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Dermatologic Applications of Photodynamic Therapy: The University of Miami Outlook
What's New in Natural Compounds for Photoprotection?
Update on Dermal Filling Agents: The University of Miami Department of Dermatology's Cosmetic Center Perspective
Combined Use of a Rotation Flap and High-Viscosity 2-Octyl Cyanoacrylate for Reconstruction of a Facial Defect After Excision of a Nodular Basal Cell Carcinoma by Mohs Micrographic Surgery
Cosmetic Dermatology Update, Part 1: Department of Dermatology and Cutaneous Surgery at the University of Miami [editorial]
Larva Currens in a Patient Scheduled for Renal Transplant
Case Report
A 54-year-old woman with polycystic disease of kidneys was scheduled for renal transplant and presented with a 2-week history of an extremely pruritic rash that primarily affected her torso, buttocks, shoulders, and thighs. She described the lesions as red, raised, and linear, typically lasting less than 24 hours at a time. She had been previously treated with a 5-day course of prednisone by another physician, without improvement. Her only new medication was glucosamine and chondroitin sulfate, which she had started one week prior to the eruption. Raloxifene hydrochloride and cetirizine hydrochloride were long-term medications.
The patient reported one similar episode many years ago. She denied any recent changes in her health and reported no gastrointestinal tract or pulmonary symptoms. She was raised in Panama and had visited there in the past year. She specifically denied walking without shoes.
On physical examination, the patient had a pink, serpiginous, urticarial plaque on the right side of the trunk that was surrounded by a few red serpiginous patches (Figure). Her white blood cell count was 6.5X103/µL (reference range, 3.5–10.5X103/µL), with 19.2% eosinophils (reference, 2.7%). Her absolute eosinophil count was elevated at 1200/µL (reference range, 0–450/µL). A review of prior laboratory test results indicated that her absolute eosinophil count also had been elevated 6 months prior to presentation. Serologic evaluation by enzyme-linked immunosorbent assay was positive for Strongyloides. Results of stool studies did not reveal ova and parasites.
PLEASE REFER TO THE PDF TO VIEW THE FIGURE
The patient was treated with oral thiabendazole 1500 mg twice daily for 2 days and her transplant was postponed. Her rash resolved, but 2 weeks later, her white blood cell count was 5.6X103/µL, with 11.6% eosinophils. She was subsequently treated with a single dose of 200 µg/kg of ivermectin. Results of a complete blood count obtained 2 weeks later demonstrated that her eosinophil count was within reference range and she was able to proceed with the transplant. The patient's sister (the donor) also was born in Panama and had negative serologic evaluation results for Strongyloides. The patient did well following the transplant and the results of repeat serologic evaluations performed 4 months after the transplant were negative for Strongyloides.
Comment
Strongyloides stercoralis is an intestinal nematode primarily found in tropical or subtropical countries. Humans are infected by filariform larvae that dwell in the soil. Larvae penetrate intact skin, gain access to the venous system, pass through the heart to the lungs, enter the pulmonary alveoli, migrate up the tracheobronchial tree, and are swallowed, thereby entering the gastrointestinal tract.1 The larvae mature into adult females that penetrate the mucosa of the small intestine and deposit eggs. The eggs hatch into rhabditiform larvae that are passed in the stool to the soil where transformation into the infective form (filariform) occurs. Autoinfection may take place when this transformation to the infective-stage larvae occurs within the gastrointestinal tract, enabling the infective larvae to invade the lower large bowel or perianal skin and begin the migratory pathway. Autoinfection can allow the persistence of infection for long periods of time and also can allow chronic infections to persist in climates where free-living larvae cannot survive.2
Uncomplicated infection with S stercoralis can cause cutaneous, gastrointestinal tract, and pulmonary symptoms corresponding to the involvement of organs during the parasite's life cycle. Rash is uncommon in acute infection, though it is common in chronic disease. Maculopapular eruptions and chronic urticaria have been reported in up to two-thirds of patients.3 Larva currens is a migratory, rapidly extending, serpiginous, urticarial lesion that is pathognomonic for chronic strongyloidiasis. The rash typically lasts from several hours to several days. It most commonly affects the buttocks, perineum, and thighs, and is secondary to invasion of perianal skin by filariform larvae from the patient's intestine. Arthur and Shelley4 proposed the term larva currens (running larva) because the larvae and subsequent rash can move up to 10 cm per hour.
In a healthy host, the cellular immune system seems to limit parasite invasion of mucosal tissues.5 If immunosuppression occurs, individuals with strongyloidiasis can develop a hyperinfective syndrome and massive numbers of larvae can invade any organ of the body, with a mortality rate of 70% to 90%.6,7 The cutaneous manifestation of disseminated strongyloidiasis is the rapid onset of a petechial and purpuric eruption that typically involves the proximal extremities and trunk and results from massive invasion of the skin by filariform larvae. The "thumbprint sign" refers to a pattern of periumbilical ecchymoses resembling multiple thumbprints that can occur in hyperinfection.8
Gastrointestinal tract symptoms predominate in acute infection. Diarrhea and midepigastric pain that may mimic peptic ulcer disease are common. Diarrhea also can alternate with constipation. Other gastrointestinal tract symptoms include nausea, vomiting, anorexia, pruritus ani, and bloating.1 Some severe cases can have malabsorption and evidence of a protein-losing enteropathy.9,10
Pulmonary symptoms in acute infection can occur and include wheezing, coughing, and shortness of breath.1 Larval migration through the lungs also can lead to transient pulmonary infiltrates. Some patients have presented with asthma.11 Patients with chronic disease may have gastrointestinal tract and pulmonary symptoms, though chronic infection tends to be indolent and patients may be asymptomatic.
Diagnosis can be difficult, as results from stool samples often are negative and multiple samples may be required. Results of biopsies performed on larva currens specimens usually do not reveal larvae, though biopsy results of the petechial and purpuric eruptions of disseminated disease will reveal larvae. Serologic testing with enzyme-linked immunosorbent assay has a sensitivity of approximately 90%.12,13
Traditionally, thiabendazole has been used to treat this infection, though in approximately 30% of cases, the parasite is not eradicated from the feces. Ivermectin has been found to be more effective for treating uncomplicated chronic disease.14
In most cases of disseminated disease, patients were receiving corticosteroids or other immunosuppressive drugs or had an underlying illness, such as malignancy or AIDS.1,2,15,16 Our patient was scheduled to undergo a renal transplant and fatal disseminated strongyloidiasis has been reported in patients undergoing renal transplant.2,16 Morgan et al2 reviewed 29 cases of strongyloidiasis complicating renal transplants; 15 patients died.
Infection in the immunocompromised patient can be complicated by the fact that invasive larvae can transport gram-negative bacilli from the intestine to sites of migration, such as the pulmonary and central nervous systems.5 Gram-negative sepsis, meningitis, or pneumonia can result. Diagnosis can be difficult because eosinophilia often is absent in immunocompromised patients with disseminated disease.5
Although common in tropical and subtropical countries, other geographic regions of endemic Strongyloides are recognized. The climate and soil of the southeastern United States favor the survival of the organism,5 and the parasite was reported in 3% (N=561) of a group of rural Kentucky schoolchildren17; similar findings were reported in another study conducted in Kentucky.18Strongyloides also was the most commonly detected parasite in a review of stool samples examined at the University of Kentucky Medical Center.19 Ex–prisoners of war who served in Southeast Asia during World War II also constitute an at-risk group in the United States.20-22
It is imperative to rule out the presence of this parasite prior to transplant in patients with a geographic history predisposing them to infection, a history of eosinophilia, or symptoms of chronic strongyloidiasis.1 Many transplantation centers routinely screen for this parasite as part of the pretransplant evaluation. Although uncommon in acute infections, cutaneous involvement often is present in chronic strongyloidiasis.1 It also is important to follow patients already treated for larva currens closely posttransplant, as therapeutic failures occur.
- Longworth DL, Weller PF. Hyperinfection syndrome with strongyloidiasis. In: Remington JS, Swartz MN, eds. Current Clinical Topics in Infectious Diseases. New York, NY: McGraw-Hill; 1986:1-26.
- Morgan JS, Schaffner W, Sone WJ. Opportunistic strongyloidiasis in renal transplant recipients. Transplantation. 1986;42:518-524.
- Grove DI. Strongyloidiasis in allied ex–prisoners of war in south-east Asia. Br Med J. 1980;280:598-601.
- Arthur RP, Shelley WB. Larva currens; a distinctive variant of cutaneous larva migrans due to Strongyloides stercoralis. AMA Arch Derm. 1958;78:186-190.
- Zygmunt DJ. Strongyloides stercoralis. Infect Control Hosp Epidemiol. 1990;11:495-497.
- Singh S. Human strongyloidiasis in AIDS era: its zoonotic importance. J Assoc Physicians India. 2002;50:415-422.
- Rothenberg ME. Eosinophilia. N Engl J Med. 1998;338:1592-1600.
- Bank DE, Grossman ME, Kohn SR, et al. The thumbprint sign: rapid diagnosis of disseminated strongyloidiasis. J Am Acad Dermatol. 1990;23(2, pt 1):324-326.
- Milner PF, Irvine RA, Barton CJ, et al. Intestinal malabsorption in Strongyloides stercoralis infestation. Gut. 1965;6:574-581.
- O'Brien W. Intestinal malabsorption in acute infection with Strongyloides stercoralis. Trans R Soc Trop Med Hyg. 1975;69:69-77.
- Nwokolo C, Imohiosen EA. Strongyloidiasis of respiratory tract presenting as "asthma". Br Med J. 1973;2:153-154.
- Neva FA, Gam AA, Burke J. Comparison of larval antigens in an enzyme-linked immunosorbent assay for strongyloidiasis in humans. J Infect Dis. 1981;144:427-432.
- Genta RM. Strongyloidiasis. In: Walls KW, Schantz PM, eds. Immunodiagnosis of Parasitic Diseases. Vol 1. Orlando, FL: Academic Press Inc; 1986:183-199.
- Igual-Adell R, Oltra-Alcaraz C, Soler-Company E, et al. Efficacy and safety of ivermectin and thiabendazole in the treatment of strongyloidiasis. Expert Opin Pharmacother. 2004;5:2615-2619.
- Maayan S, Wormser GP, Widerhorn J, et al. Strongyloides stercoralis hyperinfection in a patient with the acquired immune deficiency syndrome. Am J Med. 1987;83:945-948.
- Weller IV, Copland P, Gabriel R. Strongyloides stercoralis infection in renal transplant recipients [letter]. Br Med J (Clin Res Ed). 1981;282:524.
- Walzer PD, Milder JE, Banwell JG, et al. Epidemiologic features of Strongyloides stercoralis infection in an endemic area of the United States. Am J Trop Med Hyg. 1982;31:313-319.
- Fulmer HS, Huempfner HR. Intestinal helminths in eastern Kentucky: a survey in three rural counties. Am J Trop Med Hyg. 1965;14:269-275.
- Milder JE, Walzer PD, Kilgore G, et al. Clinical features of Strongyloides stercoralis infection in an endemic area of the United States. Gastroenterology. 1981;80:1481-1488.
- Genta RM, Weesner R, Douce RW, et al. Strongyloidiasis in US veterans of the Vietnam and other wars. JAMA. 1987;258:49-52.
- Gill GV, Welch E, Bailey JW, et al. Chronic Strongyloides stercoralis infection in former British Far East prisoners of war. QJM. 2004;97:789-795.
- Pelletier LL Jr. Chronic strongyloidiasis in World War II Far East ex–prisoners of war. Am J Trop Med Hyg. 1984;33:55-61.
Case Report
A 54-year-old woman with polycystic disease of kidneys was scheduled for renal transplant and presented with a 2-week history of an extremely pruritic rash that primarily affected her torso, buttocks, shoulders, and thighs. She described the lesions as red, raised, and linear, typically lasting less than 24 hours at a time. She had been previously treated with a 5-day course of prednisone by another physician, without improvement. Her only new medication was glucosamine and chondroitin sulfate, which she had started one week prior to the eruption. Raloxifene hydrochloride and cetirizine hydrochloride were long-term medications.
The patient reported one similar episode many years ago. She denied any recent changes in her health and reported no gastrointestinal tract or pulmonary symptoms. She was raised in Panama and had visited there in the past year. She specifically denied walking without shoes.
On physical examination, the patient had a pink, serpiginous, urticarial plaque on the right side of the trunk that was surrounded by a few red serpiginous patches (Figure). Her white blood cell count was 6.5X103/µL (reference range, 3.5–10.5X103/µL), with 19.2% eosinophils (reference, 2.7%). Her absolute eosinophil count was elevated at 1200/µL (reference range, 0–450/µL). A review of prior laboratory test results indicated that her absolute eosinophil count also had been elevated 6 months prior to presentation. Serologic evaluation by enzyme-linked immunosorbent assay was positive for Strongyloides. Results of stool studies did not reveal ova and parasites.
PLEASE REFER TO THE PDF TO VIEW THE FIGURE
The patient was treated with oral thiabendazole 1500 mg twice daily for 2 days and her transplant was postponed. Her rash resolved, but 2 weeks later, her white blood cell count was 5.6X103/µL, with 11.6% eosinophils. She was subsequently treated with a single dose of 200 µg/kg of ivermectin. Results of a complete blood count obtained 2 weeks later demonstrated that her eosinophil count was within reference range and she was able to proceed with the transplant. The patient's sister (the donor) also was born in Panama and had negative serologic evaluation results for Strongyloides. The patient did well following the transplant and the results of repeat serologic evaluations performed 4 months after the transplant were negative for Strongyloides.
Comment
Strongyloides stercoralis is an intestinal nematode primarily found in tropical or subtropical countries. Humans are infected by filariform larvae that dwell in the soil. Larvae penetrate intact skin, gain access to the venous system, pass through the heart to the lungs, enter the pulmonary alveoli, migrate up the tracheobronchial tree, and are swallowed, thereby entering the gastrointestinal tract.1 The larvae mature into adult females that penetrate the mucosa of the small intestine and deposit eggs. The eggs hatch into rhabditiform larvae that are passed in the stool to the soil where transformation into the infective form (filariform) occurs. Autoinfection may take place when this transformation to the infective-stage larvae occurs within the gastrointestinal tract, enabling the infective larvae to invade the lower large bowel or perianal skin and begin the migratory pathway. Autoinfection can allow the persistence of infection for long periods of time and also can allow chronic infections to persist in climates where free-living larvae cannot survive.2
Uncomplicated infection with S stercoralis can cause cutaneous, gastrointestinal tract, and pulmonary symptoms corresponding to the involvement of organs during the parasite's life cycle. Rash is uncommon in acute infection, though it is common in chronic disease. Maculopapular eruptions and chronic urticaria have been reported in up to two-thirds of patients.3 Larva currens is a migratory, rapidly extending, serpiginous, urticarial lesion that is pathognomonic for chronic strongyloidiasis. The rash typically lasts from several hours to several days. It most commonly affects the buttocks, perineum, and thighs, and is secondary to invasion of perianal skin by filariform larvae from the patient's intestine. Arthur and Shelley4 proposed the term larva currens (running larva) because the larvae and subsequent rash can move up to 10 cm per hour.
In a healthy host, the cellular immune system seems to limit parasite invasion of mucosal tissues.5 If immunosuppression occurs, individuals with strongyloidiasis can develop a hyperinfective syndrome and massive numbers of larvae can invade any organ of the body, with a mortality rate of 70% to 90%.6,7 The cutaneous manifestation of disseminated strongyloidiasis is the rapid onset of a petechial and purpuric eruption that typically involves the proximal extremities and trunk and results from massive invasion of the skin by filariform larvae. The "thumbprint sign" refers to a pattern of periumbilical ecchymoses resembling multiple thumbprints that can occur in hyperinfection.8
Gastrointestinal tract symptoms predominate in acute infection. Diarrhea and midepigastric pain that may mimic peptic ulcer disease are common. Diarrhea also can alternate with constipation. Other gastrointestinal tract symptoms include nausea, vomiting, anorexia, pruritus ani, and bloating.1 Some severe cases can have malabsorption and evidence of a protein-losing enteropathy.9,10
Pulmonary symptoms in acute infection can occur and include wheezing, coughing, and shortness of breath.1 Larval migration through the lungs also can lead to transient pulmonary infiltrates. Some patients have presented with asthma.11 Patients with chronic disease may have gastrointestinal tract and pulmonary symptoms, though chronic infection tends to be indolent and patients may be asymptomatic.
Diagnosis can be difficult, as results from stool samples often are negative and multiple samples may be required. Results of biopsies performed on larva currens specimens usually do not reveal larvae, though biopsy results of the petechial and purpuric eruptions of disseminated disease will reveal larvae. Serologic testing with enzyme-linked immunosorbent assay has a sensitivity of approximately 90%.12,13
Traditionally, thiabendazole has been used to treat this infection, though in approximately 30% of cases, the parasite is not eradicated from the feces. Ivermectin has been found to be more effective for treating uncomplicated chronic disease.14
In most cases of disseminated disease, patients were receiving corticosteroids or other immunosuppressive drugs or had an underlying illness, such as malignancy or AIDS.1,2,15,16 Our patient was scheduled to undergo a renal transplant and fatal disseminated strongyloidiasis has been reported in patients undergoing renal transplant.2,16 Morgan et al2 reviewed 29 cases of strongyloidiasis complicating renal transplants; 15 patients died.
Infection in the immunocompromised patient can be complicated by the fact that invasive larvae can transport gram-negative bacilli from the intestine to sites of migration, such as the pulmonary and central nervous systems.5 Gram-negative sepsis, meningitis, or pneumonia can result. Diagnosis can be difficult because eosinophilia often is absent in immunocompromised patients with disseminated disease.5
Although common in tropical and subtropical countries, other geographic regions of endemic Strongyloides are recognized. The climate and soil of the southeastern United States favor the survival of the organism,5 and the parasite was reported in 3% (N=561) of a group of rural Kentucky schoolchildren17; similar findings were reported in another study conducted in Kentucky.18Strongyloides also was the most commonly detected parasite in a review of stool samples examined at the University of Kentucky Medical Center.19 Ex–prisoners of war who served in Southeast Asia during World War II also constitute an at-risk group in the United States.20-22
It is imperative to rule out the presence of this parasite prior to transplant in patients with a geographic history predisposing them to infection, a history of eosinophilia, or symptoms of chronic strongyloidiasis.1 Many transplantation centers routinely screen for this parasite as part of the pretransplant evaluation. Although uncommon in acute infections, cutaneous involvement often is present in chronic strongyloidiasis.1 It also is important to follow patients already treated for larva currens closely posttransplant, as therapeutic failures occur.
Case Report
A 54-year-old woman with polycystic disease of kidneys was scheduled for renal transplant and presented with a 2-week history of an extremely pruritic rash that primarily affected her torso, buttocks, shoulders, and thighs. She described the lesions as red, raised, and linear, typically lasting less than 24 hours at a time. She had been previously treated with a 5-day course of prednisone by another physician, without improvement. Her only new medication was glucosamine and chondroitin sulfate, which she had started one week prior to the eruption. Raloxifene hydrochloride and cetirizine hydrochloride were long-term medications.
The patient reported one similar episode many years ago. She denied any recent changes in her health and reported no gastrointestinal tract or pulmonary symptoms. She was raised in Panama and had visited there in the past year. She specifically denied walking without shoes.
On physical examination, the patient had a pink, serpiginous, urticarial plaque on the right side of the trunk that was surrounded by a few red serpiginous patches (Figure). Her white blood cell count was 6.5X103/µL (reference range, 3.5–10.5X103/µL), with 19.2% eosinophils (reference, 2.7%). Her absolute eosinophil count was elevated at 1200/µL (reference range, 0–450/µL). A review of prior laboratory test results indicated that her absolute eosinophil count also had been elevated 6 months prior to presentation. Serologic evaluation by enzyme-linked immunosorbent assay was positive for Strongyloides. Results of stool studies did not reveal ova and parasites.
PLEASE REFER TO THE PDF TO VIEW THE FIGURE
The patient was treated with oral thiabendazole 1500 mg twice daily for 2 days and her transplant was postponed. Her rash resolved, but 2 weeks later, her white blood cell count was 5.6X103/µL, with 11.6% eosinophils. She was subsequently treated with a single dose of 200 µg/kg of ivermectin. Results of a complete blood count obtained 2 weeks later demonstrated that her eosinophil count was within reference range and she was able to proceed with the transplant. The patient's sister (the donor) also was born in Panama and had negative serologic evaluation results for Strongyloides. The patient did well following the transplant and the results of repeat serologic evaluations performed 4 months after the transplant were negative for Strongyloides.
Comment
Strongyloides stercoralis is an intestinal nematode primarily found in tropical or subtropical countries. Humans are infected by filariform larvae that dwell in the soil. Larvae penetrate intact skin, gain access to the venous system, pass through the heart to the lungs, enter the pulmonary alveoli, migrate up the tracheobronchial tree, and are swallowed, thereby entering the gastrointestinal tract.1 The larvae mature into adult females that penetrate the mucosa of the small intestine and deposit eggs. The eggs hatch into rhabditiform larvae that are passed in the stool to the soil where transformation into the infective form (filariform) occurs. Autoinfection may take place when this transformation to the infective-stage larvae occurs within the gastrointestinal tract, enabling the infective larvae to invade the lower large bowel or perianal skin and begin the migratory pathway. Autoinfection can allow the persistence of infection for long periods of time and also can allow chronic infections to persist in climates where free-living larvae cannot survive.2
Uncomplicated infection with S stercoralis can cause cutaneous, gastrointestinal tract, and pulmonary symptoms corresponding to the involvement of organs during the parasite's life cycle. Rash is uncommon in acute infection, though it is common in chronic disease. Maculopapular eruptions and chronic urticaria have been reported in up to two-thirds of patients.3 Larva currens is a migratory, rapidly extending, serpiginous, urticarial lesion that is pathognomonic for chronic strongyloidiasis. The rash typically lasts from several hours to several days. It most commonly affects the buttocks, perineum, and thighs, and is secondary to invasion of perianal skin by filariform larvae from the patient's intestine. Arthur and Shelley4 proposed the term larva currens (running larva) because the larvae and subsequent rash can move up to 10 cm per hour.
In a healthy host, the cellular immune system seems to limit parasite invasion of mucosal tissues.5 If immunosuppression occurs, individuals with strongyloidiasis can develop a hyperinfective syndrome and massive numbers of larvae can invade any organ of the body, with a mortality rate of 70% to 90%.6,7 The cutaneous manifestation of disseminated strongyloidiasis is the rapid onset of a petechial and purpuric eruption that typically involves the proximal extremities and trunk and results from massive invasion of the skin by filariform larvae. The "thumbprint sign" refers to a pattern of periumbilical ecchymoses resembling multiple thumbprints that can occur in hyperinfection.8
Gastrointestinal tract symptoms predominate in acute infection. Diarrhea and midepigastric pain that may mimic peptic ulcer disease are common. Diarrhea also can alternate with constipation. Other gastrointestinal tract symptoms include nausea, vomiting, anorexia, pruritus ani, and bloating.1 Some severe cases can have malabsorption and evidence of a protein-losing enteropathy.9,10
Pulmonary symptoms in acute infection can occur and include wheezing, coughing, and shortness of breath.1 Larval migration through the lungs also can lead to transient pulmonary infiltrates. Some patients have presented with asthma.11 Patients with chronic disease may have gastrointestinal tract and pulmonary symptoms, though chronic infection tends to be indolent and patients may be asymptomatic.
Diagnosis can be difficult, as results from stool samples often are negative and multiple samples may be required. Results of biopsies performed on larva currens specimens usually do not reveal larvae, though biopsy results of the petechial and purpuric eruptions of disseminated disease will reveal larvae. Serologic testing with enzyme-linked immunosorbent assay has a sensitivity of approximately 90%.12,13
Traditionally, thiabendazole has been used to treat this infection, though in approximately 30% of cases, the parasite is not eradicated from the feces. Ivermectin has been found to be more effective for treating uncomplicated chronic disease.14
In most cases of disseminated disease, patients were receiving corticosteroids or other immunosuppressive drugs or had an underlying illness, such as malignancy or AIDS.1,2,15,16 Our patient was scheduled to undergo a renal transplant and fatal disseminated strongyloidiasis has been reported in patients undergoing renal transplant.2,16 Morgan et al2 reviewed 29 cases of strongyloidiasis complicating renal transplants; 15 patients died.
Infection in the immunocompromised patient can be complicated by the fact that invasive larvae can transport gram-negative bacilli from the intestine to sites of migration, such as the pulmonary and central nervous systems.5 Gram-negative sepsis, meningitis, or pneumonia can result. Diagnosis can be difficult because eosinophilia often is absent in immunocompromised patients with disseminated disease.5
Although common in tropical and subtropical countries, other geographic regions of endemic Strongyloides are recognized. The climate and soil of the southeastern United States favor the survival of the organism,5 and the parasite was reported in 3% (N=561) of a group of rural Kentucky schoolchildren17; similar findings were reported in another study conducted in Kentucky.18Strongyloides also was the most commonly detected parasite in a review of stool samples examined at the University of Kentucky Medical Center.19 Ex–prisoners of war who served in Southeast Asia during World War II also constitute an at-risk group in the United States.20-22
It is imperative to rule out the presence of this parasite prior to transplant in patients with a geographic history predisposing them to infection, a history of eosinophilia, or symptoms of chronic strongyloidiasis.1 Many transplantation centers routinely screen for this parasite as part of the pretransplant evaluation. Although uncommon in acute infections, cutaneous involvement often is present in chronic strongyloidiasis.1 It also is important to follow patients already treated for larva currens closely posttransplant, as therapeutic failures occur.
- Longworth DL, Weller PF. Hyperinfection syndrome with strongyloidiasis. In: Remington JS, Swartz MN, eds. Current Clinical Topics in Infectious Diseases. New York, NY: McGraw-Hill; 1986:1-26.
- Morgan JS, Schaffner W, Sone WJ. Opportunistic strongyloidiasis in renal transplant recipients. Transplantation. 1986;42:518-524.
- Grove DI. Strongyloidiasis in allied ex–prisoners of war in south-east Asia. Br Med J. 1980;280:598-601.
- Arthur RP, Shelley WB. Larva currens; a distinctive variant of cutaneous larva migrans due to Strongyloides stercoralis. AMA Arch Derm. 1958;78:186-190.
- Zygmunt DJ. Strongyloides stercoralis. Infect Control Hosp Epidemiol. 1990;11:495-497.
- Singh S. Human strongyloidiasis in AIDS era: its zoonotic importance. J Assoc Physicians India. 2002;50:415-422.
- Rothenberg ME. Eosinophilia. N Engl J Med. 1998;338:1592-1600.
- Bank DE, Grossman ME, Kohn SR, et al. The thumbprint sign: rapid diagnosis of disseminated strongyloidiasis. J Am Acad Dermatol. 1990;23(2, pt 1):324-326.
- Milner PF, Irvine RA, Barton CJ, et al. Intestinal malabsorption in Strongyloides stercoralis infestation. Gut. 1965;6:574-581.
- O'Brien W. Intestinal malabsorption in acute infection with Strongyloides stercoralis. Trans R Soc Trop Med Hyg. 1975;69:69-77.
- Nwokolo C, Imohiosen EA. Strongyloidiasis of respiratory tract presenting as "asthma". Br Med J. 1973;2:153-154.
- Neva FA, Gam AA, Burke J. Comparison of larval antigens in an enzyme-linked immunosorbent assay for strongyloidiasis in humans. J Infect Dis. 1981;144:427-432.
- Genta RM. Strongyloidiasis. In: Walls KW, Schantz PM, eds. Immunodiagnosis of Parasitic Diseases. Vol 1. Orlando, FL: Academic Press Inc; 1986:183-199.
- Igual-Adell R, Oltra-Alcaraz C, Soler-Company E, et al. Efficacy and safety of ivermectin and thiabendazole in the treatment of strongyloidiasis. Expert Opin Pharmacother. 2004;5:2615-2619.
- Maayan S, Wormser GP, Widerhorn J, et al. Strongyloides stercoralis hyperinfection in a patient with the acquired immune deficiency syndrome. Am J Med. 1987;83:945-948.
- Weller IV, Copland P, Gabriel R. Strongyloides stercoralis infection in renal transplant recipients [letter]. Br Med J (Clin Res Ed). 1981;282:524.
- Walzer PD, Milder JE, Banwell JG, et al. Epidemiologic features of Strongyloides stercoralis infection in an endemic area of the United States. Am J Trop Med Hyg. 1982;31:313-319.
- Fulmer HS, Huempfner HR. Intestinal helminths in eastern Kentucky: a survey in three rural counties. Am J Trop Med Hyg. 1965;14:269-275.
- Milder JE, Walzer PD, Kilgore G, et al. Clinical features of Strongyloides stercoralis infection in an endemic area of the United States. Gastroenterology. 1981;80:1481-1488.
- Genta RM, Weesner R, Douce RW, et al. Strongyloidiasis in US veterans of the Vietnam and other wars. JAMA. 1987;258:49-52.
- Gill GV, Welch E, Bailey JW, et al. Chronic Strongyloides stercoralis infection in former British Far East prisoners of war. QJM. 2004;97:789-795.
- Pelletier LL Jr. Chronic strongyloidiasis in World War II Far East ex–prisoners of war. Am J Trop Med Hyg. 1984;33:55-61.
- Longworth DL, Weller PF. Hyperinfection syndrome with strongyloidiasis. In: Remington JS, Swartz MN, eds. Current Clinical Topics in Infectious Diseases. New York, NY: McGraw-Hill; 1986:1-26.
- Morgan JS, Schaffner W, Sone WJ. Opportunistic strongyloidiasis in renal transplant recipients. Transplantation. 1986;42:518-524.
- Grove DI. Strongyloidiasis in allied ex–prisoners of war in south-east Asia. Br Med J. 1980;280:598-601.
- Arthur RP, Shelley WB. Larva currens; a distinctive variant of cutaneous larva migrans due to Strongyloides stercoralis. AMA Arch Derm. 1958;78:186-190.
- Zygmunt DJ. Strongyloides stercoralis. Infect Control Hosp Epidemiol. 1990;11:495-497.
- Singh S. Human strongyloidiasis in AIDS era: its zoonotic importance. J Assoc Physicians India. 2002;50:415-422.
- Rothenberg ME. Eosinophilia. N Engl J Med. 1998;338:1592-1600.
- Bank DE, Grossman ME, Kohn SR, et al. The thumbprint sign: rapid diagnosis of disseminated strongyloidiasis. J Am Acad Dermatol. 1990;23(2, pt 1):324-326.
- Milner PF, Irvine RA, Barton CJ, et al. Intestinal malabsorption in Strongyloides stercoralis infestation. Gut. 1965;6:574-581.
- O'Brien W. Intestinal malabsorption in acute infection with Strongyloides stercoralis. Trans R Soc Trop Med Hyg. 1975;69:69-77.
- Nwokolo C, Imohiosen EA. Strongyloidiasis of respiratory tract presenting as "asthma". Br Med J. 1973;2:153-154.
- Neva FA, Gam AA, Burke J. Comparison of larval antigens in an enzyme-linked immunosorbent assay for strongyloidiasis in humans. J Infect Dis. 1981;144:427-432.
- Genta RM. Strongyloidiasis. In: Walls KW, Schantz PM, eds. Immunodiagnosis of Parasitic Diseases. Vol 1. Orlando, FL: Academic Press Inc; 1986:183-199.
- Igual-Adell R, Oltra-Alcaraz C, Soler-Company E, et al. Efficacy and safety of ivermectin and thiabendazole in the treatment of strongyloidiasis. Expert Opin Pharmacother. 2004;5:2615-2619.
- Maayan S, Wormser GP, Widerhorn J, et al. Strongyloides stercoralis hyperinfection in a patient with the acquired immune deficiency syndrome. Am J Med. 1987;83:945-948.
- Weller IV, Copland P, Gabriel R. Strongyloides stercoralis infection in renal transplant recipients [letter]. Br Med J (Clin Res Ed). 1981;282:524.
- Walzer PD, Milder JE, Banwell JG, et al. Epidemiologic features of Strongyloides stercoralis infection in an endemic area of the United States. Am J Trop Med Hyg. 1982;31:313-319.
- Fulmer HS, Huempfner HR. Intestinal helminths in eastern Kentucky: a survey in three rural counties. Am J Trop Med Hyg. 1965;14:269-275.
- Milder JE, Walzer PD, Kilgore G, et al. Clinical features of Strongyloides stercoralis infection in an endemic area of the United States. Gastroenterology. 1981;80:1481-1488.
- Genta RM, Weesner R, Douce RW, et al. Strongyloidiasis in US veterans of the Vietnam and other wars. JAMA. 1987;258:49-52.
- Gill GV, Welch E, Bailey JW, et al. Chronic Strongyloides stercoralis infection in former British Far East prisoners of war. QJM. 2004;97:789-795.
- Pelletier LL Jr. Chronic strongyloidiasis in World War II Far East ex–prisoners of war. Am J Trop Med Hyg. 1984;33:55-61.
Follow-Up Study Finds Calcium Hydroxylapatite Safe at 4 Years
WAIKOLOA, HAWAII Calcium hydroxylapatite, injected as an implant for soft-tissue augmentation of the nasolabial folds and other facial areas, was safe after 4 years of follow-up in a two-center study of over 100 patients.
The investigators found that results lasted about 8 months for the majority of patients; results lasted longer (about 1012 months) in patients who received multiple injections and touch-up sessions.
Dr. Bruce E. Katz of the department of dermatology at Mount Sinai School of Medicine, New York, described the findings (Dermatol. Surg. 2007;33:1227) during a presentation at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.
The 113 patients in the study ranged in age from 26 to 78 years; 100 of them were women. The nasolabial folds were injected in 86 patients. A single injection was given at a single session to 75 patients (66%), and 38 (34%) had more than one session, said Dr. Katz. Most patients were given a 1-mL injection of calcium hydroxylapatite at a session; 12 were given a 2-mL injection.
Calcium hydroxylapatite (Radiesse) is a synthetically sourced, semipermanent, soft-tissue filler that comprises 25- to 45-mcm microspheres suspended in an aqueous gel. The microspheres "form a scaffold for tissue growth," he said. The calcium hydroxylapatite particles degrade over time to calcium particles and phosphate ions. "This material is highly biocompatible, it's durable, it does not migrate, it's not antigenic, and it's [radiopaque]."
Seven patients in the study reported adverse events, which were short term and minor, resolving within a month, according to Dr. Katz. These adverse events included three cases of transient ecchymoses, two patients with inflammation and edema, and two with nongranulomatous submucosal nodules of the lip.
A subset of 41 patients rated efficacy of treatment on a scale of 1 (satisfactory) to 5 (excellent), he said. The mean score of visual satisfaction after treatment was 4.6. The mean scores of those physicians who rated results using the same scale were 4.5 for visual satisfaction and 4.6 for the feel of the implant. At 6 months' follow-up, patients' mean scores were 4.8 for visual satisfaction and 4.9 for the feel of the treatment; physicians' mean scores were 4.5 for visual satisfaction and 4.9 for feel.
Dr. Katz has received compensation from BioForm Medical Inc. for making presentations on calcium hydroxylapatite.
SDEF and SKIN & ALLERGY NEWS are wholly owned subsidiaries of Elsevier.
WAIKOLOA, HAWAII Calcium hydroxylapatite, injected as an implant for soft-tissue augmentation of the nasolabial folds and other facial areas, was safe after 4 years of follow-up in a two-center study of over 100 patients.
The investigators found that results lasted about 8 months for the majority of patients; results lasted longer (about 1012 months) in patients who received multiple injections and touch-up sessions.
Dr. Bruce E. Katz of the department of dermatology at Mount Sinai School of Medicine, New York, described the findings (Dermatol. Surg. 2007;33:1227) during a presentation at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.
The 113 patients in the study ranged in age from 26 to 78 years; 100 of them were women. The nasolabial folds were injected in 86 patients. A single injection was given at a single session to 75 patients (66%), and 38 (34%) had more than one session, said Dr. Katz. Most patients were given a 1-mL injection of calcium hydroxylapatite at a session; 12 were given a 2-mL injection.
Calcium hydroxylapatite (Radiesse) is a synthetically sourced, semipermanent, soft-tissue filler that comprises 25- to 45-mcm microspheres suspended in an aqueous gel. The microspheres "form a scaffold for tissue growth," he said. The calcium hydroxylapatite particles degrade over time to calcium particles and phosphate ions. "This material is highly biocompatible, it's durable, it does not migrate, it's not antigenic, and it's [radiopaque]."
Seven patients in the study reported adverse events, which were short term and minor, resolving within a month, according to Dr. Katz. These adverse events included three cases of transient ecchymoses, two patients with inflammation and edema, and two with nongranulomatous submucosal nodules of the lip.
A subset of 41 patients rated efficacy of treatment on a scale of 1 (satisfactory) to 5 (excellent), he said. The mean score of visual satisfaction after treatment was 4.6. The mean scores of those physicians who rated results using the same scale were 4.5 for visual satisfaction and 4.6 for the feel of the implant. At 6 months' follow-up, patients' mean scores were 4.8 for visual satisfaction and 4.9 for the feel of the treatment; physicians' mean scores were 4.5 for visual satisfaction and 4.9 for feel.
Dr. Katz has received compensation from BioForm Medical Inc. for making presentations on calcium hydroxylapatite.
SDEF and SKIN & ALLERGY NEWS are wholly owned subsidiaries of Elsevier.
WAIKOLOA, HAWAII Calcium hydroxylapatite, injected as an implant for soft-tissue augmentation of the nasolabial folds and other facial areas, was safe after 4 years of follow-up in a two-center study of over 100 patients.
The investigators found that results lasted about 8 months for the majority of patients; results lasted longer (about 1012 months) in patients who received multiple injections and touch-up sessions.
Dr. Bruce E. Katz of the department of dermatology at Mount Sinai School of Medicine, New York, described the findings (Dermatol. Surg. 2007;33:1227) during a presentation at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.
The 113 patients in the study ranged in age from 26 to 78 years; 100 of them were women. The nasolabial folds were injected in 86 patients. A single injection was given at a single session to 75 patients (66%), and 38 (34%) had more than one session, said Dr. Katz. Most patients were given a 1-mL injection of calcium hydroxylapatite at a session; 12 were given a 2-mL injection.
Calcium hydroxylapatite (Radiesse) is a synthetically sourced, semipermanent, soft-tissue filler that comprises 25- to 45-mcm microspheres suspended in an aqueous gel. The microspheres "form a scaffold for tissue growth," he said. The calcium hydroxylapatite particles degrade over time to calcium particles and phosphate ions. "This material is highly biocompatible, it's durable, it does not migrate, it's not antigenic, and it's [radiopaque]."
Seven patients in the study reported adverse events, which were short term and minor, resolving within a month, according to Dr. Katz. These adverse events included three cases of transient ecchymoses, two patients with inflammation and edema, and two with nongranulomatous submucosal nodules of the lip.
A subset of 41 patients rated efficacy of treatment on a scale of 1 (satisfactory) to 5 (excellent), he said. The mean score of visual satisfaction after treatment was 4.6. The mean scores of those physicians who rated results using the same scale were 4.5 for visual satisfaction and 4.6 for the feel of the implant. At 6 months' follow-up, patients' mean scores were 4.8 for visual satisfaction and 4.9 for the feel of the treatment; physicians' mean scores were 4.5 for visual satisfaction and 4.9 for feel.
Dr. Katz has received compensation from BioForm Medical Inc. for making presentations on calcium hydroxylapatite.
SDEF and SKIN & ALLERGY NEWS are wholly owned subsidiaries of Elsevier.
Eye Shield Use During Laser Procedures Strongly Advised
WAIKOLOA, HAWAII Dr. Roy G. Geronemus warned against the cavalier approach of not using eye shields during laser surgery.
"The eyelid is very thin," he observed at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation. When using a device that works at 1.5 mm, "you damned well better" protect the patient's eyelids.
"With the CO2 lasers, I think you should put a shield underneath the eyelids if you're treating the lids." Because it is possible that plastic shields will melt, said Dr. Geronemus of the New York University Medical Center, he prefers to use metal eye shields.
In a subsequent presentation, Dr. R. Rox Anderson, professor of dermatology at Harvard Medical School, Boston, and director of the Wellman Center for Photomedicine at Massachusetts General Hospital, also advocated for routine use of an eye shield, "especially if you're going to be treating inside the bony orbit."
Both lasers and intense pulsed lights used for hair removal in this area can be extremely damaging to the patient's eyes, he noted. "These devices are made to kill melanin-containing structures at great depth in the tissue, and the greatest amount of melanin in the body is in the uveal tract and the retina," Dr. Anderson said. "They're retinal killers."
Eye shields can also protect against possible injury from cryogen spray, he said. "There are cases of cryogen spray freezing the cornea and hurting it."
Dr. Anderson cautioned not to let anesthetics get under the eye shields when inserting them. "Most of our anesthetics, particularly EMLA [combination lidocaine and prilocaine cream], are really quite irritating," Dr. Anderson said, and can cause corneal burns.
Dr. Anderson disclosed that he had no relevant conflicts.
Dr. Geronemus disclosed that he is a shareholder in Thermage Inc., Reliant Technologies Inc., and Light BioScience LLC.
He is on the medical advisory boards of PhotoMedex Inc., Lumenis Ltd., Rhytec Inc., Candela Corp., Zeltiq Aesthetics, and Skin Cancer Company, and is an investigator for Reliant Technologies, Medicis Pharmaceutical Corp., Rhytec, DUSA Pharmaceuticals Inc., L'Oreal, Cutera Inc., Allergan Inc., and DermTech International. SDEF and SKIN & ALLERGY NEWS are wholly owned subsidiaries of Elsevier.
WAIKOLOA, HAWAII Dr. Roy G. Geronemus warned against the cavalier approach of not using eye shields during laser surgery.
"The eyelid is very thin," he observed at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation. When using a device that works at 1.5 mm, "you damned well better" protect the patient's eyelids.
"With the CO2 lasers, I think you should put a shield underneath the eyelids if you're treating the lids." Because it is possible that plastic shields will melt, said Dr. Geronemus of the New York University Medical Center, he prefers to use metal eye shields.
In a subsequent presentation, Dr. R. Rox Anderson, professor of dermatology at Harvard Medical School, Boston, and director of the Wellman Center for Photomedicine at Massachusetts General Hospital, also advocated for routine use of an eye shield, "especially if you're going to be treating inside the bony orbit."
Both lasers and intense pulsed lights used for hair removal in this area can be extremely damaging to the patient's eyes, he noted. "These devices are made to kill melanin-containing structures at great depth in the tissue, and the greatest amount of melanin in the body is in the uveal tract and the retina," Dr. Anderson said. "They're retinal killers."
Eye shields can also protect against possible injury from cryogen spray, he said. "There are cases of cryogen spray freezing the cornea and hurting it."
Dr. Anderson cautioned not to let anesthetics get under the eye shields when inserting them. "Most of our anesthetics, particularly EMLA [combination lidocaine and prilocaine cream], are really quite irritating," Dr. Anderson said, and can cause corneal burns.
Dr. Anderson disclosed that he had no relevant conflicts.
Dr. Geronemus disclosed that he is a shareholder in Thermage Inc., Reliant Technologies Inc., and Light BioScience LLC.
He is on the medical advisory boards of PhotoMedex Inc., Lumenis Ltd., Rhytec Inc., Candela Corp., Zeltiq Aesthetics, and Skin Cancer Company, and is an investigator for Reliant Technologies, Medicis Pharmaceutical Corp., Rhytec, DUSA Pharmaceuticals Inc., L'Oreal, Cutera Inc., Allergan Inc., and DermTech International. SDEF and SKIN & ALLERGY NEWS are wholly owned subsidiaries of Elsevier.
WAIKOLOA, HAWAII Dr. Roy G. Geronemus warned against the cavalier approach of not using eye shields during laser surgery.
"The eyelid is very thin," he observed at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation. When using a device that works at 1.5 mm, "you damned well better" protect the patient's eyelids.
"With the CO2 lasers, I think you should put a shield underneath the eyelids if you're treating the lids." Because it is possible that plastic shields will melt, said Dr. Geronemus of the New York University Medical Center, he prefers to use metal eye shields.
In a subsequent presentation, Dr. R. Rox Anderson, professor of dermatology at Harvard Medical School, Boston, and director of the Wellman Center for Photomedicine at Massachusetts General Hospital, also advocated for routine use of an eye shield, "especially if you're going to be treating inside the bony orbit."
Both lasers and intense pulsed lights used for hair removal in this area can be extremely damaging to the patient's eyes, he noted. "These devices are made to kill melanin-containing structures at great depth in the tissue, and the greatest amount of melanin in the body is in the uveal tract and the retina," Dr. Anderson said. "They're retinal killers."
Eye shields can also protect against possible injury from cryogen spray, he said. "There are cases of cryogen spray freezing the cornea and hurting it."
Dr. Anderson cautioned not to let anesthetics get under the eye shields when inserting them. "Most of our anesthetics, particularly EMLA [combination lidocaine and prilocaine cream], are really quite irritating," Dr. Anderson said, and can cause corneal burns.
Dr. Anderson disclosed that he had no relevant conflicts.
Dr. Geronemus disclosed that he is a shareholder in Thermage Inc., Reliant Technologies Inc., and Light BioScience LLC.
He is on the medical advisory boards of PhotoMedex Inc., Lumenis Ltd., Rhytec Inc., Candela Corp., Zeltiq Aesthetics, and Skin Cancer Company, and is an investigator for Reliant Technologies, Medicis Pharmaceutical Corp., Rhytec, DUSA Pharmaceuticals Inc., L'Oreal, Cutera Inc., Allergan Inc., and DermTech International. SDEF and SKIN & ALLERGY NEWS are wholly owned subsidiaries of Elsevier.
Deep Filler Injections Tackle Aging Bone Structure
WAIKOLOA, HAWAII Deep filler injections can address volume loss that occurs in facial bone structure during the aging process, according to Dr. Howard K. Steinman.
"The shape and volume of the maxilla and mandible change with aging," Dr. Steinman said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.
"This significantly contributes to facial age-related cosmetic deformities," he added.
Injecting fillers deep, near the periosteum, can address these issues, he said. Although this has been well documented in plastic surgery literature, it is probably a new concept for most dermatologists.
Dr. Steinman, who is in private practice in Chula Vista, Calif., said that he first became aware of the clinical importance of facial skeletal movement last year at SDEF in Hawaii during a workshop that was led by Dr. William Philip Werschler of the University of Washington, Seattle, and Dr. Danny Vleggaar of the Nouvelle Clinique Vert Pré, Geneva.
"Ever since I discovered this and researched it, it has altered the way that I see my cosmetic patients and how I use fillers," he said. "Understanding these changes often permits more effective correction with less filler volume."
Dr. Steinman described the maxilla as a "ledge of the midface tissues." As the maxilla moves inferiorly and posteriorly, the muscles and other soft tissues attached to it descend. This aging process is in addition to laxity and the loss of fat volume over time. Lateral tear troughs, for example, begin to form as a result of the descent of the maxilla causing enlargement of the orbital rim, in addition to the soft tissue changes.
Putting filler immediately above the periosteum replaces orbital rim that has moved. "You're going to lift up the tissues, and you're going to help redrape and eliminate the lateral tear trough," he said, noting that he routinely does this using Radiesse (BioForm Medical).
When working on nasal labial folds, Dr. Steinman angles the needle down all the way to the periosteum and injects as he pulls back slightlya technique he learned from Dr. Vleggaar.
He imagines a triangle in the corner of the nose and the nasal labial fold.
"I do three injections from the inferior apex of the triangle, injecting superiorly and filling this triangle," he said. "This is a great technique for doing rejuvenation of this fold with very little filler."
The mandible also changes as patients get older, he said. The height of the mandibular shortens, which the muscles and soft tissue attached to the mandible rim have to accommodate for, resulting in "jowling" and the formation of prejowl sulcus.
To correct this problem, he injects deeply along the mandibular rim "bulking it up" as best he can before injecting into the subdermal plane. Again, a small quantity of filler can be used in this procedure, he noted.
With the advent of botulinum toxin type A, said Dr. Steinman "all of us that were 'pre-Botox' in our training suddenly learned to see facial muscles and their cosmetic effects," he said. "They're part of [the] assessment armamentarium."
He predicted dermatologists will start to perceive facial skeletal changes the same way they now perceive facial muscles and will adapt treatments accordingly.
Dr. Steinman disclosed that he had no relevant conflicts of interest.
SDEF and SKIN & ALLERGY NEWS are wholly owned subsidiaries of Elsevier.
Dr.Steinman suggests imagining a triangle in the corner of the nose and nasal labial fold (before, left image). Perform "three injections from the inferior apex of the triangle, injecting superiorly and filling" it (after, right). Photos courtesy Dr. Howard K. Steinman
Facial skeletal changes will be perceived by dermatologists in the same way that facial muscles are now perceived. DR. STEINMAN
WAIKOLOA, HAWAII Deep filler injections can address volume loss that occurs in facial bone structure during the aging process, according to Dr. Howard K. Steinman.
"The shape and volume of the maxilla and mandible change with aging," Dr. Steinman said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.
"This significantly contributes to facial age-related cosmetic deformities," he added.
Injecting fillers deep, near the periosteum, can address these issues, he said. Although this has been well documented in plastic surgery literature, it is probably a new concept for most dermatologists.
Dr. Steinman, who is in private practice in Chula Vista, Calif., said that he first became aware of the clinical importance of facial skeletal movement last year at SDEF in Hawaii during a workshop that was led by Dr. William Philip Werschler of the University of Washington, Seattle, and Dr. Danny Vleggaar of the Nouvelle Clinique Vert Pré, Geneva.
"Ever since I discovered this and researched it, it has altered the way that I see my cosmetic patients and how I use fillers," he said. "Understanding these changes often permits more effective correction with less filler volume."
Dr. Steinman described the maxilla as a "ledge of the midface tissues." As the maxilla moves inferiorly and posteriorly, the muscles and other soft tissues attached to it descend. This aging process is in addition to laxity and the loss of fat volume over time. Lateral tear troughs, for example, begin to form as a result of the descent of the maxilla causing enlargement of the orbital rim, in addition to the soft tissue changes.
Putting filler immediately above the periosteum replaces orbital rim that has moved. "You're going to lift up the tissues, and you're going to help redrape and eliminate the lateral tear trough," he said, noting that he routinely does this using Radiesse (BioForm Medical).
When working on nasal labial folds, Dr. Steinman angles the needle down all the way to the periosteum and injects as he pulls back slightlya technique he learned from Dr. Vleggaar.
He imagines a triangle in the corner of the nose and the nasal labial fold.
"I do three injections from the inferior apex of the triangle, injecting superiorly and filling this triangle," he said. "This is a great technique for doing rejuvenation of this fold with very little filler."
The mandible also changes as patients get older, he said. The height of the mandibular shortens, which the muscles and soft tissue attached to the mandible rim have to accommodate for, resulting in "jowling" and the formation of prejowl sulcus.
To correct this problem, he injects deeply along the mandibular rim "bulking it up" as best he can before injecting into the subdermal plane. Again, a small quantity of filler can be used in this procedure, he noted.
With the advent of botulinum toxin type A, said Dr. Steinman "all of us that were 'pre-Botox' in our training suddenly learned to see facial muscles and their cosmetic effects," he said. "They're part of [the] assessment armamentarium."
He predicted dermatologists will start to perceive facial skeletal changes the same way they now perceive facial muscles and will adapt treatments accordingly.
Dr. Steinman disclosed that he had no relevant conflicts of interest.
SDEF and SKIN & ALLERGY NEWS are wholly owned subsidiaries of Elsevier.
Dr.Steinman suggests imagining a triangle in the corner of the nose and nasal labial fold (before, left image). Perform "three injections from the inferior apex of the triangle, injecting superiorly and filling" it (after, right). Photos courtesy Dr. Howard K. Steinman
Facial skeletal changes will be perceived by dermatologists in the same way that facial muscles are now perceived. DR. STEINMAN
WAIKOLOA, HAWAII Deep filler injections can address volume loss that occurs in facial bone structure during the aging process, according to Dr. Howard K. Steinman.
"The shape and volume of the maxilla and mandible change with aging," Dr. Steinman said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.
"This significantly contributes to facial age-related cosmetic deformities," he added.
Injecting fillers deep, near the periosteum, can address these issues, he said. Although this has been well documented in plastic surgery literature, it is probably a new concept for most dermatologists.
Dr. Steinman, who is in private practice in Chula Vista, Calif., said that he first became aware of the clinical importance of facial skeletal movement last year at SDEF in Hawaii during a workshop that was led by Dr. William Philip Werschler of the University of Washington, Seattle, and Dr. Danny Vleggaar of the Nouvelle Clinique Vert Pré, Geneva.
"Ever since I discovered this and researched it, it has altered the way that I see my cosmetic patients and how I use fillers," he said. "Understanding these changes often permits more effective correction with less filler volume."
Dr. Steinman described the maxilla as a "ledge of the midface tissues." As the maxilla moves inferiorly and posteriorly, the muscles and other soft tissues attached to it descend. This aging process is in addition to laxity and the loss of fat volume over time. Lateral tear troughs, for example, begin to form as a result of the descent of the maxilla causing enlargement of the orbital rim, in addition to the soft tissue changes.
Putting filler immediately above the periosteum replaces orbital rim that has moved. "You're going to lift up the tissues, and you're going to help redrape and eliminate the lateral tear trough," he said, noting that he routinely does this using Radiesse (BioForm Medical).
When working on nasal labial folds, Dr. Steinman angles the needle down all the way to the periosteum and injects as he pulls back slightlya technique he learned from Dr. Vleggaar.
He imagines a triangle in the corner of the nose and the nasal labial fold.
"I do three injections from the inferior apex of the triangle, injecting superiorly and filling this triangle," he said. "This is a great technique for doing rejuvenation of this fold with very little filler."
The mandible also changes as patients get older, he said. The height of the mandibular shortens, which the muscles and soft tissue attached to the mandible rim have to accommodate for, resulting in "jowling" and the formation of prejowl sulcus.
To correct this problem, he injects deeply along the mandibular rim "bulking it up" as best he can before injecting into the subdermal plane. Again, a small quantity of filler can be used in this procedure, he noted.
With the advent of botulinum toxin type A, said Dr. Steinman "all of us that were 'pre-Botox' in our training suddenly learned to see facial muscles and their cosmetic effects," he said. "They're part of [the] assessment armamentarium."
He predicted dermatologists will start to perceive facial skeletal changes the same way they now perceive facial muscles and will adapt treatments accordingly.
Dr. Steinman disclosed that he had no relevant conflicts of interest.
SDEF and SKIN & ALLERGY NEWS are wholly owned subsidiaries of Elsevier.
Dr.Steinman suggests imagining a triangle in the corner of the nose and nasal labial fold (before, left image). Perform "three injections from the inferior apex of the triangle, injecting superiorly and filling" it (after, right). Photos courtesy Dr. Howard K. Steinman
Facial skeletal changes will be perceived by dermatologists in the same way that facial muscles are now perceived. DR. STEINMAN
Combo Treatment Improves Body Contouring Outcomes
KISSIMMEE, FLA. Body contouring using an external focused ultrasound device and a device that uses infrared light, bipolar radiofrequency energy, and mechanical massage is more effective than is ultrasound alone for treating localized fat, a study suggests. The combination approach also requires fewer treatments to achieve similar results, Dr. Luigi Mazzi reported at the annual meeting of the American Society for Laser Medicine and Surgery.
Over 15 months, 198 patientsmostly women aged 2452 yearswere treated for localized fat, including 54 who were treated with UltraShape Ltd.'s Contour I ultrasound device and 144 who were treated with the Contour I in combination with Syneron Medical Ltd.'s VelaSmooth device.
Patients received up to three ultrasound treatment sessions targeting localized fat on the abdomen, flanks, and/or outer thighsmost patients received treatments on multiple areas during each sessionfollowed immediately by a VelaSmooth treatment. VelaSmooth also was used weekly between ultrasound treatments, said Dr. Mazzi, who is in private practice in Verona, Italy.
During the study period, 1,082 ultrasound treatments (an average of 20 per patient) and 1,164 combination ultrasound and VelaSmooth treatments (8 per patient) were performed.
The outer thighs were the most commonly treated area (44% of treatments), followed by the abdomen (33% of treatments) and flanks (23% of patients), he noted.
An average circumference reduction of 4 cm per patient was noted after the last treatment with ultrasound plus VelaSmooth, versus 3 cm after the last treatment with ultrasound alone. Better results with fewer treatments were seen in the abdomen and flanks, whereas upper thighs with sclerotic fat tissue typically required more treatments to obtain satisfactory results, said Dr. Mazzi, who received honoraria from Syneron.
Side effects were comparable in both groups, with minor discomfort reported in 23% of patients; mild and transient erythema reported by 76%; and burning reported in 1%.
These treatments are indicated for the patient with a body mass index below 29 kg/m
The treatments are not intended for weight loss or for treating cellulite or skin laxity, although Dr. Mazzi believes the combined approach used in this study appears to result in improved skin tightening.
The Contour I device is used in Europe and Canada but is not yet approved for use in the United States. Approval by the Food and Drug Administration is anticipated later this year, he said.
A 45-year-old woman is shown before undergoing combination therapy to treat localized fat on her outer thighs (left). She is shown again after undergoing one treatment with ultrasound plus four treatments with VelaSmooth (right). Photos courtesy Dr. Luigi Mazzi
KISSIMMEE, FLA. Body contouring using an external focused ultrasound device and a device that uses infrared light, bipolar radiofrequency energy, and mechanical massage is more effective than is ultrasound alone for treating localized fat, a study suggests. The combination approach also requires fewer treatments to achieve similar results, Dr. Luigi Mazzi reported at the annual meeting of the American Society for Laser Medicine and Surgery.
Over 15 months, 198 patientsmostly women aged 2452 yearswere treated for localized fat, including 54 who were treated with UltraShape Ltd.'s Contour I ultrasound device and 144 who were treated with the Contour I in combination with Syneron Medical Ltd.'s VelaSmooth device.
Patients received up to three ultrasound treatment sessions targeting localized fat on the abdomen, flanks, and/or outer thighsmost patients received treatments on multiple areas during each sessionfollowed immediately by a VelaSmooth treatment. VelaSmooth also was used weekly between ultrasound treatments, said Dr. Mazzi, who is in private practice in Verona, Italy.
During the study period, 1,082 ultrasound treatments (an average of 20 per patient) and 1,164 combination ultrasound and VelaSmooth treatments (8 per patient) were performed.
The outer thighs were the most commonly treated area (44% of treatments), followed by the abdomen (33% of treatments) and flanks (23% of patients), he noted.
An average circumference reduction of 4 cm per patient was noted after the last treatment with ultrasound plus VelaSmooth, versus 3 cm after the last treatment with ultrasound alone. Better results with fewer treatments were seen in the abdomen and flanks, whereas upper thighs with sclerotic fat tissue typically required more treatments to obtain satisfactory results, said Dr. Mazzi, who received honoraria from Syneron.
Side effects were comparable in both groups, with minor discomfort reported in 23% of patients; mild and transient erythema reported by 76%; and burning reported in 1%.
These treatments are indicated for the patient with a body mass index below 29 kg/m
The treatments are not intended for weight loss or for treating cellulite or skin laxity, although Dr. Mazzi believes the combined approach used in this study appears to result in improved skin tightening.
The Contour I device is used in Europe and Canada but is not yet approved for use in the United States. Approval by the Food and Drug Administration is anticipated later this year, he said.
A 45-year-old woman is shown before undergoing combination therapy to treat localized fat on her outer thighs (left). She is shown again after undergoing one treatment with ultrasound plus four treatments with VelaSmooth (right). Photos courtesy Dr. Luigi Mazzi
KISSIMMEE, FLA. Body contouring using an external focused ultrasound device and a device that uses infrared light, bipolar radiofrequency energy, and mechanical massage is more effective than is ultrasound alone for treating localized fat, a study suggests. The combination approach also requires fewer treatments to achieve similar results, Dr. Luigi Mazzi reported at the annual meeting of the American Society for Laser Medicine and Surgery.
Over 15 months, 198 patientsmostly women aged 2452 yearswere treated for localized fat, including 54 who were treated with UltraShape Ltd.'s Contour I ultrasound device and 144 who were treated with the Contour I in combination with Syneron Medical Ltd.'s VelaSmooth device.
Patients received up to three ultrasound treatment sessions targeting localized fat on the abdomen, flanks, and/or outer thighsmost patients received treatments on multiple areas during each sessionfollowed immediately by a VelaSmooth treatment. VelaSmooth also was used weekly between ultrasound treatments, said Dr. Mazzi, who is in private practice in Verona, Italy.
During the study period, 1,082 ultrasound treatments (an average of 20 per patient) and 1,164 combination ultrasound and VelaSmooth treatments (8 per patient) were performed.
The outer thighs were the most commonly treated area (44% of treatments), followed by the abdomen (33% of treatments) and flanks (23% of patients), he noted.
An average circumference reduction of 4 cm per patient was noted after the last treatment with ultrasound plus VelaSmooth, versus 3 cm after the last treatment with ultrasound alone. Better results with fewer treatments were seen in the abdomen and flanks, whereas upper thighs with sclerotic fat tissue typically required more treatments to obtain satisfactory results, said Dr. Mazzi, who received honoraria from Syneron.
Side effects were comparable in both groups, with minor discomfort reported in 23% of patients; mild and transient erythema reported by 76%; and burning reported in 1%.
These treatments are indicated for the patient with a body mass index below 29 kg/m
The treatments are not intended for weight loss or for treating cellulite or skin laxity, although Dr. Mazzi believes the combined approach used in this study appears to result in improved skin tightening.
The Contour I device is used in Europe and Canada but is not yet approved for use in the United States. Approval by the Food and Drug Administration is anticipated later this year, he said.
A 45-year-old woman is shown before undergoing combination therapy to treat localized fat on her outer thighs (left). She is shown again after undergoing one treatment with ultrasound plus four treatments with VelaSmooth (right). Photos courtesy Dr. Luigi Mazzi