Research - New Age Research Foundation

Publications in peer-reviewed journals by NASRF research fellows

Lee H, Saladi RN, Fox JL. Cohort study on patient response to botulinum toxin cosmetic therapy. Journal of Cosmetic Dermatology Vol. 7, 39–42

Abstract:Background Botulinum toxin (BTX) therapy is currently the most popular cosmetic procedure in the United States. However, few studies exist regarding post-procedure perceptions of the patients’ BTX therapy. Objective The aim of this cohort study was to determine patients’ responses from pre- to post-BTX treatment experience. Methods and materials One hundred twenty-three BTX patients of six different dermatologic cosmetic practices in various boroughs of New York and Long Island in the state of New York completed the questionnaire. Six hundred eighty-three surveys were sent out and 123 completed surveys were obtained. Numerous questions were asked regarding how patients felt and responded towards the overall procedure of their BTX therapy. Results Eighty-eight percent of patients were satisfied or extremely satisfied with their dermatologists. Sixty-five percent of patients felt over 60% improvement in areas treated. Fifty-eight percent of patients anticipated making repeat visits, whereas the biggest concern for returning was due to the expensive cost of BTX. Conclusion Our study correlated with previous studies done on retention rate of BTX cosmetic patients and satisfaction level on areas treated. The cost of BTX remained one of the primary concerns for repeat visits. Most patients were happy with their visits to the dermatology offices for BTX procedure, although things can be done to further enhance their visits and the likelihood that they will return.

Skolinick A, Saladi RN, Fox JL. An Update On Suncreens:. J of the Amer Osteo Coll of Derm
Vol 8. No 1. Pages 23-29.

Abstract: Protection from ultraviolet radiation (UVR) has been around for centuries. As medical evidence began to shed light on the harmful effects of UVR, the evolution of sunscreens began to take shape. Sunscreens are constantly being modified to increase efficacy as well as to encourage greater compliance -- new active ingredients currently approved in Europe, Japan, and Australia will eventually be introduced to the United States market. Sunscreen active ingredients have been integrated into cosmetics and clothing, and spray lotions have made application more convenient. The sun protection factor (SPF) scale continues to be the gold standard when assessing the strength of a sunscreen, but it remains flawed because of the numerous factors that decrease its accuracy. As sunscreen application continues to grow, so does the controversy surrounding its role in reducing the risk for skin cancer, vitamin D metabolism, and photoprotection. Based on a review of current literature, sunscreen is one important defense against ultraviolet radiation; others include avoidance of prolonged exposure, protective clothing, and education. Skin phototypes differ between individuals, and it is important for consumers to recognize the SPF, application regimen, and delivery method that fits them best.

James J, Saladi RN, Fox JL. Traction alopecia in Sikh male patients. J Am Board Fam Med. 2007: 20(5):497-8.

Abstract:This article reports on traction alopecia among Sikh males as a result of stress on the hair from wearing a turban. Treatment for this condition in such a population is difficult. Permanent removal of the turban is religiously forbidden. Therefore, the traction continues, as will the alopecia, possibly accompanied by seborrheic dermatitis and psoriasis.

Some of the ongoing projects include

Cohort Study: Behavioral Factors in Melanoma Patients before and after their diagnosis:

Status: Completed. Under Review “Journal of Melanoma Research”

Objective: To explore the behavioral habits of melanoma patients before their diagnosis and after diagnosed with melanoma, as well as obtaining their insight how education of melanoma prevention and awareness is conducted.

Study: The patient pool included over 600 patients from all over the five boroughs of New York City. All of these patients were either diagnosed or treated at one of six dermatology institutions. In order to compare & broaden the study, similar research is being done at George Washington University as well.

How the results can be used: The main purpose of these results is to improve the education of sun protection for the prevention of melanoma and any type of skin cancer. By understanding what sun protection habits people are neglecting even after diagnosis, it will be made clear where education needs to be focused. Education is only good if the patient is not only listening but also following the advice. If patients are not following that piece of advice, the education must emphasize the failure in the educational process. By questioning former patients about their opinions regarding the education they received, we can receive their insights. Many patients are more than willing to give their opinions on how the education can be improved. They know exactly what information needs to be emphasized as well as the best way to present the education in order to have the most effectiveness. These opinions and ideas can be incorporated into an even better education program for the prevention of melanoma and skin cancer.

Sun Damage Prevention & Risk Awareness

Purpose/Goal:
The purpose of this study is threefold. (1) To determine general public awareness of the harmful effects of Ultraviolet (UV) radiation, (2) to assess knowledge of proper use and application of sunscreen/sun block, and (3) to examine trends in sun protection habits and the use protective sun care products. Simultaneous to this research study, a public educational campaign will focus on the proper use of sunscreen/block for the goal of preventing sun related skin damage and related diseases.

Relevance:
Current knowledge regarding public understanding of sunscreen/sun block usage is minimal. Few, previously conducted studies, acknowledge the increased risk for sun related diseases based on suboptimal skin protection from the sun or UV rays. However, the proper uses of protective mechanisms are not well known, and there is a need for more widespread campaigns with focused messages to reinforce the importance of reliable sun protection over the long term.
The current lack of information on dangers of sun exposure, and on proper sun protection, further creates the potential for a large number of skin cancer patients. Documenting the patterns of sun block usage will help to determine the current level of awareness, such that a proper plan can be assessed for future education. Insufficient current research on sun care behaviors makes it difficult for skin cancer advocacy groups to define and focus their work. Thus, the results of this study will aid dermatology and skin cancer organizations in determining how to best allocate their resources for maximum effect.
Therefore, this study has relevance for multiple reasons. First, the study aims to solidify knowledge about public perception of skin disease risk due to sun exposure. Second, the study will assess public proficiency in the proper application of sunscreen. Third, it will determine the correlation between practical use of sun care products/methods and knowledge thereof. Lastly, the study will serve as an educational tool to alert the public to proper sun care mechanisms to increase protection from UV rays. Studying these topics offers the possibility of advancing understanding of how sun care protective mechanisms are utilized everyday.

Review of Literature:
Extensive review of published literature underlines the importance of learning more about how sun care and related disease prevention is currently utilized. Additionally, this review impresses the need for a campaign to raise public awareness of the dangers of sun radiation with the hope of causing behavioral changes to protect from UV radiation.3 The exponentially increasing incidence of skin cancer indicates that current campaigns are not adequate to fully achieve desired results. Nonetheless, the limited scope of current information brings to light the discrepancy between fact, public knowledge, and usage of skin protective mechanisms.
Multiple studies have been conducted to assess general knowledge about the effects of sun exposure. Women and men were found to differ in the skin precautions utilized; and men reported an overall greater value of a tan and a greater outdoor exposure to sun than did women.4 Teenagers also indicated an understanding that excessive sun exposure is both harmful and a cause of skin cancer and sunburn.5 Despite this documented knowledge of sun associated risks, the likelihood of use of sun damage prevention techniques was 53%, for respondents who spent greater than one hour outdoors in sunny weather.5
Studied sunscreen behaviors indicated that while knowledge about sun protection generally increases with age, attitudes and behaviors toward positive sun protection typically declines as an individual ages. Thus, sunburn rates increase with age.6 However, confounding this finding, studies report that sun protection behaviors are positively associated with age in African Americans.7
Particular sunscreen behaviors have also been studied. Such studies, generally done retrospectively, indicated that sun protection has become part of a routine beach behavior and that sunscreen is the most popular preventative measure. But the prevalent rates of skin cancer contrast these reports and reinforce a continued need for the improvement of sun protection behaviors and further study for greater understanding.8

Methods & Procedures
This cohort study will use a descriptive survey designed to determine patterns of sun screen/block use and knowledge assessed in three demographic groups: among the general public (i.e. at malls), among sun bathers (at beach), and in an institutional setting (at dermatology practice(s)) in the Tri-State area. In total, a sample of approximately 1800 people will be surveyed. These individuals will be men and women of all races over the age of thirteen. Variables such as race, gender, skin type, and behavioral attitudes will be noted in the survey. Participants will be required to speak and understand English well enough to complete the written survey independently.

All surveys will be conducted by a group of 16 research fellows, including four medical students, and twelve undergraduate students. The research methodology, processes, data gathering, analysis and interpretation will be overseen by a senior dermatology resident, research dermatologist and two board certified dermatologists who will also review and approve the final version of the manuscript for its publication.

Timeline
The study began at the end of June 2007. All surveys were collected throughout the month of July and data analysis commenced immediately upon completion of the surveys. Thereafter, findings were examined and conclusions drawn in preparation to draft and publish the results. The results of the study are being prepared for publication in several journals.

Review Articles: Scholarly Exchange of Information

Article 1: Skin Cancer and Its Etiologic Relationships

Status: Under review for publication
Abstract
Context: Skin cancer is the most common type of cancer in fair-skinned populations around the world. A better understanding of the various etiologies of skin cancer could be an essential step in its prevention.
Objective: This article will provide readers with up- to- date statistical, epidemiological and literature based information on skin cancer and its many etiologies.
Data Sources and Study Selection: Searches of MEDLINE, online resources, standard text books, and the ACP Journal Club were performed to identify English-language articles published between the years 1970 - 2007. The references of each retrieved article were reviewed and an expert in the field was contacted to identify additional relevant articles.
Data Extraction: Using a combination of more than 100 search terms, we included articles of skin cancer etiology that were cohort studies, case-control studies, cross-sectional studies, or systematic reviews of cohort, case-control, and/or cross-sectional studies.
Data Synthesis: Multiple factors have been found to be associated with skin cancer development. Factors associated with skin cancer include ultraviolet radiation, immunosuppression by various agents, human papilloma virus, genetic susceptibility, ionizing radiation, environmental pollutants and chemical carcinogens, other risk factors include artificial UV radiation, skin color, age, smoking, history of skin cancer and precursor lesions, dermatoses and keratoses, chronically injured or non-healing wounds, scars, diet and cutaneous metastases.Conclusion: Skin Cancer is an important public health concern. A sensible sun protection strategy is advocated for its prevention. The first line of defense against skin cancer includes the use of protective clothing, avoidance of excessive exposure to UV radiation, the use of sunscreen, and most importantly, education about the harmful effects of the sun’s rays. Knowing the causative factors for skin cancer can reduce or possibly eliminate personal risk.

Article 2: Chemical Warfare Agents & Our Preparedness

Status: Under review for publication
Overview: Chemicals agents have been used as weapons of warfare in the past. The skin is the most widely exposed area of the body. The skin is usually the first and most commonly affected organ system that is damaged by the use of chemical warfare. Chemical warfare have been used in different eras of conflicts ranging from World War I, Iran-Iraq war to as recently as the 2002 plot to poison the water supply of the American Consulate in Rome. These chemical warfare agents are easily obtained and often inexpensive. In this article the use of commonly used vesicants and toxic blood agents as potential agents of chemical warfare and terrorism is outlined. The dose dependent effect of these agents exposure on the skin, eyes, and respiratory system are described, as well as the possible extents of injuries, the mechanisms of action and the long term complications. Prevention and management of these agents exposure are briefly discussed. It is pertinent that our dermatologic community become more aware and prepared, on how recognize the signs and symptoms of chemical warfare if it were to occur.

Case Studies

Regaining normal sensation while on treatment with Erbium: YAG Laser in two patients suffering from hyperesthesia: Case Series.

Status: Accepted in The Journal of Cosmetic Dermatology Abstract

Background: Hyperesthesia is defined as a neurological symptom where there is an unusual increased or altered sensitivity to sensory stimuli. A new treatment option utilizing Erbium laser therapy in two patients suffering from hyperesthesia is reported. Observations: Two females suffered from nerve damage to the neck and shoulder area after having cancer surgery which left them with severe hyperesthesia and extreme pain. Both patients received Erbium and CO2 laser treatment for facial resurfacing of wrinkles as well as Erbium: YAG treatment for the reduction of a post-surgical scar. Within several weeks of the treatment, the patients reported 50-100% improvement in their symptoms. Conclusions: Although laser use in pain relief has been recently documented, our review of the literature reveals that these may be the first reported cases of relief of hyperesthesia using laser of any type. It is possible that the Erbium: YAG laser treatment was responsible for the reduction in hyperesthesia and chronic pain. We recommend that additional patients be treated using similar parameters before the final conclusions are made.

Long pulsed Alexandrite laser assisted tattoo removal: An open study.

Status: Under submission

Abstract
Laser assisted tattoo removal is a firmly established technology that has led dermatologists to seek out the right laser wavelength for treating various color tattoos. We present the Long-pulsed Alexandrite laser or a combination of Long-pulsed Alexandrite laser and Nd:YAG or Ruby laser (combined therapy) as viable options for the removal of stubborn tattoos. This treatment can also be considered for patients who want to reduce the number of treatments they need to receive. We treated eight patients of different skin types and mostly black tattoos with either the Nd:YAG, Ruby laser, Long-pulsed Alexandrite laser, or a combined therapy. Of the eight patients treated the number of treatments required was 25 % less with long pulsed alexandrite and 35% less with the combined therapy compared to the Nd:YAG or Ruby alone for the same size area. While the Long Pulsed Alexandrite laser may pose a greater risk of scarring, sometimes a more aggressive therapy is needed for tattoos that do not respond well to conventional treatment or for patients who opt to get rid of their tattoos in fewer treatments, even though if it may leave larger mark or a greater risk. Our open study showed promising results for stubborn tattoos indicating that a well controlled study is warranted.

*Several studies which have not been mentioned are either recently initiated or ongoing.