Optimal Mixing Ratio Reduces Pain During Lido/Epi Injection
While mixing lidocaine 1% and epinephrine 1:100,000 (Lido/Epi) solutions with sodium hydrogen carbonate (NaHCO3) reduces burning pain during infiltration, findings from a recent study suggested a 3:1 mixing ratio was associated with significantly less pain.
In the randomized, placebo-controlled study, the researchers compared pain during injection between four medicinal products (IMP1-4), which included a 3:1 mixing ratio of Lido/Epi-NaHCO₃ (IMP1), a 9:1 mixing ratio (IMP2), unbuffered Lido/Epi (IMP3), or placebo (NaCl 0.9% [IMP4]).
The researchers found the 3:1 mixing ratio was significantly less painful compared with the 9:1 ratio. Unbuffered Lido/Epi was more painful compared with buffered Lido/Epi, but IMP4 was more painful compared with any of the anesthetic solutions, they added. In all cases, the anesthesia was effective for at least 3 hours, the researchers said.
“Reported findings are of high practical relevance given the extensive use of local anesthesia today,” they concluded. However, the “results of this trial cannot be transferred to other local anesthetics such as prilocaine, bupivacaine, or ropivacaine which precipitate with NaHCO₃ admixtures.”
Vent A, Surber C, Graf Johansen NT, et al. Buffered lidocaine 1%, epinephrine 1:100'000 with sodium bicarbonate (hydrogen carbonate) in a 3:1 ratio is less painful than a 9:1 ratio: a double-blind, randomized, placebo-controlled, crossover trial [published online January 17, 2020]. J Am Acad Dermatol. doi:10.1016/j.jaad.2019.09.088
Prescription-strength Topical Steroids Readily Available Without a Prescription
Patients can purchase several prescription-strength topical corticosteroids without a prescription in many cities across the United States, according to the authors of a recent research letter published in the Journal of the American Academy of Dermatology.
While the FDA has only approved one topical corticosteroid for over-the-counter use (hydrocortisone), “patients frequently present to dermatology clinics using prescription-strength topical corticosteroids without a prescription,” the authors said. In order to evaluate the prevalence of readily available high-potency steroids, the authors went to 80 stores specializing in foreign imports in 13 cities across the United States to identify topical medicaments. Of these stores, 36 (35%) sold one or more prescription-strength topical corticosteroids without requiring a prescription.
The authors found 30 distinct prescription-strength topical steroids available, which included clobetasol propionate 0.025% to 0.05% (n=8), in combination with neomycin (n=1), ketoconazole/tolnaftate (n=1), or ketoconazole (n=1); and betamethasone dipropionate 0.05% to 0.12% (n=10), in combination with gentamicin/clotrimazole (n=4), neomycin (n=3), or gentamicin/clotrimazole (n=1). Other steroid preparations the authors found included betamethasone valerate 0.02% to 0.1% (n=5), in combination with gentamicin (n=1) or neomycin (n=1); dexamethasone 0.075% (n=1); fluocinonide 0.025% (n=5), in combination with neomycin (n=1) or neomycin/clotrimazole (n=3); and fluocinolone acetonide 0.05% (n=1).
High-potency steroids were produced in various countries, including Mexico, Switzerland, India, China, El Salvador, and Italy. Additionally, the researchers found the average price of steroids available at these stores were $6.90 per 30 g for clobetasol propionate 0.05% and $10.02 per 30 g for betamethasone dipropionate 0.05%. The cost of steroids at the stores were significantly lower than the cost in the US market based on prices from GoodRx ($195.27 and $91.37 per 30 g, respectively), the researchers noted.
“These findings underscore the importance of asking about and physically examining patients’ products,” the authors concluded. They noted that practitioners should consider the cultural aspect of this issue as well. Prescription-strength topical corticosteroids are available legally in many countries and immigrants may not be aware they need a prescription to purchase these products, they added.
“Further research is needed to assess the prevalence of [prescription-strength topical corticosteroids without a prescription] in other geographic areas as well as the availability of other types of medications illegally sold over the counter, such as skin lightening creams and oral antibiotics,” the researchers concluded. In addition, they stressed the importance of educating vulnerable patients on the potential harms associated with unmonitored prescription-strength topical corticosteroid use.
Kimyon RS, Schlarbaum JP, Liou YL, et al. Prescription-strength topical corticosteroids available over the counter: cross-sectional study of 80 stores in 13 United States cities. J Am Acad Dermatol. 2020;82(2):524-525. doi:10.1016/j.jaad.2019.10.035
Iron Deficiency Common Among Patients With HS
According to findings of a recent study in Dermatology, iron deficiency was identifiable in 75% of participants with hidradenitis suppurativa (HS).
“Iron deficiency is frequently present in inflammation-
mediated chronic diseases, irrespective of anemia,” the researchers noted. They investigated iron status using serum concentrations of ferritin, transferrin saturation (Tsat), soluble transferrin receptor, and hepcidin among 74 participants with HS and 44 healthy controls. Iron deficiency was defined as ferritin levels below 100 µg/L or ferritin levels from 100 to 299 µg/L with Tsat below 20%.
Compared with controls, participants with HS were more likely to have a deranged iron status, the researchers said, with decreased levels of ferritin, Tsat, and hepcidin. “There was also a trend towards higher values of soluble transferrin receptor,” they added. Additionally, the researchers observed that disease severity did not differentiate iron status biomarkers.
Overall, 75% of participants with HS had iron deficiency. The prevalence of iron deficiency was not related to disease severity, and none of the iron status biomarkers correlated with levels of IL-6, the researchers added.
“The majority of patients with HS demonstrated derangements in iron status typical of iron deficiency,” which were not related to proinflammatory activation or associated with disease severity, the researchers concluded. “Whether it may have a therapeutic impact needs to be further studied,” they added.
Ponikowska M, Matusiak L, Kasztura M, Jankowska EA, Szepietowski JC. Deranged iron status evidenced by iron deficiency characterizes patients with hidradenitis suppurativa [published online January 10, 2020]. Dermatology. 2020;236(1):51-57. doi:10.1159/000505184
Topical Ozone Therapy: A Potential Option for AD?
Findings from a small study conducted in China showed beneficial effects of topical ozone therapy on the microbiological diversity of the skin—specifically, decreases in Staphylococcus
aureus and increases in Acinetobacter—among patients with atopic dermatitis (AD).
“S aureus accounts for 90% of the microbiome in AD lesions and plays a role in disease flare-ups and worsen disease outcomes,” the researchers said. “Ozone treatment can improve AD conditions by its bactericidal effect on S aureus.”
In the study, they investigated the effects of topical ozone therapy on the microbiome diversity in AD lesions of 12 participants with moderate to severe disease. Participants were randomly assigned to either the treatment group or control group. For 3 days, participants in the treatment group were treated with an ozonated water shower for 15 minutes once per day followed by topical ozonated camellia oil, and those in the control group were treated with tap water shower and basal oil.
The researchers used Scoring Atopic Dermatitis (SCORAD) scores and modified Eczema Area Severity Index scores to assess the efficacy of ozone therapy, and skin samples were collected to assess microbiological composition of the targeted sites using 16S rDNA sequencing.
After 3 days of treatment, participants in the ozone treatment group experienced significant decreases in SCORAD scores and inflammatory cell infiltration in AD lesions. In addition, the researchers observed higher microecological diversity in nonlesional AD skin compared with lesional AD skin, which was negatively correlated with AD severity.
“The proportion of S aureus in AD lesions was positively correlated with the severity of AD, which was decreased after ozone treatment,” the researchers said. Ozone therapy was associated with increased microbiological diversity as well, they added, with significant increases in the proportion of Acinetobacter.
“Topical ozone therapy is highly effective for treatment for AD. It can change the proportional ratio of Staphylococcus and Acinetobacter, thereby restoring the microbiological diversity in AD lesions,” the researchers concluded. n
Zeng J, Dou J, Gao L, et al. Topical ozone therapy restores microbiome diversity in atopic dermatitis [published online January 24, 2020]. Int Immunopharmacol. 2020;80:106191. doi:10.1016/j.intimp.2020.106191