Edgar B. Smith

Efficacy of topical isotretinoin 0.05% gel in acne vulgaris: Results of a multicenter, double-blind investigation

Two hundred sixty-eight patients with mild to moderate acne vulgaris completed a multicenter, double-blind, controlled study comparing isotretinoin 0.05% gel with its vehicle. Patients were treated twice daily for up to 14 weeks. Efficacy was measured by counting facial inflammatory and noninflammatory lesions and by grading acne severity initially and at 2- to 3-week intervals throughout the study. The isotretinoin 0.05% gel proved to be statistically more effective than vehicle in reducing inflammatory lesions after 5 weeks and in reducing noninflammatory lesions and acne severity grade after 8 weeks. Except for two patients who dropped out because of irritation, isotretinoin 0.05% gel was well tolerated.

Prurigo: A clinical review

Prurigo is a widely used dermatologic term without a precise definition. This may be because authors cannot yet agree as to whether the pruritic papule or nodule in the various forms of prurigo is a primary lesion or is a secondary lesion resulting from excoriation. An attempt will be made to review a working classification that incorporates many of the eponymal prurigos.

Treatment of necrolytic migratory erythema in glucagonoma syndrome

The glucagonoma syndrome is characterized by elevated serum glucagon, a pancreatic alpha-cell tumor, anemia, hypoaminoacidemia, and necrolytic migratory erythema. Necrolytic migratory erythema may cause marked morbidity and is frequently misdiagnosed. A 42-year-old white woman with a 1 1/2-year history of refractory dermatitis (most severe on the lower extremities) had the glucagonoma syndrome. Her severe morbidity was markedly relieved with the administration of intravenous amino acids. This therapy was successful in controlling the necrolytic migratory erythema through recurrences after somatostatin (SMS 201-995), surgical debulking, and chemotherapy proved inadequate.

Pharmacokinetics of three doses of once-weekly fluconazole (150, 300, and 450 mg) in distal subungual onychomycosis of the toenail

BACKGROUND Preliminary clinical data suggest that fluconazole is effective in the treatment of patients with onychomycosis. To design optimum dosage regimens, a better understanding of fluconazoles distribution into and elimination from nails is needed. OBJECTIVE The purpose of this study was to determine plasma and toenail concentrations of fluconazole. METHODS In this multicenter, randomized, double-blind investigation, fluconazole (150 mg, 300 mg, or 450 mg) or matching placebo was administered once a week for a maximum of 12 months to patients with onychomycosis of the toenail. A total of 151 subjects participated in the pharmacokinetic assessment. Blood samples and distal toenail clippings from both affected and healthy nails were obtained for fluconazole concentration determinations at baseline, at the 2-week visit, at each monthly visit until the end of treatment, and then at 2, 4, and 6 months (nail samples only at the latter two) after fluconazole was discontinued. RESULTS Fluconazole was detected in healthy and affected nails at the 2-week assessment in nearly all subjects. The median time to reach steady-state fluconazole concentrations in healthy nails was 4 to 5 months in the three fluconazole dose groups. In affected nails, steady-state fluconazole concentrations were achieved more slowly, with a median time of 6 to 7 months. At the 8-month assessment, affected toenail fluconazole concentrations were higher than corresponding plasma fluconazole concentrations, with ratios of 1.31 to 1.50 in the three active treatment groups. Toenail concentrations of fluconazole declined slowly after treatment was discontinued, with elimination half-lives of 2.5, 2.4, and 3.7 months for the 150, 300, and 450 mg doses, respectively. Measurable fluconazole concentrations were still present in toenails at 6 months after treatment in most subjects. CONCLUSION Fluconazole penetrates healthy and diseased nails rapidly, yielding detectable concentrations after two weekly doses. Once it penetrates nail, fluconazole persists for up to 6 months or longer after therapy is stopped. These favorable pharmacokinetic characteristics support a once-weekly fluconazole dosage regimen for the treatment of patients with onychomycosis.

Double-blind comparison of naftifine cream and clotrimazole/betamethasone dipropionate cream in the treatment of tinea pedis

chenoid infiltrate of lymphocytes. Immunofluorescence examination of a perivesicular papule was characterized by numerous ovoid bodies scattered in the papillary dermis. These stained for IgM, IgG, and fibrinogen. IgG, C3, and fibrinogen were also deposited linearly along the dermoepidermal junction. Immunofluorescence studies on normal-appearing skin showed a strong linear band of IgG and C3 at the dermoepidermal junction without staining of colloid bodies. Serum and blister fluid were positive at a titer of 1:80 for basement membrane zone (BMZ) antibodies. A diagnosis ofLPP was made. She was initially treated with prednisone, 40 mg daily (1.5 mg/kg/day), with a good response, no new vesicles appeared and the papular lesions cleared. After 2 weeks circulating BMZ antibodies decreased to a titer of 1:20. The dosage of prednisone was reduced to 20 mg daily for 14 days and then discontinued. Topical fluorinated corticoids were administered for an additional month. At that time she had resolution of all lesions. Two months later, she had a relapse of LP, without blistering, on both ankles. At the time of relapse circulating BMZ antibodies were absent.

Caripito itch: Dermatitis from contact with Hylesia moths

Caripito itch, a pruritic dermatosis rarely seen in the United States, is caused by contact with moths of the genus Hylesia--specifically, with urticating abdominal hairs of the adult female moth. The purpose of this study was to investigate an outbreak of Caripito itch that occurred in thirty-four of thirty-five crew members of a British oil tanker who were exposed to Hylesia moths at the port of Caripito, Venezuela. Methods of investigation included general history and physical examination of all crew members, complete inspection of the ship, transparent-tape slide preparations from involved skin, cutaneous histopathologic studies, and entomologic examination of the moths. The patients had a typical papulourticarial eruption, primarily on exposed surfaces. Although Hylesia moths do not occur in the United States, primary care physicians and dermatologists, especially those located in port cities, should be aware of cutaneous lepidopterism caused by Hylesia moths.

A clinical trial of topical terbinafine (a new allylamine antifungal) in the treatment of tinea pedis.

Twenty-three patients were enrolled in a randomized, double-blind trial of terbinafine 1% cream compared with placebo vehicle in the treatment of tinea pedis. Of the 20 patients who were evaluated for efficacy, 10 received terbinafine and 10 received placebo. Except for the terbinafine-treated patients being an average of 11 years older than the patients receiving placebo and the median duration of disease being 6 weeks longer in the placebo group, the two groups were demographically and clinically similar. Results of mycologic tests and clinical findings showed terbinafine to be significantly more effective than placebo in the treatment of tinea pedis. Significantly more terbinafine-treated patients than placebo-treated patients showed conversion to negative culture and microscopy at end of therapy and a significant reduction in scored signs and symptoms. Overall efficacy at follow-up (combined mycologic and clinical findings) was also significantly greater in the terbinafine group (78%) than in the placebo group (zero) (p less than 0.001). Unexplained elevation of liver function test results was noted in three placebo-treated patients and in one terbinafine-treated patient, but these changes were not considered clinically relevant or drug related.

Spreading pigmented actinic keratosis

We present four cases of spreading pigmented actinic keratoses, an only recently described pigmented lesion of sun-exposed areas, in which the histologic appearance is that of actinic keratosis with the additional feature of excessive melanin deposition in the lower epidermis and in the upper dermis. Clinically, it is a brown patch or plaque with a smooth surface, usually larger than 1 cm, that tends to spread centrifugally. Clinical differential diagnoses include seborrheic keratosis, melanocytic nevus, senile lentigo, lentigo maligna, and lentigo maligna melanoma. This pigmented lesion is probably much more common than the existing literature would indicate.

Erythrasma: Overlooked or Misdiagnosed?

When erythrasma was described over 100 years ago,’ little was known about the causative agent, and the disease was considered to be a fungal infection. The organism was originally called Microsporum minutissirnurn and has been known by various fungal and bacterial names. In 1961, when the organism was proved to be a gram-positive bacillus in the diphtheroid group, it was named Corynebacterium minutissimum.2 Since then, several studies on erythrasma have appeared in the English literature describing its incidence, bacteriology, and treatment, and the disease has finally been accepted as a bacterial infection. The organism, C. minutissimum, is a short grampositive rod with subterminal granules. It is best cultured in a medium containing 20% fetal bovine serum, 2% agar, and 78% tissue culture medium 199. Growth occurs within 12-24 hours as small, shiny, moist, translucent, greyish-white colonies that fluoresce various tones of coral red to orange under Wood’s light. The fluorescence of the colony persists for 2-4 days. The organism can also grow on blood agar and occasionally on other media, but the colonies may not fluoresce. There seems to be no doubt that this organism is a member of the normal skin flora. The conditions for multiplication of the organisms on the skin and tor subsequent clinical infection are unknown. Moisture, obesity, and diabetes are some ot the predisposing factors. The lesions of erythrasma are asymptomatic, welldefined patches ot irregular shape and size. At first the color i s red but later becomes brownish. The surfaces are rather smooth but tend to be finely scaly and wrinkled. The lesions are most commonly tound in the body folds, particularly the groin, axillary, intergluteal, and, in the female, the inframammary areas (Figs. 1, 2). Lesions in the toewebs are also trequent and show scaling, iissuring, and marceration. The generalized form, referred to

Eosinophilic pustular folliculitis

Sterile, pruritic papules and papulopustules that formed annular rings developed on the back of a 58-year-old woman. The individual lesions evidenced peripheral extension with central clearing and were characterized by exacerbations and partial remissions. The general health of the patient was good. Laboratory determinations showed moderate peripheral blood eosinophilia. Spongiosis with eosinophilic exocytosis, often localized to the hair follicles, was found on examination of histologic specimens. These findings led to a diagnosis of eosinophilic pustular folliculitis, a disease of unknown cause that has rarely been reported in the North American literature.