间比较差异有统计学意义(P＜0.01),深在型与混合型之间比较差异有统计学意义(P＜0.01).咪喹莫特外用后4～8周,IH开始生长控制并出现消退现象.56.0％ (28/50)混合型IH出现深部病灶的增生.皮肤反应主要为红斑、表皮剥落、结痂,程度轻微.结论 浅表型IH和混合型IH的浅表病灶是外用咪喹莫特治疗的适应证,治疗后局部皮肤反应轻微,不引起局部组织萎缩和身体发育迟滞,对腔穴部位及皮肤皱褶处应避免使用,用药方式简单便捷,可作为IH浅表病灶的安全有效的治疗方法.     

Analysis of Erythema after Er:YAG Laser Skin Resurfacing

BACKGROUND Postoperative erythema can be expected to occur in every patient after laser resurfacing, and pigmentary disturbances may be related to the intensity and the duration of erythema.
OBJECTIVE This study was undertaken to assess the clinical features of erythema, the factors that influence its duration, and the relation between the duration of erythema and the incidence of hyperpigmentation and hypopigmentation in skin of Asian persons after Er:YAG laser resurfacing.
METHODS A total of 218 patients (skin phototypes III to V) were recruited and treated with a short-pulsed Er:YAG laser, a variable-pulsed Er:YAG laser, or a dual-mode Er:YAG laser for skin resurfacing. Clinical assessments were performed retrospectively using medical charts and serial photographs.
RESULTS Postoperative erythema was observed in all patients after Er:YAG laser resurfacing with a mean duration of 4.72 months. In 98.2% of patients, erythema faded completely within 12 months. Postinflammatory hyperpigmentation was observed in 38.1% of patients after Er:YAG laser resurfacing.
CONCLUSIONS Skin phototype, level of ablation, and depth of thermal damage caused by a long-pulsed laser appear to be important factors that affect the duration of erythema. Moreover, prolonged erythema was related to the risk of postinflammatory hyperpigmentation.     

Electron beam therapy for skin cancer of the head and neck.

We retrospectively analyzed 99 patients with 115 sites of skin cancer, predominantly involving the head and neck, treated with electron beam therapy. Our objective was to determine the local control rate, radiotherapy reactions, cosmesis, and salvage treatment. Forty-three percent of patients received radiotherapy after biopsy, 41% were treated for recurrence following other modalities of treatment, and 16% had positive margins after surgical excision. With minimum and mean follow-up of 24 and 47 months, respectively, local control was achieved in 88% of patients. Six of 14 local recurrences were salvaged by surgery (five patients) and radiotherapy (one patient) for a total local control of 93%. Serial photographs and data were available to analyze cosmesis in 56 patients. Excellent or good cosmesis was achieved in 91%. Side effects were mild and self-limiting. EBT is highly efficacious and offers excellent cosmesis.     

A Randomized Controlled Trial of High-Viscosity 2-Octyl Cyanoacrylate Tissue Adhesive versus Sutures in Repairing Facial Wounds Following Mohs Micrographic Surgery

BACKGROUND: High-viscosity 2-octyl cyanoacrylate (HVOCA) is a rapidly polymerizing liquid topical adhesive indicated for epidermal approximation of superficial lacerations and surgical wounds. Use of HVOCA in repair of facial wounds after Mohs micrographic surgery (MMS) has not been reported. OBJECTIVE: To compare aesthetic outcome of HVOCA versus sutured epidermal closure of linearly repaired facial wounds following MMS. METHODS: Patients undergoing MMS for facial tumors with postoperative wounds >3 cm appropriate for linear closure were recruited. After placement of dermal sutures, half the wound was randomly selected for closure with HVOCA and the other half was closed with 5-0 polypropylene suture. RESULTS: Fourteen patients (13 men and 1 woman; mean age, 72+/-8.8 years; range, 52-81 years) with basal cell or squamous cell carcinoma of the face (n=12) or neck (n=2) were enrolled. The mean wound length was 4.9+/-1.9 cm (range, 3.1-10 cm). No postoperative complications, including bleeding, infection, or dehiscence, occurred. Using photographs obtained 3 months postoperatively, five dermatologists (including two Mohs surgeons) blinded to the intervention rated cosmesis using a visual analog scale from 1 (worst) to 10 (best). The mean ratings for HVOCA half (6.64+/-1.55) versus sutured half (6.77+/-1.88) were not significantly different (p=.35). Paired comparisons of rater preferences similarly showed no cosmetic differences. All 14 patients preferred OCA for ease of postoperative care. CONCLUSION: HVOCA tissue adhesive is cosmetically equivalent to epidermal sutures in the linear repair of facial wounds following MMS. This technique represents an additional option for Mohs surgeons.