THINKING OUTSIDE THE BOX Ted Rosen, MD Baylor College of Medicine Houston, Texas

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1 THINKING OUTSIDE THE BOX Ted Rosen, MD Baylor College of Medicine Houston, Texas RADICAL TOPICAL THERAPEUTIC PEARLS {SOMETIMES BASED ON BASICS} Hong Kong Jade Market 2014 ZINC! DISCLOSURE OF RELATIONSHIPS WITH INDUSTRY Ted Rosen, MD F005 Pearls From Members DISCLOSURES I do not have any relevant relationships with industry. ZINC: FAST FACTS: LOW ZINC LEVELS ASSOCIATED WITH Immune deficiency: macrophage and neutrophil function, lymphocyte activation / proliferation, complement activity; loss of modulation of TNFα and NO species Delayed wound healing: decreased matrix metalloproteinase activity, decreased keratinocyte migration, increased keratinocyte apoptosis Autoimmun Rev. 2015;14: Wound Repair Regen. 2007;15(1):2-16 GENITAL HERPES: NEW RX? Topical zinc sulfate Zn +2 in-vitro impairs HSV growth Can zinc salt treat active genital HSV? Can zinc salt reduce recurrence rate? 100 clinical + Tzanck verified men with genital HSV treated for 6 months To active lesion (or area): Q5d x 1mo, then Q10d x 2 mo, then Q15d x 3 mo ZnSO 4 solution; 5 minute exposure Indian J Sex Transm Dis. 2013;34:

2 GENITAL HERPES: NEW RX? Recurrence rate over 6 months Distilled water control 80% 1% Zinc sulfate 33.33% 2% Zinc sulfate 20% 4% Zinc sulfate 3.33% Vasodilation: increased immune cells Increased activity T- and B- cells Increased phagocytosis pmn s Increased cytokine release Direct toxic effect on microbes Indian J Sex Transm Dis. 2013;34: Chromoblastomycosis Sporotrichosis Atypical mycobacteria Leishmaniasis HSV-1, HSV-2 Chromoblastomycosis Sporotrichosis Atypical mycobacteria Leishmaniasis HSV-1, HSV-2 Chromoblastomycosis Sporotrichosis Atypical mycobacteria Leishmaniasis HSV-1, HSV-2 AND HSV-1 OR HSV-2 Small handheld device Approved everywhere but USA Emits C heat x 4 seconds 1-2 applications shortens HSV-1 course to 1.85 days (mean) ~$100; need refills of heat generating cartridge E-Bay, Amazon Praktische Dermatologie. 2011;17: Clin Cosmet Investig Dermatol Jun 5;6:

3 AND MOLLUSCUM Small (n=21) Chinese prospective study; patented IR heating unit 44 0 C (111 0 F) for 30 minutes, once weekly x 12 weeks 13 children, 8 sexually active adults (ages 21-28) Average # lesions = 59 (ie. Bad molluscum) 12/21 complete clearance 12 weeks (children & adults) Facial lesions relatively resistant compared to other sites Br J Dermatol Jul 5. doi: /bjd [Epub ahead of print]? There are many brands of electric heating pads Sunbeam, TheraTherm, Thermophore, SoftHeat, Conair Price points $20-80 Dry or Moist heat, various covers, sizes, shapes, controls (digital v. manual), timer type Infrared heating pads: very deep, very hot (UTK, Biomat) Maximum temperatures varies widely 75 0 F F Moist > Dry Sunbeam brand tends to be hottest, SoftHeat coolest CHONDRODERMATITIS NODULARIS HELICIS Standard therapy: Surgical removal; Topical/IL steroids Open label study (n=11) CNH Nitroglycerin patches 5mg, 12 hours daily, x 2 months 7/11 (63.6%) complete resolution 2 (18%) stopped Rx due to headache; 1(9%) non-responder MOA: Reversal of ischemia due to vasodilation? Supports prior work w/ nitroglycerin gel (2011) Dermatol Ther 27:278, 2014 Dermatol Ther 27:278,

4 NAIL PSORIASIS: THE CURE? NAIL PSORIASIS 31 patients w/ bilat symmetric psoriatic nail dystrophy Indigo naturalis oil (Lindioil) versus olive oil One drop, applied BID x 12 weeks Objective NAPSI score used to compare groups ~50% improvement in score with active compared to <20% improvement in score with control oil Chinese trial. Can you get this in USA? Phytomedicine 2014;21: JAMA Dermatol. 2015, Mar 4. Spontaneous resolution ½ of all lesions within 2 years Topical steroids (+ occlusion) Intralesional steroids Topical TCI Scarification Dapsone Cyclosporine Phototherapy (PUVA) Chlorambucil 1-6 mg/day GRANULOMA ANNULARE EXCIMER LASER Monochromatic high intensity light, 308nm Approved: Psoriasis and Vitiligo Induces apoptosis of both epidermal and dermal pathogenic T-cells through DNA damage Induces delayed synthesis of immunosuppressive biologic agents, such as prostaglandins, IL-1 receptor antagonist and IL-10 and IL-15 Coll Antropol 2014;38: Photodermatol Photoimmunol Photomed 2012;28: GA: EXCIMER LASER 308 nm Fluence of 300mJ/cm 2 FIVE doses per session, weekly Four months Rx: Refractory GA resolved No recurrence at 6 months GA: EXCIMER LASER UNKA TEDDY S METHOD 308 nm Fluence of mJ/cm 2 TWO doses per session, weekly Four-Six months Rx: Refractory GA resolved No recurrence at 6 months J Clin Aesthet Dermatol 5:43, 2012 J Clin Aesthet Dermatol 5:43,

5 Excimer Laser, 308nm, 450J/cm 2, Two passes per weekly session, Pre, x16 weeks and x 20 weeks TOPICAL DAPSONE GEL THINK OF THE POSSIBILITIES! Dapsone inhibits PMN adhesion and migration Aside from acne.. Leukocytoclastic vasculitis Cutis. 2017;99: Granuloma faciale Dermatol Online J Aug 17;20(8) Dermatitis herpetiformis J Cutan Med Surg. 2016;20: Rosacea J Drugs Dermatol. 2015;14:602-6 ROSACEA RX: DAPSONE GEL 7.5% QD (90 DAYS) NEW RX DIGITAL MYXOID CYSTS? 5

6 DIGITAL MYXOID CYST: POLIDOCANOL 63 patients: Fingers and Toes Removal of gelatinous material, followed by Injection of 3% polidocanol to restore cyst size In 6 weeks, 68.3% resolution (12 weeks: 77.8%) For non-responders, repeat.ultimately 84% complete resolution rate AEs: inflammation, joint stiffness, pain, and ecchymosis; All resolved in 3 mo THINK OUTSIDE THE BOX! USE RADICALLY DIFFERENT PEARLS Ted Rosen, MD Professor of Dermatology Baylor College of Medicine Houston, Texas Dermatol Surg 2016;42: