Wart Treatment by Type of Drug and Procedure

The new advance in treatment of genital warts has been imiquimod (Aldara). This encourages the patient’s autoimmune system to attack the wart. This is particularly helpful in the moist areas of the skin or mucosal surfaces.

Salicylic acid
Salicylic acid can be applied either in the form of plasters or as liquid on to the warts. This will break down the thickened skin on the surface. It is more effective if the area is covered. These are useful for warts on the hands, knees and feet. They do turn the skin white. They can be used in combination with paring of the warts. Treatment with these at nighttime and covering with duct tape can be effective although slow.

Podophyllin

Podophyllin has a long history of use. It is useful mostly in genital warts. It should be applied very carefully on the warts, trying to prevent spread on to normal skin. It should be washed off after a few hours. There is irritation usually for a few days. Repeat treatments are usually required. A more purified form of podophyllin called podophyllotoxin is available for patient use. It can be used once or twice daily for a few days in succession. This produces some irritation. It has the advantage of not being as irritating as podophyllin and can be applied by the patients themselves.

Vitamin Acid

Vitamin acid (Tretinoin) is a vitamin A preparation. It is used in the treatment of acne and photo damage. Vitamin A products tend to regulate the surface of the skin, generally trying to keep the epidermis behaving normally. It may also cause some inflammation. In some individuals it can help reduce or even eliminate warts.

Cantharone

Cantharone (cantharidin) is derived from an insect. It can be very helpful in children but the application is painful. Inflammation and
blistering usually occurs later in the day, after application. Multiple treatments may be required. There are two concentrations. The
stronger version combines Cantharone with podophyllin and salicylic acid. Very occasionally the blistering reaction can be quite severe
and associated with swelling and pain. It is often very effective even in resistant warts.

Cryotherapy

Cryotherapy is the use of liquid nitrogen. This can be applied either with a Q-Tip or it can be sprayed on to the skin. It causes destruction by freezing water inside the cells. This damages the cell causing death. It is painful to apply and there is blistering associated with this. Multiple treatments may be required. Thawing and freezing again makes this therapy more effective. It can be a problem in dark skin in that it can either increase or decrease pigmentation, which can be permanent. This treatment can be used in combination with other therapies.

Electrodesiccation

Electrodesiccation is the use of an electric needle to burn warts. It usually requires a local anesthetic. It does have a potential risk of scarring. Very large warts can sometimes be scraped off before they are cauterized.

CO2 Laser

The CO2 laser has been used for many years. It essentially vaporizes water in the skin and causes destruction. It leaves a hole in the skin which will heal. There is often scarring with this technique. Other lasers such as the pulse dye laser are easier to use. The yellow light is absorbed by blood in the vessels that feed the warts. This is a similar laser used in the treatment of red birthmarks. The pulse dye laser at a high power setting can be effective particularly if multiple pulses are used in succession.

Aldara

Aldara is an immune response modulator. It boosts the patient’s immune response to viruses. It can also encourage the production of a
lasting immune memory. It has been available in Canada since 1999. It works best in the genital area as penetration into the skin is easier. When it is used elsewhere it often has to be covered to help with penetration into the skin. It has been shown to work well particularly in women. It is applied three times weekly. There will be some inflammation associated with this. The results may be enhanced by combining this with liquid nitrogen. This drug has added a very significant tool in treating genital warts.

A Novel Combination for Treatment of Acne Vulgaris

Adapalene 0.1% and Benzoyl Peroxide 2.5%: A Novel Combination for Treatment of Acne Vulgaris

Topical products commonly used to treat acne include retinoids and antimicrobials, due to their effects on different components of pathogenesis. Accordingly, a fixed combination of adapalene 0.1% and benzoyl peroxide (BPO) 2.5% was developed (Epiduo™, Galderma) and was approved by the US FDA in December 2008 for the treatment of acne. The superior efficacy of this combination was demonstrated in 2 large randomized controlled trials. This paper reviews the evidence for efficacy and tolerability of the combination of the retinoid adapalene 0.1% and BPO 2.5%, a once-daily gel formulation for the treatment of acne.

Adapalene, a receptor-selective naphthoic acid derivative with retinoid-like properties, has comedolytic, anticomedogenic, and anti-inflammatory effects. Benzoyl peroxide (BPO) is a highly lipophilic oxidizing agent with bacteriocidal and keratolytic effects. The addition of adapalene with BPO does not result in chemical or photo-instability of the combined product. Retinoids are considered first line therapy for mild comedonal and inflammatory acne.¹ In dermatological practice, topical retinoids are the class of agents most commonly used as topical monotherapy for acne. When 2 topical agents are used, the agents most frequently selected are retinoids and BPO, either alone or with antibiotics.² In view of the primary role of these 2 classes of topical agents, a single formulation comprising both is rational and may increase adherence and improve overall efficacy.

Review of Clinical Studies

Dose-ranging Studies

Individually, topical retinoids and BPO are potentially irritating agents and a combination product may increase this potential. In an irritancy study³ comparing adapalene 0.1% gel, tazarotene cream 0.05%, and tretinoin microsphere gel 0.04% used in combination with 2 different clindamycin/BPO products under occlusion, the adapalene 0.1% gel was reported to be the least irritating. This 3-week randomized, controlled intraindividual study involved test site applications at the back under occlusion. The tolerability of 2 different combination clindamycin/BPO topical products followed 8 hrs later by adapalene 0.1% gel, tazarotene cream 0.05%, and tretinoin microsphere gel 0.04% was evaluated. Regardless of the type of clindamycin/BPO combination, the mean cumulative irritancy index and erythema scores were significantly lower for sites involving adapalene gel. The combination of adapalene 0.1% and BPO 2.5% was selected for further development based on a cutaneous tolerability study⁴ evaluating adapalene 0.1% combined with either BPO 2.5% or 5%. In that study, 60 healthy subjects were randomized into a 3 week split-face trial with daily application of adapalene 0.1% + BPO 2.5%, adapalene 0.1% + BPO 5%, BPO 2.5% or 5%. This study showed that irritation scores (total sum score comprising erythema, dryness, pruritus, and stinging/burning) for adapalene 0.1% + BPO 2.5% were lower than for the combination product containing BPO 5%, and similar to BPO 5% alone.

Randomized-Controlled Trials (See Table 1)

A Phase II/III randomized, double-blind, parallel group study5 of adapalene 0.1% + BPO 2.5% gel, adapalene 0.1% gel, BPO 2.5% gel, or vehicle gel used nightly for 12 weeks involved 517 acne patients enrolled in a 2:2:2:1 ratio, respectively. The combination arm was significantly more effective in achieving a facial acne global grade of clear/almost clear (i.e., 28% vs. 16% vs. 15% vs. 10%, respectively). The differences were significant against the BPO (P=0.003) and vehicle (P=0.02) arms, and borderline for adapalene itself (P=0.08). Significant improvements in the lesion counts were observed for the combination compared with monotherapy and vehicle arms. Total acne lesions were reduced by 51% (median 78 at baseline to 40 at end of study), inflammatory lesions by 63% (27 to 17), and noninflammatory lesions by 51% (44 to 22). Overall local tolerability of the combination was similar to that for adapalene alone, with a somewhat higher percentage of subjects in the combination group having erythema, dryness, and/or stinging/burning. Mean tolerability scores, based on erythema, scaling, dryness, and stinging/burning, peaked at the first week and declined thereafter. Mean symptom scores were mild or less for all treatment arms.

A subsequent larger Phase III double-blind, randomized-controlled trial⁶ (RCT) with similar trial design involving 1668 patients randomized into the same 4 treatment arms in a 1:1:1:1 ratio was performed. Results demonstrated that the combination was more effective in achieving clear/almost clear global scores (30% vs. 20% for adapalene 0.1% gel , 22% for BPO 2.5% gel and 10% for vehicle gel), and in reducing acne counts. Total acne counts were reduced by 56% (median 76 at baseline to 35 at end of study), inflammatory lesions by 62% (27 to 11), and noninflammatory lesions by 54% (44 to 20). A significant reduction in all lesion counts were noted within the first week of treatment compared with vehicle. Local intolerability adverse events were mild-to-moderate in all treatment arms and peaked during the first week. However, more patients in the adapalene + BPO combination group experienced signs and symptoms of local intolerability compared with the other treatment groups. The number of patients with adverse events leading to discontinuation was slightly higher with the combination compared with adapalene monotherapy, BPO monotherapy, and vehicle groups: 11 (2.7%) vs. 4 (1.0%), 5 (1.2%), and 2 (0.5%), respectively. The most frequent treatment-related adverse event was dry skin, which was higher in the combination and adapalene groups than in the BPO monotherapy and vehicle groups (i.e., 6.0%, 4.3%, 1.9%, and 2.2% respectively).

Study	Summary	Epiduo™	Adapalene 0.1% in Vehicle Gel	BPO 2.5% in Vehicle Gel	Vehicle Gel
Thiboutot, et al.5	number of patients	149	148	149	71
	success rate (%)	28	16	15	10
	P-value (vs. Epiduo™)		0.008	0.003	0.002
	total lesions (median % change)	-51	-35*	-36*	-31*
	inflammatory lesions	-63	-46*	-44*	-38*
	noninflammatory lesions	-51	-33*	-36*	-38*
Stein-Gold et al.6	number of patients	415	420	415	418
	success rate (%)	30	20	22	11
	P-value (vs. Epiduo™)		<0.001	0.006	<0.001
	total lesions (median % change)	-56	-47**	-48**	-28**
	inflammatory lesions	-62	-50**	-56**	-34**
	noninflammatory lesions	-54	-49**	-44**	-29**
Pooled outcomes	number of patients	564	568	564	489
	success rate (%)	28	18	19	10
Table 1: Efficacy of Epiduo™ and its components on success rate and lesion reduction in acne (success defined as investigator global scores of clear or almost clear). * P <0.001; ** P < 0.017

Long-term Safety and Efficacy

The long-term tolerability and safety of adapalene 0.1% + BPO 2.5% gel was evaluated in 452 acne subjects over 12 months.⁷ Of these, 327 completed the study (72%). No subjects discontinued due to lack of efficacy, while discontinuation due to adverse events was 2%. Overall, treatment was well tolerated with mean scores for local intolerance (comprising erythema, dryness, scaling, and burning/stinging) reported as mild or less in all study visits. The mean worst scores of subjects were consistent with mild irritation. The highest irritation scores were recorded at the first week and subsequently declined thereafter. The most common adverse event was dry skin (17%). Efficacy, based on the intent to treat population with last observation carried forward, was 65% reduction in total, 70% in inflammatory, and 66% in noninflammatory lesion counts.

Conclusion

The combination of adapalene 0.1% + BPO 2.5% gel in a single formulation is a novel topical agent for the treatment of mild-to-moderate inflammatory acne. The clinical efficacy and tolerability of this fixed dose combination over 12 weeks has been shown in 2 large high quality RCTs. Furthermore, long-term tolerability and ongoing efficacy has been demonstrated in a 12-month study.

J. K. L. Tan, MD, FRCPC
Department of Medicine, University of Western Ontario, London, ON, Canada

Taking Elidel Top To Treat Atopic Dermatitis

PIMECROLIMUS - TOPICAL : Pronunciation: (pim-eck-row-LEE-muss) , Brand Name(s): Elidel

Elidel Top is used to treat the following:  Atopic Dermatitis, Eczema Skin Condition Resisting Treatment

Pimecrolimus is used to treat certain skin conditions such as eczema (atopic dermatitis) in people who should not use or have not responded to other eczema medications (e.g., topical steroids). Eczema is an allergic-type condition that causes red, irritated, and itchy skin. This drug works by changing the skin’s defense (immune) system, thereby decreasing the allergic reaction that causes eczema. Pimecrolimus belongs to a class of drugs known as topical calcineurin inhibitors (TCIs).

This medication is not recommended if you have a history of a certain rare genetic disorder (Netherton’s syndrome). Also, this medication should not be used by anyone who has a weakened immune system (e.g., following an organ transplant).

How to use Elidel Top

Read the Medication Guide provided by your pharmacist before you start using pimecrolimus and each time you get a refill. If you have any questions regarding the information, consult your doctor or pharmacist.

Wash your hands with soap and water before using this medication. Apply a thin layer to the affected areas of skin, usually twice daily or as directed by your doctor. Rub the medication into the skin gently and completely. Wash your hands after using this product unless your hands are being treated. If your doctor recommends a moisturizer, apply it after this medication.

Pimecrolimus is for use on the skin only. Avoid getting this medication in your eyes or on the inside of your nose or mouth. Do not apply this medication to open wounds or infected areas. Do not cover the treated area with plastic or waterproof bandages unless directed to do so by your doctor. Do not bathe, shower or swim right after applying this medication.

Use this medication exactly as directed. Your doctor may instruct you to stop using it once your eczema has cleared up and to start using it again if signs or symptoms reappear. Consult your doctor for details.

Inform your doctor if your condition does not improve after 6 weeks of using this medication or if your condition worsens at any time.

WARNINGS

Patients have benefited from use of pimecrolimus when it is used correctly. Long-term safety for this drug is not known at this time. There have been rare reports of cancers (e.g., skin cancer, lymphoma) in patients using pimecrolimus. It is not known whether pimecrolimus caused these cancers when used on the skin. Further studies to determine the long-term safety of this product are ongoing. In the unlikely event that unusual lumps, swollen glands, or growths (especially on the skin) occur, contact your doctor immediately.

The FDA recommends the following: This drug should be used only if other drugs have failed or if other medications are not considered appropriate by your doctor. Pimecrolimus should be used on the skin for short treatment periods only. If needed, treatment may be repeated with breaks in between. Use the smallest amount that will treat your condition properly, and apply only on the affected skin. Also, this medication should not be used in children younger than 2 years. As with all medications, discuss the risks, benefits, and proper use of this medication with your doctor.

Dermabrasion 101

Dermabrasion is one of three commonly used office-based surgical skin resurfacing and rejuvenation procedures. The technique takes its origin from ancient Egypt in 1500 B.C. where healers used a form of sandpaper to even out scars. Today the technique has seen over 3500 years of evolution.

Dermabrasion mechanically removes the most superficial layers of the skin and allows your skins normal healing properties to rejuvenate the skin itself. It is designed to reduce or remove moderate wrinkles, fine lines, skin blemishes, and uneven skin surfaces. In addition to wrinkle treatment, the technique has been used to treat acne scars, hide or camouflage surgical or traumatic scars and in select cases to remove precancerous lesions.

Microdermabrasion is not the same treatment as dermabrasion and will not be discussed further than this paragraph. Microdermabrasion is a much more superficial and thus a less dramatic rejuvenation procedure with little to no recovery period. Being a more mild procedure than dermabrasion, multiple treatments of micordermabrasion are often required and may never achieve the same degree of rejuvenation as traditional dermabrasion. Microdermabrasion uses a device that sprays a fine beam of aluminum oxide microcrystals to superficially peel the skin surface while simultaneously removing the tissue debris. As microdermabrasion is not as invasive a procedure, non-medical personnel offer this treatment through many spas and clinics.

Skin rejuvenation can also be performed with lasers or chemical peels. These modalities will not be discussed in this article.

CAUTIONS
Patients with darker skin complexions (Fitzpatrick skin types III to VI) may experience permanent skin discoloration or blotchiness with dermabrasion procedures. Patients of African, Asian and Hispanic descent should specifically be cautioned about skin discoloration.

PRE-TREATMENT CARE

Patients with a history of oral herpes infections should be placed on oral acyclovir prior to this treatment to avoid a herpes flare or extension of the condition following dermabrasion.
THE PROCEDURE
Dermabrasion is performed in an out-patient (often office) setting under local anesthesia. Full-face dermabrasion is performed under conscious sedation or general anesthesia, often with the assistance of an anesthetist. A small motorized hand piece rotates a wire brush or diamond fraise at speeds of 15,000 to 30,000 rpm. Skilled manipulation of the rotating brush or fraise removes the upper layers of skin in the areas requiring treatment. This results in a raw, open, partial thickness (through skin) wound that heals by epithelialization of the surface of the skin in a relatively short period of time. Initially the small pinpoint bleeding of the raw wound may be alarming but will subside rapidly with appropriate wound care.

THE RECOVERY
The recovery following dermabrasion skin resurfacing is approximately 2-3 weeks. Early post-operative pain is controlled with prescription medications for the first few days. Most patients require only over-the-counter medications or are comfortable without pain medication within days of the procedure. The skin may weep for the first 10-12 days but eventually stops as the surface layers of the skin are restored. Redness of the treated area is a normal part of recovery and disappears within 3-4 weeks of the procedure. Complete sun avoidance on the treated area must be observed until the redness in the skin has disappeared. Remember good sun protection should still be observed well after the healing period, as it was likely the sun damage to your skin that has driven you to seek this form of treatment in the first place.

Make-up can be used to cover the early skin discoloration once the skin has healed. Please ask your physician or surgeon for directions on when make-up can be used safely.
COMPLICATIONS

A discussion of potential complications is essential with every discussion about a surgical procedure. It is important to know that although complications from surgery are possible they are not common. Some possible complications associated with a dermabrasion are listed into both early and late complications:

EARLY
* Excessive surface bleeding
* Redness (fades with time)
* Infection (viral)
* Skin sensitivity

LATE
* Hyperpigmentation
* Hypopigmentation
* Milia
* Asymmetry (between sides)
* Residual wrinkles
* Scarring

For a more detailed discussion on expected results, recovery, and specific complications, please see your individual surgeon.

COST
Dermabrasion procedures are not covered under most insurance plans and the final cost for such procedures will be at the discretion of the plastic surgeon performing the procedure. Most surgeons quote costs based on the number of aesthetic areas being treated. The average cost of this procedure, is $1000 and higher.

DISCLAIMER
This website does not cover all of the medical knowledge related to dermabrasion nor does it deal with all possible risks and complications of skin resurfacing procedures. Although it is designed to provide the patient with greater depth of information in some areas, it is not intended to substitute for the in depth discussion between patient and surgeon that must occur prior to any surgical or treatment procedure. For a more detailed discussion on expected results, recovery, and specific complications, please see your plastic surgeon or dermatologist.

Author: Dr. Bryce J Cowan BSc MSc MD PhD FRCS(C)
Plastic, Reconstructive, Mohs & Aesthetic Surgeon

Skincare Dollars and Sense

Many consumers are frustrated by skin care products that don’t do what they claim to. Worse still is investing in an expensive yet ineffective cream or treatment only to discover the cheapest drug-store brand would work just as well. In a world of hyper-consumerism, false advertising and a plethora of products from which to choose, how do you choose the good from the bad?

There are some great products on the market that can genuinely improve your skin’s appearance and help your skin look smoother, more radiant, and youthful. But, there are literally thousands of products to choose from and unless you spend hours a day researching beauty products, it’s difficult to find the one of the few that actually produces real results and eliminates years of aging from your face and body.

Not only should a quality skin product help reduce bags under, and fine lines around, the eyes, but it should even out coloration inconsistencies caused by age spots and other unwanted pigment concentrations.

In a marketing-rich world of super models and glamorous actors, many will understandably spend any amount of money to make themselves look better or younger. Cosmetic surgery and skin care is a multi-billion dollar industry.

As the law of supply and demand proves, the higher the demand for youth and beauity, the more manufacturers will rush to provide the solution. Many times this rush results in the creation of an inferior product with little to no research and development to back it.

All of the money goes into the marketing of the product. On the surface everything looks great. The bottles and jars that the creams come in look appealing. The magazine advertisements are glossy, complete with a youthful looking model or a well known celebrity who doesn’t even really use the products.

You can’t really blame these companies. When you are spending a fortune paying for marketing, whether it be on the product containers, magazine, radio, and TV ads, royalties paid to celebrities and models, you have to charge a lot of money for your products or you’re going to lose money.

On the other hand, this doesn’t mean you and I have to fall for these types of marketing schemes. After all, these companies aren’t going to encounter any shortage of people who will open their wallets and purses to purchase their products anytime soon. The reality is most people simply won’t take any time to research products and understand what ingredients work and what ingredients are actually bad for your skin!

Retinoids and Dry Skin

Dry skin recommendations and supplements that can help your skin

RETINOIDS
The group of medicines known as retinoids are derived from Vitamin A. Creams containing the retinoids retinol and retinaldehyde can be obtained over the counter at pharmacies and supermarkets. Other topical retinoids containing tretinoin or isotretinoin require a doctor’s prescription. Adapalene is a related prescription medicine.  Topical retinoids can be applied to any area but are most often used on the face, the neck and the back of hands.

When you first start using the retinoid, apply your night cream first then re-apply the retinoid. Do this every third night for two weeks. Then apply moisturizer followed by retinoid every other night. If no redness occurs after two weeks you can adjust your regimen and apply the retinoid after cleansing but before your night cream. Then apply the night cream after the retinoid. Do this, using the retinoid every other day, for one week.

If you experience redness or flaking, begin using the retinoid every night. In about twenty-four weeks you will notices fewer wrinkles and smoother skin as well as preventing future wrinkles. Since retinoids speed up the rare at which skin cells divide, some flaking is normal. This flaking is not additional dryness, but rather dead skin cells sloughing off. You can use a facial scrub once or twice a week before an important event to remove these fakes, allowing your skin to look radiant. Stronger products are more irritating than those with a lower percentage of retinoids, so you can switch products depending on your needs.