Dermatology

My patient complains of severe facial scarring from childhood acne that is not improving. How should I advise her?

FA Manian MD, MPH, , , , Leave a comment

Severe facial scarring after childhood acne is not uncommon, having been shown to affect 43% of acne patients.1 Fortunately, there are several evidence-based treatments available to improve their appearance.

One procedure that you could recommend to your patient is microneedling, also known as percutaneous collagen induction or collagen induction therapy.2 This therapy works by using extremely fine needles to create small puncture wounds in the epidermis and superficial dermis, leading to tissue proliferation and collagen remodeling with subsequent enhancement in scar appearance.3 In fact, one randomized clinical trial showed a statistically significant 41% mean improvement following the procedure4. Adverse effects are limited with this treatment, with participants experiencing no issues other than mild erythema and edema.4

Another highly effective solution is laser therapy, which includes resurfacing (carbon dioxide, CO2; erbium-doped yttrium aluminum garnet, Er:YAG) and fractional (nonablative, NAFL; and ablative, AFL) lasers. One study compared the efficacy of these different lasers. Improvement in scar appearance was measured with a scale graded from 0 to 10. The mean improvement scores of the CO2, Er:YAG, NAFL, and AFL groups were 6.0, 5.8, 2.2, and 5.2, respectively.5 The Er:YAG laser has even been shown to have significantly better results than microneedling (70% improvement vs 30% improvement).6 The biggest downside to laser therapy is that patients reported more erythema, swelling, and crusting when compared to microneedling; however, they experienced significantly less pain.6

Other potentially effective treatments for acne scars include dermal fillers and chemical peels, neither of which have been shown to be superior to microneedling or laser therapy individually. However, certain peels do seem to significantly improve the effects of microneedling when used together.7 The good news is that all four can be performed easily in the office setting, so a referral to a board-certified dermatologist or plastic surgeon would be a good first step to addressing your patient’s problem.

Request for treatment of scars years after onset of acne should not be surprising in a general medicine practice. Acne is the most common skin condition in the United States, affecting over 50 million people.8 Unfortunately, in severe cases, inflammation can lead to scarring in cosmetically sensitive areas, leading to a lower quality of life and higher rates of anxiety and depression.9

Bonus Pearl: Did you know that platelet-rich plasma (PRP), a concentrate of platelets and growth factors obtained from venipuncture, has been shown to enhance the effects of microneedling and laser therapy through increased protein synthesis, collagen remodeling, and accelerated wound healing? 10

Contributed by Aditya Nellore, MD,  St. Louis, Missouri

 

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References:

  1. Tan J, Kang S, Leyden J. Prevalence and Risk Factors of Acne Scarring Among Patients Consulting Dermatologists in the USA. J Drugs Dermatol. 2017 Feb 1;16(2):97-102. PMID: 28300850. https://pubmed.ncbi.nlm.nih.gov/28300850/
  2. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction of depressed scars and wrinkles. Dermatol Surg. 1995 Jun;21(6):543-9. doi: 10.1111/j.1524-4725.1995.tb00259.x. PMID: 7773602. https://pubmed.ncbi.nlm.nih.gov/7773602/
  3. Fabbrocini G, Fardella N, Monfrecola A, Proietti I, Innocenzi D. Acne scarring treatment using skin needling. Clin Exp Dermatol. 2009 Dec;34(8):874-9. doi: 10.1111/j.1365-2230.2009.03291.x. Epub 2009 May 22. PMID: 19486041. https://pubmed.ncbi.nlm.nih.gov/19486041/
  4. Alam M, Han S, Pongprutthipan M, Disphanurat W, Kakar R, Nodzenski M, Pace N, Kim N, Yoo S, Veledar E, Poon E, West DP. Efficacy of a needling device for the treatment of acne scars: a randomized clinical trial. JAMA Dermatol. 2014 Aug;150(8):844-9. doi: 10.1001/jamadermatol.2013.8687. PMID: 24919799. https://pubmed.ncbi.nlm.nih.gov/24919799/
  5. You HJ, Kim DW, Yoon ES, Park SH. Comparison of four different lasers for acne scars: Resurfacing and fractional lasers. J Plast Reconstr Aesthet Surg. 2016 Apr;69(4):e87-95. doi: 10.1016/j.bjps.2015.12.012. Epub 2016 Jan 7. PMID: 26880620. https://pubmed.ncbi.nlm.nih.gov/26880620/
  6. Osman MA, Shokeir HA, Fawzy MM. Fractional Erbium-Doped Yttrium Aluminum Garnet Laser Versus Microneedling in Treatment of Atrophic Acne Scars: A Randomized Split-Face Clinical Study. Dermatol Surg. 2017 Jan;43 Suppl 1:S47-S56. doi: 10.1097/DSS.0000000000000951. PMID: 28009690. https://pubmed.ncbi.nlm.nih.gov/28009690/
  7. El-Domyati M, Abdel-Wahab H, Hossam A. Microneedling combined with platelet-rich plasma or trichloroacetic acid peeling for management of acne scarring: A split-face clinical and histologic comparison. J Cosmet Dermatol. 2018 Feb;17(1):73-83. doi: 10.1111/jocd.12459. Epub 2017 Dec 10. PMID: 29226630. https://pubmed.ncbi.nlm.nih.gov/29226630/
  8. Bickers DR, Lim HW, Margolis D, Weinstock MA, Goodman C, Faulkner E et al. The burden of skin diseases: 2004 a joint project of the American Academy of Dermatology Association and the Society for Investigative Dermatology. Journal of the American Academy of Dermatology 2006;55:490-500. https://pubmed.ncbi.nlm.nih.gov/16908356/
  9. Yazici K, Baz K, Yazici AE, Köktürk A, Tot S, Demirseren D, Buturak V. Disease-specific quality of life is associated with anxiety and depression in patients with acne. J Eur Acad Dermatol Venereol. 2004 Jul;18(4):435-9. doi: 10.1111/j.1468-3083.2004.00946.x. PMID: 15196157. https://pubmed.ncbi.nlm.nih.gov/15196157/
  10. Hashim PW, Levy Z, Cohen JL, Goldenberg G. Microneedling therapy with and without platelet-rich plasma. Cutis. 2017 Apr;99(4):239-242. PMID: 28492598. https://pubmed.ncbi.nlm.nih.gov/28492598/

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis, Massachusetts General Hospital, Harvard Catalyst, Harvard University, their affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

 

 

My patient complains of severe facial scarring from childhood acne that is not improving. How should I advise her?

My 19-year-old patient wishes treatment for his chronic acne while waiting for his dermatology appointment. What treatment should I recommend?

FA Manian MD, MPH, , , , , , , , , , , , , Leave a comment

Irrespective of your patient’s acne severity, a good starting point is over-the-counter topical benzoyl peroxide.1 Benzoyl peroxide not only kills the bacteria that causes acne (Cutibacterium acnes) through the release of free oxygen radicals, but also functions as a comedolytic.2

If your patient’s acne is mild to moderate (defined as non-inflammatory lesions [comedones] or less than 5 inflammatory lesions [papulopustules]), you may consider prescribing a topical retinoid such as tretinoin 0.025%, adapalene 0.1%, or tazarotene 0.05% in combination with the benzoyl peroxide.1,3 These agents have been shown to have both comedolytic and anti-inflammatory effects, and are the cornerstone of topical therapy for all acne cases, save for the most mild.1,4

In moderate to severe acne (defined as multiple inflammatory lesions), you can consider prescribing an oral antibiotic in combination with the retinoid and benzoyl peroxide.1,3 The first-line therapy in this situation is often a tetracycline, such as daily doxycycline in the 1.7 to 2.4 mg/kg dose range.5,6 

As with all medications, please familiarize yourself with contraindications and adverse side effects of these drugs before prescribing (eg, doxycycline-related photosensitivity or adverse impact on GI flora, or avoiding tretinoin in pregnancy).

For extremely severe acne (defined as widespread inflammatory lesions, nodules, and/or scarring), you should consider referral to a dermatologist for Accutane (isotretinoin) treatment.3 However, the aforementioned treatment options should be sufficient to control your patient’s symptoms until seen by a dermatologist!           

Bonus Pearl: Did you know that besides anabolic-androgenic steroids, dietary supplements containing vitamins B6/B12, iodine and whey have also been linked to acne?7

Contributed by Aditya Nellore, Fourth-Year Medical Student, St. Louis University Medical School, St. Louis, Missouri   

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References:

  1. Zaenglein AL, Pathy AL, Schlosser BJ, Alikhan A, Baldwin HE, Berson DS, Bowe WP, Graber EM, Harper JC, Kang S, Keri JE, Leyden JJ, Reynolds RV, Silverberg NB, Stein Gold LF, Tollefson MM, Weiss JS, Dolan NC, Sagan AA, Stern M, Boyer KM, Bhushan R. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016 May;74(5):945-73.e33. doi: 10.1016/j.jaad.2015.12.037. Epub 2016 Feb 17. Erratum in: J Am Acad Dermatol. 2020 Jun;82(6):1576. PMID: 26897386. https://www.jaad.org/article/S0190-9622(15)02614-6/fulltext#tbl6
  2. Cunliffe WJ, Holland KT. The effect of benzoyl peroxide on acne. Acta Derm Venereol. 1981;61(3):267-9. PMID: 6167116. https://pubmed.ncbi.nlm.nih.gov/6167116/
  3. Purdy S, Deberker D. Acne vulgaris. BMJ Clin Evid. 2008 May 15;2008:1714. PMID: 19450306; PMCID: PMC2907987. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2907987/
  4. Cunliffe WJ, Caputo R, Dreno B, Förström L, Heenen M, Orfanos CE, Privat Y, Robledo Aguilar A, Meynadier J, Alirezai M, Jablonska S, Shalita A, Weiss JS, Chalker DK, Ellis CN, Greenspan A, Katz HI, Kantor I, Millikan LE, Swinehart JM, Swinyer L, Whitmore C, Czernielewski J, Verschoore M. Clinical efficacy and safety comparison of adapalene gel and tretinoin gel in the treatment of acne vulgaris: Europe and U.S. multicenter trials. J Am Acad Dermatol. 1997 Jun;36(6 Pt 2):S126-34. doi: 10.1016/s0190-9622(97)70056-2. PMID: 9204091. https://pubmed.ncbi.nlm.nih.gov/9204091/
  5. Tan J, Humphrey S, Vender R, Barankin B, Gooderham M, Kerrouche N, Audibert F, Lynde C; POWER study group. A treatment for severe nodular acne: a randomized investigator-blinded, controlled, noninferiority trial comparing fixed-dose adapalene/benzoyl peroxide plus doxycycline vs. oral isotretinoin. Br J Dermatol. 2014 Dec;171(6):1508-16. doi: 10.1111/bjd.13191. Epub 2014 Oct 28. PMID: 24934963. https://pubmed.ncbi.nlm.nih.gov/24934963/
  6. Leyden, James J., et al. “A randomized, phase 2, dose-ranging study in the treatment of moderate to severe inflammatory facial acne vulgaris with doxycycline calcium.” Journal of Drugs in Dermatology: JDD6 (2013): 658-663. https://pubmed.ncbi.nlm.nih.gov/23839182/
  7. Zamil DH, Perez-Sanchez A, Katta R. Acne related to dietary supplements. Dermatol Online J. 2020 Aug 15;26(8):13030/qt9rp7t2p2. PMID: 32941710. https://pubmed.ncbi.nlm.nih.gov/32941710/

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis, Massachusetts General Hospital, Harvard Catalyst, Harvard University, their affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

My 19-year-old patient wishes treatment for his chronic acne while waiting for his dermatology appointment. What treatment should I recommend?

My patient presents for evaluation of a mole on her arm. What features of the mole should I look for to help me distinguish a benign mole from melanoma?

FA Manian MD, MPHLeave a comment

Great question! Identifying a melanoma is a lot easier than you might think. A good starting point is the ABCDE criteria, which stands for Asymmetry, Border irregularity, Color variation, Diameter > 6 mm/Dark, and Evolution over time (see Fig 1 below). 1 Higher number of these characteristics in a particular lesion increases the probability of it being melanoma. For example, in the presence of just one characteristic, the positive likelihood ratio (LR) is 1.5 with the probability of melanoma of 7.4%. However, if all five characteristics are present, the positive LR rises to 107, while the probability of melanoma increases to 85%. 2,3,4

Another useful trick is looking for the “ugly duckling sign” (UDS), which refers to any pigmented lesion that appears obviously different than others on a patient’s body.5 For example, let’s say you’re seeing a patient with multiple small, circular, equally-sized moles on his forearm. A few inches away, he has a significantly larger mole with an irregular border. This would qualify as a positive UDS.  While the sensitivities of melanoma recognition are similar for the UDS and the ABCDE criteria (100% and 99%, respectively), the UDS has been shown to significantly improve specificity (88.3%) and accuracy (90.9%) when compared to the ABCDE criteria alone (57.4% and 66.7 %, respectively).6 So incorporating both sets of criteria into your approach to melanoma recognition may be prudent.

Once you suspect a melanoma, your should refer your patient to a dermatologist for an excisional biopsy, the gold standard for melanoma diagnosis.  This procedure consists of excising the entire lesion with 1-3 mm margins.7 The resulting sample can then be used to histologically confirm the diagnosis, prognosticate, and guide management.

Primary care providers play a crucial role in the early detection and treatment of melanoma, so keep your eyes open for any “unusual” looking moles, even if you’re seeing a patient for something unrelated!

Bonus Pearl

Did you know that cardiac involvement with melanoma is not uncommon, affecting an estimated 28% to 56% of patients with metastatic melanoma? 8

 

Figure 1: ABCDE criteria to help differentiate benign skin lesions from melanoma

i

 From Pawan Sonawane, Sahel Shardhul, Raju Mendhe, “Cloud based mobile solution for early detection of Skin Cancer using Artificial Intelligence”, International Journal of Scientific Research in Computer Science, Engineering and Information Technology (IJSRCSEIT), ISSN : 2456-3307, Volume 7 Issue 3, pp. 312-324, May-June 2021. Available at doi : https://doi.org/10.32628/CSEIT217327 Journal URL : https://ijsrcseit.com/CSEIT217327 (https://www.researchgate.net/publication/352394140_Cloud_based_mobile_solution_for_early_detection_of_Skin_Cancer_using_Artificial_Intelligence)

Contributed by Aditya Nellore, 4th year Medical Student, St. Louis University Medical School, St. Louis, Missouri

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References:

  1. Goldsmith SM. Why Is Darkness an Essential Feature for Melanoma Recognition? Skinmed. 2021 Oct 1;19(5):334-336. PMID: 34861912. (https://pubmed.ncbi.nlm.nih.gov/34861912/)
  2. Duarte AF, Sousa-Pinto B, Azevedo LF, Barros AM, Puig S, Malvehy J, Haneke E, Correia O. Clinical ABCDE rule for early melanoma detection. Eur J Dermatol. 2021 Dec 1;31(6):771-778. doi: 10.1684/ejd.2021.4171. PMID: 35107069. (https://pubmed.ncbi.nlm.nih.gov/35107069/)
  3. Thomas L, Tranchand P, Berard F, Secchi T, Colin C, Moulin G. Semiological value of ABCDE criteria in the diagnosis of cutaneous pigmented tumors. Dermatology. 1998;197(1):11-7. doi: 10.1159/000017969. PMID: 9693179. (https://pubmed.ncbi.nlm.nih.gov/9693179/)
  4. Ebell M. Clinical diagnosis of melanoma. Am Fam Physician. 2008 Nov 15;78(10):1205, 1208. PMID: 19035070. (https://pubmed.ncbi.nlm.nih.gov/19035070/)
  5. Gaudy-Marqueste C, Wazaefi Y, Bruneu Y, Triller R, Thomas L, Pellacani G, Malvehy J, Avril MF, Monestier S, Richard MA, Fertil B, Grob JJ. Ugly Duckling Sign as a Major Factor of Efficiency in Melanoma Detection. JAMA Dermatol. 2017 Apr 1;153(4):279-284. doi: 10.1001/jamadermatol.2016.5500. PMID: 28196213. (https://pubmed.ncbi.nlm.nih.gov/28196213/)
  6. Ilyas M, Costello CM, Zhang N, Sharma A. The role of the ugly duckling sign in patient education. J Am Acad Dermatol. 2017 Dec;77(6):1088-1095. doi: 10.1016/j.jaad.2017.06.152. Epub 2017 Sep 28. PMID: 28964538. (https://pubmed.ncbi.nlm.nih.gov/28964538/)
  7. Swetter SM, Tsao H, Bichakjian CK, Curiel-Lewandrowski C, Elder DE, Gershenwald JE, Guild V, Grant-Kels JM, Halpern AC, Johnson TM, Sober AJ, Thompson JA, Wisco OJ, Wyatt S, Hu S, Lamina T. Guidelines of care for the management of primary cutaneous melanoma. J Am Acad Dermatol. 2019 Jan;80(1):208-250. doi: 10.1016/j.jaad.2018.08.055. Epub 2018 Nov 1. PMID: 30392755. (https://pubmed.ncbi.nlm.nih.gov/30392755/)
  8. Goldberg AD, Blankstein R, Padera RF. Tumors metastatic to the heart. Circulation. 2013 Oct 15;128(16):1790-4. doi: 10.1161/CIRCULATIONAHA.112.000790. PMID: 24126323. (https://pubmed.ncbi.nlm.nih.gov/24126323/)

Disclosures: The listed questions and answers are solely the responsibility of the author and do not necessarily represent the official views of Mercy Hospital-St. Louis, Massachusetts General Hospital, Harvard Catalyst, Harvard University, their affiliate academic healthcare centers, or its contributors. Although every effort has been made to provide accurate information, the author is far from being perfect. The reader is urged to verify the content of the material with other sources as deemed appropriate and exercise clinical judgment in the interpretation and application of the information provided herein. No responsibility for an adverse outcome or guarantees for a favorable clinical result is assumed by the author. Thank you!

 

My patient presents for evaluation of a mole on her arm. What features of the mole should I look for to help me distinguish a benign mole from melanoma?