Danny Wolf

Vitamin E: the radical protector

Since its discovery and isolation the importance of vitamin E in maintaining normal physiologic processes and its value in treating various disease states have been the subject of much controversy. It was our intention to review and highlight some of the arguments and problems regarding the usefulness of vitamin E and to try to put them into proper perspective. The major area of interest concerning vitamin E lies essentially in its role in preventing damage caused by free radicals. The latter are now known to play an important role in radiation induced carcinogenesis, photoaging and photosensitization. The chemistry of vitamin E, its physiological function as a major antioxidant and its interaction with other antioxidants are described by the sum of animal studies, in vitro research and epidemiological investigations. In preparing the current data, it appeared that despite the controversy and conflicting results the body of literature as a whole judges vitamin E to be useful as an antioxidant. Although, in principle, the use of vitamin E can be quite advantageous, the manner of its administration, especially regarding topical application, remains unclear.

Antimalarials: unapproved uses or indications.

Antimalarial drugs (AMs) were developed primarily to treat malaria; however, they can be beneficial for many dermatological, immunological, and rheumatological diseases for which they are mostly used today. Chloroquine (CQ) and hydroxychloroquine (HCQ), two of the most fascinating drugs developed in the last 50 years, have been tried with various results in a wide variety of disorders. Of these many diseases only malaria, lupus erythematosus (different forms), and rheumatoid arthritis are FDA-approved and have FDA-labeled indications. Much work has been expended to study and analyze the beneficial effects of the AMs in dermatologic diseases, but there is still a lack of validated information and guidelines for the physician on precise indications, value, and efficacy for each specific disease of a given drug in terms of the dosage, treatment schedule, safety, cautions, monitoring protocol, and appropriate laboratory tests. All this is partly because the AMs are not licensed for many, perhaps most, of the dermatologic indications for which they are used in clinical practice. It is our intention to gather, critically review, and organize the relevant information from the voluminous literature concerning the use of AMs in various nonineffective skin diseases. This review is an attempt to create a systematic and practical reference source for the many dermatologists who have to prescribe these medications for FDA-unapproved indications for their patients, and for the benefit of those patients who need and deserve the treatment.

Soaps, shampoos, and detergents

In clinical dermatology, few questions are asked more commonly than “What is the best way for me to clean my skin or hair?” The modern dermatologist needs to be familiar with the physiologic action of cleansing products available on the market. This familiarity should include chemical composition, application, cosmetic benefits, and safety, as well as potential hazards. This knowledge must be acquired from objective, independent, peer-reviewed scientific literature, and not from promotional sheets or biased, pseudoscientific articles that are distributed in great quantity by the cosmetic companies, which have heavily vested commercial interests. It is our hope that this chapter will be such an objective and evenhanded source of information for guiding practicing dermatologists.

Norwegian-type scabies mimicking contact dermatitis in an immunosuppressed patient.

Patients taking immunosuppressive drugs are susceptible to various forms of infection, including dermatologic disease. Recently, atypical manifestations of scabies have been reported in such patients. In the case reported here, a 26-year-old woman who had had a renal transplant and was taking immunosuppressive drugs had a pruritic rash on the back that closely resembled contact dermatitis. However, skin scrapings from the involved areas and punch biopsy specimen of the back showed live scabies mites. The pruritus was relieved and the skin lesions disappeared within ten days of treatment with scabicides. We believe that current widespread use of immunosuppressive agents may result in more cases of atypical forms of scabies. Therefore, physicians who deal with immunosuppressed patients should be aware of this possibility.

The benefits of smoking in skin diseases

Cigarette smoking is now the chief avoidable cause of illness and death in the Western world, responsible for one of every five deaths each year. In contrast to its many adverse effects, cigarette smoking might actually be of some benefit in certain diseases. Although the hazards of cigarette smoking in various organ systems have been extensively studied for the past 20 years, the beneficial effects of this habit have received little attention. This is clearly reflected throughout this special issue of Clinics in Dermatology, in which all the chapters are devoted to the adverse effects of smoking in contrast to our lone chapter on its possible beneficial effects. There seems to be a kind of wistfulness to hear something good on smoking, not only on the part of smokers who are under constant pressure to give up their habit, but also on the part of scientists and researchers who are interested in the topic. Revealing the beneficial effects of smoking is not intended to encourage people to smoke or to release them from any pressures to discontinue their habit. Rather, knowledge of the positive effects of smoking on skin diseases is important not only because it might unlock the door to a better understanding of their causes and pathogenesis, but it might also lead to a better understanding of all the effects of smoking, both the good and the bad. Although some of the beneficial effects of smoking have been mentioned in various chapters of this issue of Clinics, concentrating them in a single chapter will provide a more composite picture of what is involved. Moreover, a discussion of the ill effects of smoking would be both incomplete and unbalanced without an attempt to present the other side of the coin, even though, in light of the facts, this will not be a simple undertaking.

Metasma: a mask of stress

We wish to present a concise method of detecting coexisting ACA in sera identified positive for Topo I by ID. We observed that Topo-I antigens could be extracted by treatment with 0-1 N HCl for JO min at room temperature, while centromere antigens were resistant to this treatment. Therefore. ACA which was masked by Topo I could be detected after treatment DfHEp-2 cells with HCl. Using both untreated HEp-2 cells and HCl-treated HEp-2 cells, we screened 47different sera found positive for Topo-I by the ID method. Only one serum produced both the Hne speckled stainings for Topo I and the discrete speckled stainings for ACA on untreated HEp-2 cells. When HCI-treated HEp-2 ceils were used as the substrate, this serum clearly showed the typical staining for ACA on mitotic cells. Of the 47 sera, only one was positive for ACA on HCI-treated HEp-2 cells. Our study indicates that ACA and Topo I are mutually exclusive in Japanese patients with SSc. although they may rarely coexist in low titres. The use of HCI-treated HEp-2 cells provides a concise method for screening the coexistence of hoth antibodies.

Focal nodular hyperplasia of the liver after intraconazole treatment.

A 38-year-old woman developed focal nodular hyperplasia of the liver after she had received a 4-month treatment with intraconazole 200 mg/d for a fungal infection of her fingernails. Because the patient underwent yearly liver ultrasound examinations because of the removal of a breast carcinoma, when the tumor was discovered incidentally, it was clear that it had developed within the past year after she had begun receiving intraconazole. Although various chemical agents and drugs have been considered as possible etiologic factors in the development of focal nodular hyperplasia of the liver, cases occurring after intraconazole therapy have not been reported before. Apart from the theoretical considerations with regard to the pathogenesis of nodular hyperplasia of the liver, this case could gain practical importance, as it shows a new adverse effect of a drug that has been used in more than 34 million patients over the past 10 years. Furthermore, this case should draw attention to the possibility of drug-induced benign hepatic tumors, as they may mimic malignant and metastatic disorders, which might be especially alarming in patients undergoing routine examinations after removal of malignant tumors, such as our patient.

Pityriasis rosea and Ketotifen

A 4-year-old female patient who developed a skin eruption similar to pityriasis rosea after treatment with ketotifen (Zaditen) is presented. The relationship between ketotifen and the eruption has been based on circumstantial evidence and confirmed by the positive results of the MIF test and the rat mast cell degranulation test.

Bleomycin-induced flagellate dermatitis.

A 30-year-old, generally healthy male underwent combination chemotherapy following orchidectomy for a mixed germ cell tumor of the right testis with metastases to the lungs, liver, and inguinal lymph nodes. According to the bleomycin, etoposide, and cisplatin (BEP) protocol, each three-week cycle of chemotherapy included bleomycin 30 mg on days 1, 8, and 15, and etoposide 150 mg and cisplatin 30 mg on days 1–5, with no intervals between each cycle. Several days after starting the second chemotherapeutic cycle (four weeks after treatment began), the subject developed erythematous and edematous linear lesions (‘‘flagellate dermatitis’’) on his forehead, upper chest (Fig. 1), abdomen, and upper and lower limbs

Cosmetics and contact dermatitis

Modern cosmetic and skin care products are safe for most users and adverse reactions to them are very rare considering the number of people in contact with numerous products over a lifetime of use. Improvements in safety, tolerance, and skin compatibility will not prevent cosmetic product side effects from increasing in the future because of the continuing goals of intensifying their biological activity and therapeutic efficacy. Therefore, now more than ever, dermatologists should be familiar with all possible untoward reactions to cosmetics. Adverse reactions include an extreme variant of sensitive skin, called “cosmetic intolerance syndrome,” describing individuals who are no longer able to tolerate a wide range of cosmetic products. “True” allergic reactions to cosmetics occur much less commonly than irritant reactions. These are of great importance to the dermatologist because they are more serious, more difficult to treat, and require absolute abstention from the causative agent. Eczematous, damaged skin is especially prone to develop allergies.