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Actinic keratoses (AKs) exist on a continuum with squamous cell carcinoma and can occur as sub-clinical and clinically visible lesions in cancerized fields on sun-damaged skin. Ingenol mebutate effectively treats AKs on areas up to 25 cmPhase I, multicenter, open-label, uncontrolled, non-randomized trial. Patients received ingenol mebutate gel for three consecutive days on approximately 250 cmOf 61 patients, 10 (face =8; arm =2) had ingenol mebutate in whole blood at subnanomolar levels (0.235-0.462 nM). The assayed metabolites were below the lower limit of quantification. Local skin responses increased during Days 1-4 and declined thereafter, approaching baseline by Day 16. Most adverse events were pain/pruritus of mild or moderate intensity.Subnanomolar systemic exposure to ingenol mebutate was measured after application of the gel to approximately 250 cm

Background: Androgenetic alopecia is a common condition of adult men. Finasteride, a type 2 5α-reductase inhibitor, decreases the formation of dihydrotestosterone from testosterone. Objective: Two separate clinical studies were conducted to establish the optimal dose of finasteride in men with this condition. Methods: Men from 18 to 36 years of age with moderate vertex male pattern hair loss received finasteride 5, 1, 0.2, or 0.01 mg/day or placebo based on random assignment. Efficacy was determined by scalp hair counts, patient self-assessment, investigator assessment, and assessment of clinical photographs. Safety was assessed by clinical and laboratory measurements and by analysis of adverse experiences. Results: Efficacy was demonstrated for all end points for finasteride at doses of 0.2 mg/day or higher, with 1 and 5 mg demonstrating similar efficacy that was superior to lower doses. Efficacy of the 0.01 mg dose was similar to placebo. No significant safety issues were identified in the trials. Conclusion: Finasteride 1 mg/day is the optimal dose for the treatment of men with male pattern hair loss and was subsequently identified for further clinical development.

Previous attempts at classifying small graft transplants have focused mainly upon graft size and have not taken into consideration other technical factors involved in graft production that may influence the outcome of the surgery. The proposed classification attempts to consider these factors by including various technical aspects of harvesting, dissection, and placement, all of which impact the quality and quantity of the small grafts used in the procedure. By standardizing the nomenclature, as well as the description of the other factors involved in the surgery, communication between physicians and patients may be facilitated. In addition, different procedures may be more accurately studied and compared.

Facial appearance plays a pivotal role in the formation of one's sense of self-esteem. We are recognized by our face more than any other single feature. Hence, the aging face can have a significant effect on personal interactions as well as quality of life. Aging has both intrinsic and extrinsic components. Hair loss is one intrinsic factor that dramatically affects appearance. Senescence, as it relates to hair, may involve recession or balding and also changes in hair texture, volume, and color. Patterned hair loss in both genders is genetically predetermined. Significant hair loss draws attention from the face to the forehead or crown. Furthermore, insufficient hair for facial framing makes one appear older than one's true chronologic age (Fig. 1). Androgenetic alopecia is the most common cause of hair loss in the aged patient. The recognition that androgens play a role in hair loss is a surprisingly modern concept, first suggested by Hamilton in 1942. 10 He subsequently devised a classification scheme for male pattern baldness. The newer and more widely accepted classification scheme for male pattern baldness was developed by Norwood and published in 1975 (Fig. 2). 18 In 1977, Ludwig described a similar classification scheme for androgenetic alopecia in women. 15 Female androgenetic alopecia, in contrast to that of men, occurs in a more diffuse pattern, especially after menopause when bitemporal hair loss can become significant. The incidence of male pattern baldness varies significantly with age. By the age of 60, over 50% of men will be a Norwood type III, IV, V, VI, or VII. 18 Increasingly, men and women are seeking treatments for hair loss and fortunately have an expanding list of options for treatment. An excellent review of medical options was recently published by Sawaya. 25 Perhaps what patients seek the most information about, and one of the most common procedures, is hair transplantation surgery.

BACKGROUND. Epidermoid cysts sometimes result from small-graft hair transplantation. Although hair transplant surgeons are aware of this complication, it has not been reported to date. OBJECTIVE. Our purpose is to report the clinical and histological features of posttransplant epidermoid cysts. METHODS. Four patients with posttransplant cysts, and the histological features of two of these cysts, were reviewed. RESULTS. All cysts occurred at the site of a recent micro- or minigraft, and were small ; one had become infected. Serial sectioning of one scalp biopsy showed a micro graft lying in the subcutaneous tissue in close proximity to an epidermoid cyst. The cyst apparently arose from the follicular infundibulum of the graft. CONCLUSION. Posttransplant epidermoid cysts are examples of epidermal inclusion cysts. They are treated by conservative excision, and may require drainage for secondary infection. Careful operative technique should prevent some of these cysts.

In recent years, hair transplant surgeons have placed emphasis on refining the frontal hairline with minigrafts and micrografts in order to achieve a totally natural appearance. Minigrafts and micrografts can be used in areas other than the frontal hairline with excellent results. This article describes the newest techniques for harvesting and transplanting micrografts.

Multiple modalities exist for the treatment of keratoacanthoma. Excisional surgery is currently the treatment of choice for the majority of keratoacanthomas. This can result in functional and cosmetic defects when large or strategically located lesions are treated. An effective nonsurgical treatment would be desirable in such cases. Intralesional therapy, particularly with 5-fluorouracil, has been shown to be effective in the treatment of keratoacanthomas. Systemic methotrexate has been tried, with variable success. We report an open, noncontrolled study of nine consecutive patients with unusually large or strategically located solitary keratoacanthomas treated successfully with intralesional methotrexate. All lesions responded promptly, with complete resolution after a mean of 3.0 weeks and a mean of 1.7 injections. No side effects occurred, and scarring was minimal. We concluded that intralesional methotrexate is a simple and effective modality for the treatment of select keratoacanthomas and may offer greater efficacy, a more rapid response, decreased pain, and lower cost compared with intralesional 5-fluorouracil.

The technique of incisional slit grafting is described and discussed. The results of the use of this technique for hair transplantation in patients with Norwood Type VII or advanced alopecia are reported.

The following discussion provides an historical overview of modern hair restoration surgery and a proposal for a standardized graft classification system that accommodates continually evolving technique.

background : One consistent and undesired sequela resulting from scalp reductions has been the “slot” or “trough” defect, referring to the scar following the final reduction. Attempts to correct this have not been entirely satisfactory. objective : To present an approach to minimize the “slot” defect that consists of staged modified paramedian scalp reductions combined with a large posterior Z-plasty during the final reduction. methods : A paramedian crescent-shaped ellipse was marked onto the patient's scalp parallel and adjacent to the existing fringe hair. Subsequent reductions were performed in a similar manner approximately 2 months apart. The final reduction consisted of mobilization and transposition of the large flaps used in the posterior Z-plasty. results : Patients who underwent the staged modified paramedian reductions combined with a posterior Z-plasty had significant minimization and adequate camouflage of the undesirable “slot.” conclusion : Combining a large posterior Z-plasty with a paramedian reduction minimizes the slot defect. J Dermatol Surg Oncol 1992;18:996–998.

Incisional slit grafting, a new and greatly improved technique in hair transplantation, is described. Incisional slit grafting utilizes larger numbers of smaller grafts than does traditional punch grafting. No tissue is removed from the recipient bed. The vascular supply is conserved, resulting in an increased graft yield. The clumping and stalking effect associated with traditional round grafting is eliminated largely, and a more natural frontal hairline is achieved.

The triple rhomboid flap offers significant advantages over previously described methods for reducing vertex alopecia. The circular area of alopecia is converted into a hexagon. The hexagon is then excised and closed by rotation of three rhomboid flaps from the hair-bearing periphery. The specific indications for this flap are reviewed, the technical aspects are discussed, and illustrations are provided.

REPORT OF A CASE A 56-year-old white man, who had received a renal transplant and who was beleaguered by numerous actinic keratoses and verrucae, was noted on routine examination to have a bullous lesion on the right conjunctival surface. He was unaware of the lesion and had stated that it was totally asymptomatic. The patient denied any previous blistering disorders of skin or mucous membranes. His opthalmologic history revealed cataract extraction bilaterally and lens implantation with trabeculectomy performed approximately 6 years prior to presentation. He had also undergone a surgical procedure for glaucoma control. More recently, he had noted a diminution of vision bilaterally following a cerebral vascular accident. The patient's medications included prednisone and azathioprine (Imuran) taken daily following the successful renal transplantation 13 years previously. On physical examination, a tense bulla containing clear fluid was present on the conjunctiva at the 12-o'clock position superior to the iris (Fig

Several ge node rmatoses predispose a patient to develop cancer later in life. Included among these disorders are Peutz-Jeghers syndrome (gastrointestinal or breast carcinoma), Cowden's disease (breast or thyroid carcinoma), and Gardner's syndrome (gastrointe stinal carcinoma). Patients may develop cancers in other organs as well, and should be followed closely.