Accepted Manuscript About melanocyte activation in idiopathic guttate hypomelanosis by 5-fluorouracil tattooing Carlos Gustavo Wambier, MD, PhD PII: S0190-9622(18)32034-6 DOI: 10.1016/j.jaad.2018.05.1237 Reference: YMJD 12564 To appear in: Journal of the American Academy of Dermatology Received Date: 2 March 2018 Revised Date: 25 May 2018 Accepted Date: 25 May 2018 Please cite this article as: Wambier CG, About melanocyte activation in idiopathic guttate hypomelanosis by 5-fluorouracil tattooing, Journal of the American Academy of Dermatology (2018), doi: 10.1016/ j.jaad.2018.05.1237. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
1 2 About melanocyte activation in idiopathic guttate hypomelanosis by 5-fluorouracil tattooing 3 Carlos Gustavo Wambier, MD, PhD, a 4 5 6 7 8 9 10 11 12 13 14 15 a- Department of Medicine, State University of Ponta Grossa, Ponta Grossa, Brazil Corresponding author / Reprint requests: Prof. Carlos Gustavo Wambier, MD, PhD, Adjunct Professor of Dermatology, Department of Medicine, State University of Ponta Grossa. Address: Bloco M - Campus UEPG Uvaranas. Av. General Carlos Cavalcanti, 4748, 84030-900. Ponta Grossa, PR, Brazil. Phone: +55-42-3220-3793. Email: cwambier@usp.br This article has no funding source. The authors have no conflict of interest to declare. Manuscript word count: 422 References: 3 Figures: 0
16 No abstract 17 18 Key words: idiopathic guttate hypomelanosis; 5-fluorouracil; drug delivery; tattoo equipment; melanocytes. 19 20 Abbreviations and acronym list: FU: fluorouracil
21 22 23 To the Editor: I read with interest Arbache et al. s preliminary results of repigmentation of idiopathic guttate hypomelanosis in eight patients by 5-fluorouracil (FU) tattooing in a randomized, saline controlled, split-body trial. 1 As an enthusiast of the innovative 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 technique of using professional tattoo machines as drug-delivery devices, 2,3 some comments are made necessary for better interpretation and reproduction of the trial. If the active drug is 5-FU, which was the origin and the concentration of 5-FU injectable solution used? After side randomization, which solution was performed first for each patient and were the needle cartridge and cup changed before starting the other side? Dilution of the 5-FU solution could occur if starting from the saline side, and cross-contamination of saline with 5-FU could occur if starting on the active drug side if performed with the same needles/cups. Curiously, three patients presented zero repigmentation in the saline side, two patients presented mild repigmentation (26.3-14.3%), but three patients presented high percentage of repigmentation (66.7-48.6%). Could the starting side explain these striking range of repigmentation results in the saline tattooing side? The article mentioned that two blinded dermatologists determined the limb with the best clinical outcome and that statistical analysis was performed by a photographic equipment software, however, the results only state 75.3% 5-FU repigmentation vs. 33.8% placebo, P<.001. Were these results from the clinical evaluation by the dermatologists (although their sum was over 100%) or were these results from repigmentation percentage derived from software inputs of colorimetry presented in the 42 43 44 45 graph in Fig. 2, G and H? Nevertheless, the median of the results presented in the graph would be 75.8% for 5-FU repigmentation and 20.3% for saline, and the means 75% for 5-FU and 26.9% for saline, which differ from the results presented. Which statistic test was used?
46 47 48 About the conflicts of interests declared, no specific potential conflict of interest was disclosed, despite the statement that Dr Arbache s commercial involvement in this investigation was required ( ). Do authors directly profit from sales of tattoo 49 50 51 52 53 54 55 56 machines, needle cartridges, drugs, or photographic equipment mentioned in the article? What is the relationship of the authors with Traderm? Is there any advantage for the dermatologic community to have tattoo machines and needles registered by trading companies as medical devices, since they have always been bought and used by lay art professionals? The active drugs and technique used are of primary importance: the difference between microneedling, ink tattooing, and drug tattooing. Finally, I hope that more attention is given by the dermatologic scientific community to the research of multiple applications of drug tattooing.
57 References: 58 59 1. Arbache S, Roth D, Steiner D, Breunig J, Michalany NS, Arbache ST, et al. Activation of melanocytes in idiopathic guttate hypomelanosis after 5-60 61 62 63 64 65 66 67 68 69 fluorouracil infusion using a tattoo machine: Preliminary analysis of a randomized, split-body, single blinded, placebo controlled clinical trial. J Am Acad Dermatol. 2018 Jan;78(1):212 5. 2. Wambier CG, Wambier SP de F, Pereira Soares MT, Breunig J, Cappel MA, Landau M. Therapeutic pearl: 5-fluorouracil tattoo for idiopathic guttate hypomelanosis. J Am Acad Dermatol. 2017 Nov 1;9. 3. Wambier C. Dermatologic treatments with microinfusion of drugs into the skin with tattoo equipment: teaser series (abstract). J Am Acad Dermatol. 2018;78:[Poster 7834].