Taxing cosmetic procedures in the states!

In a surprising move  The White House and Senate Democrats announced “Botax.” they want to tax cosmetic procedures  like Botox, tummy tucks, nose jobs and lifts to pay for costly health care .

it is estimated that  it would earn Uncle Sam about 5.8 billion over the next decade.

Skin-smoothing Botox injections could be hard-hit. There were some 4.7 million last year and an average cost per visit of about $400, some including several injections.

it has been thought  that this is going to tax rich, women,” . whereas 86 percent of cosmetic surgery patients who are female, 60 percent of them have incomes between $30,000 and $90,000.

people who have saved  their earnings to have something to improve their appearance, are unable to pay for the cosmetic procedure anymore.

After the news, Allergan’s shares lost 2 percent on Thursday. The company, which recently projected net product sales for this year of more than $4 billion, would be on the forefront for the motion.

This comes at a time where both patient and doctors alike are hard hit with the recesstion and could be the last straw that could suffocate one of the biggest industries in the states.

Nail … when to cut?

A 22 year man , with history of trauma to his left toe two months ago. it has been painful ever since and pain is increasing, somtimes with discharge coming out but no fever. he doesnt wear tight shoes and was prescribed miconazole crem which only helped a little.

on examination left big toe is tender and the lateral nail folds are swollen and erythematous. the lateral nail edges cant be seen.

between the lateral nail folds and the nail the patient has some granulation tissue. other toes are normal

to me this looks like ingrown nail, and i believe he needs Partial nail removal  performed by clipping distal corner or by removal of the entire lateral portion of the nail. my questions are:

does he need matrictomy? since this was preciptated by trauma and he has never complained before that?

and for preventive purposes , will cotton balls be enough to to stop them from recurring?

thanks!

A Case of hemangioma treated by steroid injection

this was contributed by Dr. kamal  hussein  saleh
This  is  a case  of  hemangioma  of the face treated   by    triamicilonoe  injections  in 3 weeks apart sessiom  for six sesseon only , you can see the  changes in pictures befor and after the last injection of the steroid, the the right eye closed completely  by  drooping eye lid complicated  hemangioma, the injections  diluted  with normal saline in dose 1 mg per kg. body w.t. inject all the affected areas in face.
 

diabetic with ulcers

 

an 80 year old female, who has advanced dibetes with blindness, gastric paresis and renal failure on dialysis complained of ulcers on her lower extermeties for the last few weeks. they were on the knees, legs and feet. some were painful. on examination she had multiple shallow ulcers of varying sizes, with sorrounding erythema. it was covered by a thick adherent yelloish crust which later (1 week) became necrotic.
her differential initialy was between calciphylaxis, pyoderma gangrenosum or infection.
her dobbler showed obstruction of the posterior tibial artery.  she also had high fibrinogin level.

a biopsy was taken which showed fibrin deposition in the blood vessels. no calcium deposits.
we believe that what she has is related to her dibateic vascolpathy. she was started on pentoxifyllin and improved slightly ever since. her coagulation profile is under investigation too.
are we dealing with a vascular problem or coagulapthy?

trichomegaly a side effect or not?

Side effect of Allergan glaucoma drug is longer eyelashes; competitors spring up

By RHONDA L. RUNDLE

The Wall Street JournalIn the latest blurring of the line between cosmetics and drugs, new products that promise to make eyelashes look longer are causing a stir among physicians and regulators because they contain ingredients that are the same or similar to those in prescription drugs for an eye disease.

 

Doctors and patients alike have noticed that eyelash growth is a side effect of a glaucoma drug called Lumigan, sold by California drug maker Allergan Inc. That phenomenon has set off a race among cosmetics companies to create new eyelash treatments that contain either bimatoprost — the active ingredient in Lumigan — or other so-called prostaglandins found in glaucoma drugs.

 

The eyelash products look like mascara tubes and have a brush or tip for applying the product along the base of the lashes, and typically sell for $140 to $160 in spas and doctors’ offices. At the same time, some doctors are writing Lumigan prescriptions for their cosmetic patients, a practice allowed because a drug may be prescribed for any use once it is approved by the U.S. Food and Drug Administration for one use.

 

But the companies pushing into this arena are already facing two big fights: one with each other, the other with the FDA.

 

Allergan itself, which sells the antiwrinkle drug Botox and is making a major push into aesthetic medicine, is believed to be testing Lumigan for lash enhancement. That strategy would echo Allergan’s development of Botox for cosmetic use many years after it was launched to treat eyelid spasms and other neuromuscular problems. Earlier this month, Allergan filed a patent-infringement suit against several eyelash companies that it says use a prostaglandin in their products.

 

The scramble to develop and sell eyelash products derived from the glaucoma drug shows how the line between a cosmetic and a drug isn’t always clear. Cosmetic products can use ingredients that are also used in prescription medications.

 

However, if a company promotes its product to change the structure or function of the body — rather than just its appearance — then it is classified as a drug and must prove its safety and efficacy in human tests. The FDA’s Web site says that a product may be considered a drug if its ingredients have a well-known therapeutic use. FDA officials have so far declined to say how its rules apply to cosmetic eyelash products that contain ingredients found in glaucoma drugs.

 

FDA spokesman Brad Swezey declined to say if the agency is generally investigating cosmetic eyelash products or claims. However, in its press release Friday about the seizing of the original Jan Marini product, the agency said that Age Intervention Eyelash, if used together with a prescription glaucoma drug, could increase the risk of optic-nerve damage. Used on its own, the product “may cause other adverse effects,” including swelling of the retina and inflammation in the eye “which may lead to decreased vision.” Neither the agency nor the company has received any report of adverse effects, according to Swezey and Marini

 

Even as the cosmetics firms search for regulatory answers, Allergan is moving to defend its turf. An Allergan spokeswoman, Caroline Van Hove, declined to discuss its drug development plans. But she added: “We’ve got intellectual property in this particular area.”

 

On Nov. 7, Allergan filed a patent-infringement suit in federal court in Santa Ana, Calif., against seven eyelash-product companies. Among the defendants are Jan Marini Skin Research, Athena Cosmetics and PhotoMedex. Marini called the suit “baseless” and pledged that the company would vigorously defend itself. Athena’s Dr. Brinkenhoff and PhotoMedex’s Mr. O’Donnell declined to comment on the suit.

 

Allergan isn’t alone in trying to learn more about Lumigan’s effect on eyelashes. Physicians at the University of California at San Francisco, who say their research isn’t funded by a pharmaceutical company, are testing Lumigan and another glaucoma drug in patients who have lost their eyelashes because of alopecia areata, an autoimmune disease that causes hair loss.

 

Other researchers are developing tools to measure growth of the tiny hairs. “There are scales to look at wrinkles, but no one has developed an eyelash scale,” said Leslie Baumann, director of cosmetic dermatology at the University of Miami’s Miller School of Medicine. Dr. Baumann says many more eyelash-growth products are headed to market. They are probably safe, she says, but could permanently darken the color of the iris if allowed to drip into the eye…..

comment:

will first minoxidil then lumigan, what is next ? colchicne for constipation? lool

i wonder whether it works for scalp hair. they may have shorter anagen but its all hair after all.

Does UVR reduces the risk of cancer?

rescent study by Soerjomataram I et al :

Ultraviolet exposure may reduce the risk of colorectal and breast cancer as the result of rising vitamin D levels. Because skin cancer is positively related to sun exposure, the authors hypothesized a lower incidence of breast and colorectal cancer after skin cancer diagnosis. They analyzed the incidence of colorectal and breast cancer diagnosed from 1972 to 2002 among 26,916 Netherlands skin cancer patients (4,089 squamous cell carcinoma (SCC), 19,319 basal cell carcinoma (BCC), and 3,508 cutaneous malignant melanoma (CMM)). Patients with CMM exhibited an increased risk of breast cancer, especially advanced breast cancer (SIR = 2.20, 95% CI: 1.10, 3.94) and older patients at CMM diagnosis (SIR = 1.87, 95% CI: 1.14, 2.89). Study results suggest a beneficial effect of continuous sun exposure against colorectal cancer. The higher risk of breast cancer among CMM patients may be related to socioeconomic class, both being more common in the affluent group.

comment: vitamine D seems to have anti cancer propreties(colon, prostate, breast and probably melanoma), cumulative sun expsosure has been documtend to be a major risk factor for Squamus Cell carcinoma, but the evidene for cutaeous melanoma is still controversial. the amount of sun exposure needed to induce skin cancer is not known and therefore recommendations regarding outdoor activities (to replensih vitamin D) cant be determined. if in doubt regrading vitamin D defeciency it should always be supplemented especially for indvisulas with ligher skin types who avoid the sun for extended times.

facial rash

33 year old indian with 9 month history of this recurrent rash which improves promptly on topical steroids only to relapse after stoping treatment. he works indoors, his only exposure to sun is when he is going to or from work. rash it asymptomatic, no joint pain or history of mouth ulcers. on examination he has multiple confluent scaly erythematous to violacious papules forming plaques. distributed on his cheecks and mid forhead , hands are free.

the problem is that he isnt eligible and cant afford to pay, i would hav asked for ANA and biopsy but since i would treat blindley, i might give him the following:

mid potency topical steroid+sunscreen+ antimalrial

oblviosly am thinking about lupus, but am afriad am missing sth else , polymorhus light eruption?

this is like a real morphology test.

ur thoughts are appreciated

when to biopsy?

this was sent from my freind. i know the pic is blurred (mobile pic) he noticed this lesion for 3 weeks not painful no hx of trauma before , it started as such, no previos lesion.

so somone told him that it needs to be biopsied  (it could be cancer)! he was worried . since he s living in another city i couldnt see him but i referred him to another Dr there. 

i had no doubt that it was trauma induced (history is not necessary it could have happend while he was sleeeping), the nice smooth outline and the erythematous margins negates melanoma.

he called me later and said that it peeled off!

but what can cause confusion in my opinion is the periungual hemmorrage that can mimic a hutchinson sign. they can produce melanonychia. whats even more challanging are hemoorages underneath the nails. they can presnet in many shapes and persist for long and provoke alotta worry and unnessasary biopsies. furthermore trauma was linked to periungual melanoma in a few case reports. 

my question is: when do we have to biopsy a subungual lesion (dark brown) underneath the nail?

white mirage

 

 

 i had this patient a teenager with skin type 5 who was so depreesed cuz of her color. she is the darkest among 4 sisters all of whome r white. she was called names since she was young and apparently she doesnt go to parties no more and going through depresion.

 then i saw this article, and couldnt help to wonder why in our community do we crave white color. why do we look into brown color as an inferior color?  ?. moms are not the only ones to be blamed, we are feeding this illusion as drmatologists when we attempt to treat patients who want be paler (sorry whiter). i can understand and treat melasma and PIH but brown skin (asmarani) ? and if they finaly mange to dilute their face then what about the rest of the body.

is white more beatiful? or is it linked to superior dominant races. are we mesmorised by the white french, turk and english invader? or is white pure and pristine. i have alotta patients complaining of dark elbows and knees holding them on examination as if their limbs are someone’s else.

there are even many cosmetic products which promotes white skin, prmosing girls to ‘fade out’ thier color if they use it continously. i herd that when a vitligo patient used benoquine for depigmentaion her normal sister came asking for the cream. other patients who turned white after benoquine got married in record times. the temptation is so strong to the degree that i herd some patients who had vitligo in the finger tips only had depigmentaion.

ironicaly tan is considered a hot commodity in the west where most people are white. they even lay naked on the beach all day just to look like us. they crave tan, they burn themselves and invite skin cancer to be tan pretty. are we always looking to stand out of the crowd? to be different and unique?. will if you think about it, gold, ivory, and moon rock are all expensive and they all have one thing in common, they are scarce.

whtining injections,i herd alot about these injections but never seen them. but most patients who ask me about them are vitligo patients. am not sure what they mean when they say eber taftee3, we all know MBEHQ (benoquine cream), but i haven seen anyone who knows about these injections. it sounds like a legendary myth!they might be sterids or potent quinones if they ever exist. or are they refering to meso?

white, brown, black or tan are just shades of our skin.they are allbeatiful. nothing is wrong with any with them, its just us,  believing the myth fabricated by grannma

have a nice summer

and  a nice tan

(  :

Review of tongue lesions (quiz)

since we discussed tongue lesions over the last two weeks here is a review for tongue morpholgy. most pics were taken from dermatlas. answers are down below 

 

1- has thick nails

 

2-oral sex

3-disseminated vesicled everywhere

4- recurrent blister same location

5- strept infection

6- facial palsy

7-easely scrapes

8-smooth atrphic

9- enlarged tongue oozin blood

10- advise stoppin smokin

11-same lesions on scr0tum

12- trauma in a pregnant lady

13-asymptomatic/benign

14-DIRTY PAPULES ON CHEST?DDX

?

15- caused by fungi/abx/smokin

16- cant breathe?

1-white sponge nevus in pachynycia congenita  2-wart  3- diseminated varicella  4-fixed drug eruption  5- strawbery tongue  6-scrotal tongue  7- candidiasis  8- median rhomboid glossitis  9- lymhangioma  10- oral lichen planus  11- fordyce spots  12- pyogenic granuloma  13- geographic tongue  14- darier,DDx inclue chrons, cowdens  15-black hairy tongue  16- amyloidosis