Aditya K. Gupta

Antifungal agents: An overview. Part II

The recent introduction of a new generation of antifungal drugs promises to alter significantly therapy for both systemic and superficial mycoses, in particular, onychomycosis. This article presents an in-depth review of the azoles (the triazoles itraconazole and fluconazole), the allylamines (naftifine and terbinafine), and the morpholine derivative amorolfine.

A 40-100 MHz B-SCAN ULTRASOUND BACKSCATTER MICROSCOPE FOR SKIN IMAGING

There is a growing interest in high resolution, subsurface imaging of cutaneous tissues using higher frequency ultrasound, and several commercial systems have been developed recently which operate at 20 MHz. Some of the possible applications of higher frequency skin imaging include tumour staging, boundary definition, and studies of the response of tumours to therapy, investigations of inflammatory skin conditions such as psoriasis and eczema, and basic studies of skin aging, sun damage and the effects of irritants. Investigation of these areas is quite new, and the role of ultrasound skin imaging is continuing to evolve. Lateral resolution in the 20 MHz imaging systems ranges from 200 to 300 microns, which limits imaging applications to cutaneous structures which are relatively large in size. In this paper, a real-time ultrasound backscatter microscope (UBM) for skin imaging is described which operates in the 40-100 MHz range, providing axial resolution between 17 and 30 microns and lateral resolution between 33 and 94 microns. This improvement in resolution over current skin ultrasound systems should prove useful in determining the margins of small skin lesions, and in obtaining more precise, in vivo skin thickness measurements to characterize nonmalignant skin disease. Example images of normal skin, seborrhoeic keratosis and malignant melanoma illustrate the imaging potential of this system.

Lithium therapy associated with hidradenitis suppurativa : case report and a review of the dermatologic side effects of lithium

Lithium is frequently used in the management of several psychiatric disorders including acute mania, bipolar (manic-depressive) disorder, and recurrent depression. We describe a patient in whom hidradenitis suppurativa developed while the patient was receiving lithium. The cutaneous side effects of lithium are reviewed. The most frequent are psoriasis, acneiform lesions, folliculitis, alopecia, and a maculopapular/macular eruption. Many of these side effects respond less readily to conventional therapy while the patient is receiving lithium.

The spectrum of cutaneous reactions associated with diltiazem: Three cases and a review of the literature ☆ ☆☆

BACKGROUNDnCutaneous reactions ranging from exanthems to severe adverse events have been reported in association with calcium channel blockers.nnnOBJECTIVEnOur purpose was to document cutaneous eruptions resulting from use of diltiazem.nnnMETHODSnWe describe three patients who experienced a cutaneous reaction (i.e., hypersensitivity syndrome reaction, pruritic exanthematous eruption, and acute generalized exanthematous pustulosis) possibly induced by diltiazem, summarize adverse reaction reports obtained from the Health Protection Branch, and review the literature on calcium channel blockers inducing cutaneous reactions.nnnRESULTSnOf the 315 cases of possible diltiazem-induced adverse reactions that were reported to the Health Protection Branch, 151 (48%) were cutaneous. The number of diltiazem-induced cutaneous events was significantly greater than those induced by either nifedipine or verapamil. However, no difference was found in the proportion of serious cutaneous adverse events to either of the three drugs.nnnCONCLUSIONnDiltiazem has been associated with a variety of cutaneous reactions that appear to occur more frequently than with other calcium channel blockers.

Hypersensitivity reaction to terbinafine

3. TomsickRS.Thephenytoinsyndrome.Cutis 1983;32:53541. 4. Stanley J, Fallon-Pellicci V. Phenytoin hypersensitivity reaction. Arch Dermatol 1978;114:1350-3. 5. Parker WA, Shearer CA. Phenytoin hepatotoxicity: a case report and review. Neurology 1979;29:175-8. 6. McCarthy 1_2, Aguilar JC, Ransburg R. Fatal benign phenytoin lymphadenopathy. Arch Intem Med 1979; 139:367-8. 7. Hoffman EW. Phenytoin-induced interstitial nephritis. South Med J 1981;74:1160-1. 8. Josephs SH, Rothman SJ, Buckley RH. Phenytoin hypersensitivity. J Allergy (]fin Immunol 1980;66:166-72. 9. Dichter MA, Brodie MJ. New antiepileptic drugs. N Engl J Med 1996;334:1583-90. 10. Braddock SW, Harrington D, Vose J. Generalized nodular cutaneous pseudolymphoma associated with phenytoin therapy: use of T-cell receptor gene rearrangement in diagnosis and clinical review of cutaneous reactions to phenytoin. J Am mcad Dermatol 1992;27;337-40.

Psoriatic Nail Disease: Quality of Life and Treatment:

Nail psoriasis is common among patients with plaque psoriasis or psoriatic arthritis and has a detrimental effect on quality of life. However, there are currently no standardized therapeutic regimens for nail psoriasis. Traditional treatments for nail psoriasis, which include topical, intralesional, and oral therapies, may be time-consuming, painful, or unsafe when administered long term. Biologic therapies have demonstrated efficacy for plaque psoriasis and psoriatic arthritis; these therapies may be particularly promising for the treatment of nail psoriasis as both groups of patients have an elevated incidence of nail dystrophy. The biologic therapies adalimumab, alefacept, efalizumab, etanercept, and infliximab have demonstrated clinically important nail psoriasis improvements using the Nail Psoriasis Severity Index, a helpful tool that, upon validation, will allow comparison across treatments and trials. Large-scale, long-term trials using standardized outcome measures are needed to further evaluate biologic therapies for the treatment of nail psoriasis.

Clinical and Economic Factors in the Treatment of Onychomycosis

SummaryOnychomycosis is a fungal infection of fingernails and toenails. most cases of which are caused by dermatophytes. The disease accounts for l5% of all nail disease. and affects approximately 2 to 3% of people of all ages and both sexes.Topical treatment with tioconazole. amorolfine or ciclopirox has limited effectiveness. Oral griseofulvin 500 to 1000mg daily has been the mainstay of treatment. but prolonged therapy is required and success rates are low. Therapy with itraconazole 200mg daily for 3 to 6 months is more effective (70 to 85% success), although so—called ‘pulse’ therapy has shown similar success with potentially fewer adverse effects. Terbinafine 250mg daily produces clinical and mycological cure in approximately 80% of patients treated for 6 and 12 weeks for fingernail and toenail infections, respectively.The overall costs of treating onychomycosis are substantial, and it has been estimated that direct costs for Medicare patients with the disease were

BETAMETHASONE DIPROPIONATE POLYACRYLIC FILM-EORMING LOTION IN THE TREATMENT OF HAND DERMATITIS

US43 million in 1 year. In addition, the disease has a negative impact on quality of life, in the domains of mental functioning, health concern, social functioning and physical appearance. Few pharmacoeconomic analyses have been published, but all have indicated an advantage of oral terbinafine over griseofulvin and other oral agents. To date, no economic studies have been performed on topical agents. pulse therapy or combination treatments.

EPIDERMOLYSIS BULLOSA ACQUISITA WITH EEATURES OF BULLOUS LUPUS ERYTHEMATOSUS

The treatment of hand dermatitis is often limited by patients continued exposure to triggering factors.1 The use of a corticosteroid in a polyacrylic film‐forming vehicle, which forms a relatively impermeable film when applied to the skin, may offer an advantage over traditional steroid lotions by affording protection against irritants while allowing patients to perform routine activities using bare hands. Fifty‐eight (58) men and women ages 18–70 years participated in a 7‐day, double‐blind, randomized, positive controlled study to compare the effectiveness of these two vehicles in the treatment of eczematous hand dermatitis.

Dermatophytosis (Tinea) and Other Superficial Fungal Infections

A 30-year-old woman of Jamaican origin was referred for evaluation of a pruritic blistering disorder of two weeks duration. It began as erosions in her mouth, with subsequent spread of pruritic vesicles to the trunk and limbs. She had been previously admitted for 1 week to a local hospital and treated with prednisone, 35 mg daily, tapered by 5 mg every second day. Within two days of her discharge, new lesions again appeared and her prednisone was increased to 35 mg daily. The patient had otherwise been well with no previous hospital admissions, skin disease, arthritis, photosensitivity, psychiatric illnesses, dry eyes or mouth, or Raynauds disease. There was no family history of bullous or autoimmune disease. On examination, she was afebrile and her oral mucosa was clear. She had multiple 1-5 mm tense clear vesicles in groups on her neck, axillae, and under her breasts. There were scattered vesicles and erosions on her anterior chest, back, dorsal arms, and anterior thighs. Nikolskys sign was negative. The remainder of the physical examination was unremarkable. Laboratory investigations revealed a macrocytic anemia with hemoglobin of 110 g/L (normal 120-160), Increased mean corpuscular hemoglobin (MCH) 34 pg/L (normal 27-32), normal vitamin B12, folate, and ferritin levels, a white blood count of 4x10VL (normal 4-11) with a normal differential count and platelets. Sickle cell screen was positive. Electrolytes, blood urea, creatinine, fasting blood sugar, liver profile, G6PD, chest x-ray, and urinalysis were normal. Antinuclear antibodies were present at a titer of 1:40 and, 1 week later, at a titer of >1.320 with an atypical speckled pattern, with positive anti-Ro antibodies, negative anti-La antibodies, normal C3 and C4 levels, and increased CH50 135 u/mL (normal 18-60). Throat cultures were negative. Histologically, there was a subepidermal bulla with neutrophils lined up along the dermoepidermal junction and also forming focal collections in the dermal papillae (Figs. 1 and 2). Electron microscopy initially showed a necrotic epidermis with evidence of epidermal regeneration underneath the bulla. Studies repeated 3 weeks later showed a bulla forming below the lamina densa with the presence of