FROM THE LITERATURE
Year : 2010 | Volume
: 3 | Issue : 3 | Page : 191--192
From the literature
Venkat Charmalaya, Centre for Advanced Dermatology, Bangalore - 560 040, Karnataka, India
Venkat Charmalaya, Centre for Advanced Dermatology, Bangalore - 560 040, Karnataka
|How to cite this article:|
Anitha B. From the literature.J Cutan Aesthet Surg 2010;3:191-192
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Anitha B. From the literature. J Cutan Aesthet Surg [serial online] 2010 [cited 2020 Feb 17 ];3:191-192
Available from: http://www.jcasonline.com/text.asp?2010/3/3/191/74502
High-risk Basal Cell Carcinoma: An Update
Wollina U, Pabst F, Kronert C, Schorcht J
Expert Rev. Dermatol 2010;5(3):357-368
Basal cell carcinoma (BCC) is usually a slowly growing, but locally invasive nonmelanoma skin cancer. In this review, the authors have discussed the topic of high-risk BCC and have evaluated the diagnosis, clinical presentation and treatment options available.
High-risk BCC should be considered, when BCC presents with any of the following features: long duration, location in the mid-face or on the ear, diameter larger than 2 cm; an aggressive histological subtype such as morpheic, infiltrative, micronodular or basosquamous (or metatypic), or with perineural or perivascular infiltration; previous treatment that failed, neglected, or a history of radiation exposure. The anatomical sites of high-risk BCC are scalp with the risk of perineural invasion; periocular which is the leading cause of orbital exenteration and can lead to complications like invasion and destruction of cranium, underlying dura mater and cranial nerves, and blindness; nasal, and auricular which can invade parotid gland with concomitant facial nerve involvement. Long-standing, neglected, large BCCs of extrafacial location also are considered high-risk tumours. Although BCC rarely shows metastases, basosquamous BCC may metastasize.
Based on the current data, micrographically controlled (Mohs) surgery or frozen section-controlled excision is the treatment of choice. If complete tumour resection is not possible, radiotherapy should be considered. In patients with high-risk of recurrence, adjuvant radiotherapy is used. Medical treatment of high-risk BCC is rather limited. Cisplatin-based chemotherapy is effective in the treatment of metastatic BCC. The other recent modalities of treatment include chemo-immunotherapy, monoclonal antibodies (cetuximab) and electrochemotherapy.
Regular follow-up is necessary in patients with high-risk BCC, although there is not as yet an international consensus on how often a regular follow-up should be performed. The German Dermatologic society recommends 5 years of follow-up for all BCC patients.
Efficacy of tumescent local anaesthesia with variable lidocaine concentration in 3,430 consecutive cases of liposuction
J Am Acad Dermatol 2010;62:988-94
Tumescent local anaesthesia (TLA) is a form of anaesthesia where a saline solution of an local anaesthetic, usually lidocaine combined with epinephrine, is infused into the targeted subcutaneous area until a state of tumescence (meaning firm and swollen) is reached. Lidocaine toxicity is a potential complication of this technique. This study was conducted to determine the minimum concentration of lidocaine in the tumescent solution required to provide adequate anaesthesia in patients undergoing liposuction using TLA exclusively.
The data on liposuction procedure, performed by same surgeon in 3,430 cases during the 13-year period from 1996 to 2008, was used to arrive at the results in this study. Initially, the concentration of lidocaine used in the tumescent solution was 1000 mg/l. It was gradually reduced to reach the minimum concentration for adequate anaesthesia. It was found that 400 mg/l was adequate in nearly all cases. In some patients in certain locations, 500 mg/l was required. For a better practical approach, in all cases where body areas are treated on the legs, flanks and arms, the 400 mg/l concentration is used and where the number of body areas to be treated is small, and consequently less tumescent solution is required (face, male and female breasts, midline area of abdomen and neck) the 500 mg/l concentration is used. In the postoperative period, neither lidocaine toxicity nor any severe complication was observed in any patient.
In conclusion, for patients undergoing liposuction using TLA exclusively, the concentration of lidocaine in the normal saline solution required for adequate anaesthesia is 400 mg/l for most body areas and 500 mg/l for some sensitive areas. However, this study had certain limitations; data was based on the specific TLA technique used by same surgeon and the serum lidocaine levels were not analysed.
Safety of Lidocaine 15% and Prilocaine 5% Topical Ointment used as Local Anaesthesia for Intense Pulsed Light Treatment
Carruthers JA, Carruthers JDA, Poirier J, Oliff HS
Dermatol Surg 2010;36:1130-37
Intense pulsed light (IPL) treatment produces thermal pain; hence topical anaesthesia must be used prior to the procedure. The combination of lidocaine and prilocaine has an onset and duration of action that is well-suited for IPL procedures. But the only approved and marked lidocaine/prilocaine product (EMLA, 2.5% lidocaine and 2.5% prilocaine, Astra Zeneca, Wayne, PA) does not permit the brief IPL procedural time that patients' desire because the onset of action is 1-2 hrs, and the manufacturer recommends occlusion. A higher concentration of the mixture in an occlusive base will increase the onset of action and duration, and also meet the patients' needs. Literature cautions against applying 15% lidocaine and 5% prilocaine over an area larger than 300 cm 2 , due to the risk of systemic toxicity. The area of the face, neck and chest is 400 cm 2 or greater. Hence, this study was conducted to assess the safety of lidocaine 15%/prilocaine 5% topical anaesthetic ointment used as anaesthesia for IPL treatment.
In group 1 (n=10) the ointment was applied to face only for 30±15 min and in group 2 (n=10) it was applied to face, neck, chest for a total of 60±15 min before IPL treatment. Blood lidocaine and prilocaine levels were measured after 25.6±6.6 min after IPL was completed. In group 1, mean lidocaine level was 0.122±0.125 μg/ml and prilocaine level was 0.048±0.029 μg/ml. In group 2, the mean lidocaine level was 0.272±0.208 μg/ml and prilocaine level was 0.087±0.06 μg/ml. No adverse events related to systemic toxicity were observed or reported to the nurse before leaving the clinic, and even at a 24-hour follow-up.
In conclusion, under the treatment conditions of this study, topical application of lidocaine 15%/prilocaine 5% produced extremely low levels of systemic absorption which did not lead to any systemic complications. Although the time of exposure to the anaesthetic agents was minimized and no occlusive dressing was used, good anaesthetic effect was achieved. However, the results of this study cannot be extrapolated to children and additional studies are warranted.
Low-fluence Q-switched Neodymium-doped Yttrium Aluminum Garnet Laser for Melasma with Pre- or Post-treatment Triple Combination Cream
Jeong SY, Shin JB, Yeo UC, Kim WS, Kim IH
Dermatol Surg 2010;36:909-918
Melasma is an acquired pigmentary disorder characterized by localized hyper-pigmentation, commonly found in facial skin and in women. The various reported treatments for melasma include topical hypo-pigmenting agents, chemical peels, dermabrasion and laser treatment. Among the topical hypo-pigmenting agents, triple combination (TC) cream is considered to be primary approach. For resistant cases or severe melasma cases, chemical peels or laser offers a secondary option. In this study, the authors have compared the clinical efficacy and adverse effects of low-fluence Q-switched neodymium-doped yttrium aluminum garnet (Nd: YAG) laser when performed before and after treatment with topical TC using a split-face cross over design. This is the first study on combination treatment methods for melasma.
Thirteen patients with melasma participated in this randomized, controlled, face-split study. The TC cream (Tri-luma cream which contains 4% hydroquinone, 0.05% tretinoin and 0.01% fluocinolone acetonide) was applied every night to one side of the face (group A) for 8 weeks. Group B started with a collimated 5 to 7 ns pulse width, 1064 nm Q-switched Nd: YAG laser treatment to other side of the face weekly for 8 weeks. After 8 weeks, treatments were reversed; that is, previously TC cream-treated sides were treated with the laser (group A) for 8 weeks, and TC cream was applied for 8 weeks to previously laser-treated sides (group B). Responses were evaluated using the Melasma Area and Severity Index Scoring system, spectrophotometry measurements and subjective self-assessment method. After 16 weeks, better results were seen when laser treatment was used after 8 weeks of topical TC cream treatment than before usage of TC. There were no significant adverse effects with the laser treatment. Another notable finding was that laser treatment was found to be more effective than TC cream. Forty-five percent of the patients in group B showed complete resolution after initial laser treatment, which was three times more than the 15% of patients who showed complete resolution after initial TC treatment.
In conclusion, laser treatment after topical TC cream was found to be safer and more effective than post-treatment use of topical agents. However, the small sample size was a limitation of this study.