Part 2: CME #125: What Did We Learn in 2005?
Part 2: What Did We Learn in 2005?
Dermatologic Surgery Update
Curettage of basal cell carcinomas and Mohs surgery. Many dermatologic surgeons routinely perform curettage to help delineate tumor borders before Mohs micrographic surgery. Huang et al. examined utility of pre-operative tumor curettage in Mohs micrographic surgery for primary or recurrent, well-defined basal cell carcinomas (BCCs) less than 2 cm in diameter located on the head or neck.33 For this study, 166 patients were randomized to pre-operative tumor curettage or control group followed by Mohs. The pre-operative tumor curettage group had a 399% mean surface area increase from tumor to wound surface area versus 263% for control group (p=0.0002). The pre-operative tumor curettage group had a mean absolute surface area increase of 1.78 cm2 versus 1.40 cm2 for control group (p=0.02). The preoperative tumor curettage group had fewer tissue layers removed. Mohs micrographic surgery vs. excision of centrofacial basal cell carcinomas. Mohs has long been the standard of care for large, histologically aggressive and recurrent centrofacial BCCs in United States. Smeets et al. prospectively evaluated 397 primary and 201 recurrent centrofacial BCCs larger than 1 cm in size or smaller tumors with aggressive histologic subtype.34 Patients were randomized into two groups: One group was treated with standard surgical excision with 3-mm margins (198 primary tumors and 102 recurrent tumors) and the other group was treated with Mohs (199 primary tumors and 99 recurrent tumors). Of the 199 primary BCCs treated with surgical excision, 35 had positive surgical margins and were either re-excised (31) or treated with Mohs (3); one BCC was untreated. Of the 102 recurrent BCCs treated with surgical excision, 31 had positive surgical margins and were either re-excised (25) or treated with Mohs (5); one BCC was treated with another therapy. Of the primary carcinomas, five (3%) recurred after surgical excision compared with three (2%) after Mohs during 30 months of follow-up. Of the recurrent carcinomas, three (3%) recurred after surgical excision and none after Mohs during 18 months of follow-up. Since BCCs are slow-growing tumors, longer follow-up data are certainly needed. However, this study does raise the question of whether all centrofacial BCCs required Mohs, which is much more labor intensive and expensive.
Cosmetic Dermatology Update
Artecoll, new permanent filler. In this double-blind, multi-center study, Cohen and Holmes compared Artecoll (an injectable wrinkle filler composed of polymethylmethacrylate microspheres and bovine collagen) with a currently approved bovine collagen dermal filler (control) in 1,334 wrinkles of the glabella, nasolabial fold, radial upper lip lines, and corner-of-the-mouth lines.35 Two hundred and fifty one patients were enrolled in this trial and follow-up safety, efficacy, investigator success rating, and subject satisfaction rating data were collected at 1, 3 and 6 months. Blinded observers using a photographic facial fold assessment scale demonstrated a combined significant improvement with Artecoll compared with bovine collagen at 6 months (p<0.001). The investigator success ratings and the subject satisfaction ratings for each of the four injections sites were superior for Artecoll. At 12 months follow-up, 111 patients injected with Artecoll showed persistence of significant augmentation. Side effects were similar in the Artecoll and control groups.
Radiance FN, long-term soft tissue filler. Tzikas evaluated clinical efficacy and patient satisfaction of Radiance FN (fine needle), which consists of 35% spherical particles of synthetic calcium hydroxylapatite blended in a gel that contains water, glycerin and sodium carboxymethylcellulose, in 90 patients.36 Subdermal injection with Radiance FN was accomplished under nerve-block anesthesia by a fanning technique. The primary areas treated were lips, nasolabial folds, glabellar rhytids, marionette lines, prejowl depressions, acne scars and surgical soft tissue defects. At 6 months, appearance, softness and overall patient satisfaction were rated good or excellent in 74%, 80% and 88% of patients, respectively. Persistent visible mucosal lip nodules were detected in seven patients (7.8%), four of whom required intervention. This last side effect is concerning. Although the long-lasting nature of this product is desirable, the development of lip nodules must be considered and discussed with the patients undergoing this treatment.
Fake botulimun toxin type A (Botox). Four people were hospitalized in Florida when they were injected with non-FDA approved botulinum toxin type A. Dr. Bach McComb, an osteopathic physician whose license was suspended in 2003 on charges of over-prescribing painkillers, was charged with accidentally paralyzing his girlfriend, himself and two others with the fake drug.37 Dr. McComb allegedly used massive doses of unapproved bulk botulinum toxin type A, not the FDA-approved Allergan product. The product was purchased from a company named List Biological Laboratories in Campbell, CA, which makes diphtheria and anthrax for animal research.38 An investigation is currently underway.
Advances Improve Patient Care
Dermatology is an exciting and constantly evolving field. We have seen multiple advances in all aspects of dermatology in 2005, including medical dermatology, cosmetic dermatology and dermatologic surgery. Application of these advances should improve the care that we provide to our patients. We can also look forward to exciting changes in 2006.