Jere D. Guin

Double-blind treatment of seborrheic dermatitis with 2% ketoconazole cream

Thirty-seven patients with seborrheic dermatitis were treated topically with a 2% ketoconazole cream or its vehicle control in a double-blind study. The subjects were studied for numbers of Malassezia ovalis (Pityrosporum ovale) cells in their scalp scale; changes in numbers of yeast cells and morphology of M. ovalis were tabulated along with clinical assessment of improvement. The 2% ketoconazole cream, but not the placebo cream, reduced the numbers of viable yeast cells on the scalp. The clinical effect of 2% ketoconazole cream was good (75%-95% improvement) or better in eighteen of twenty subjects; the placebo cream produced good results in only three of seventeen subjects treated. Results of this study are consistent with the view that M. ovalis plays a central role in the pathogenesis of seborrheic dermatitis.

Contact sensitization to cyanoacrylate adhesive as a cause of severe onychodystrophy

BackgroundThe technology used for artificial nails, the chemistry of cyanoacrylates and the reported reactions to these products are briefly reviewed.

Contact sensitivity to topical corticosteroids

Five cases of contact sensitivity to topical corticosteroids are described. Two of the five patients presented with chronic hand eczema that was nonresponsive to topical steroid therapy. The others had eruptions suggestive of contact dermatitis. One patient was allergic only to amcinonide , while the other reacted to multiple corticosteroids. Two of them were also sensitive to ethylenediamine. The level of sensitivity can be mild or severe, and some with mild patch test responses are allergic to multiple corticosteroids. These patients often have a history of chronic eczema, e.g., stasis dermatitis, and the presenting complaint ranges from a failure to heal to obvious contact dermatitis. Cross-reactions occur not infrequently (based on similarities in the structure of either the corticosteroid or the ester), but these patterns are probably not sufficiently reliable to use clinically without patch test confirmation. The only treatment required is removal from the offending agent(s) and substitution of a product that does not elicit a reaction on patch testing. The findings in ninety-five other case reports are reviewed, and a practical method for patch testing to these agents is presented.

Eyelid dermatitis: A report of 215 patients

Between April 2001 and October 2003, 215 persons presented with eyelid dermatitis for the first time. They ranged in age from 4 months to 95 years, with an average age of 49.6 years and a median age of 51 years. There were 173 females and 42 males. 165 of 215 had allergic contact dermatitis (ACD) and another 9 had protein contact dermatitis without relevant positive patch tests. Atopic eczema comprised 37 of 215 (17%), but 33 of 37 also had contact allergies. Seborrheic dermatitis, psoriasis or both were found in 35 (16%). Sources of ACD included personal care products in 54 (25%), including 12 with at least 1 positive patch test to cosmetic applicators and 12 sensitive to at least 1 botanical ingredient. Allergy to artificial nails and/or nail lacquer occurred in 18 of 215 (8%). 5 persons had rosacea or periorbital dermatitis, and 2 had dermatomyositis. Other causes included bacterial, fungal and viral infections, some of which were quite unusual. The evaluation of persons presenting with eyelid dermatitis remains a relatively complex but rewarding discipline.

Pathogenesis of onychoschizia (lamellar dystrophy)

Onychoschizia or lamellar dystrophy of the nails is common, especially in adult women, but little information is available about its cause. Most theories involve environmental factors, but supportive experimental data are scarce. Therefore we studied the in vitro nail changes produced by several organic solvents, detergents, water, other polar materials, and both acidic and basic solutions. Challenged and control fingernail clippings were examined grossly, microscopically, and by scanning electron microscopy at regular intervals. There was a progressive increase in severity with prolonged wetting and drying. By 3 weeks, scanning electron microscopy demonstrated unattached individual cells in empty spaces in which separation was more prominent. Basic solutions caused some softening, but layering (peeling) was seen only after repeated hydration and dehydration. Although other factors may influence onychoschizia, the typical changes can be produced in normal nails after a 21-day challenge of repeated exposure to water followed by dehydration. These findings suggest a probable cause for the condition and a logical approach to management.

The tanning salon: An area survey of equipment, procedures, and practices

Because so little data are available on practices and procedures used by tanning salons, we studied, as customers, salons in a major city in Arkansas, the state where the practice began. We measured both ultraviolet A (UVA) and ultraviolet B (UVB) output at multiple reference points and found UVB always to be present, but at lower-than-expected levels. The highest irradiance was always at the umbilicus and the lowest was on the face. We evaluated compliance with accepted safety principles and federal guidelines and regulations; too often we found no eye protection and sometimes we found inadequate limits of exposure time. Persons with skin types I and II were sometimes promised a safe, effective UVA tan that would protect against sunburn. From our experience we concluded that if the industry is to continue, there is need for closer supervision and regulation.

Complications of topical hydrocortisone

Chronic and uninterrupted application of 1% hydrocortisone was followed by complications in six patients. Three developed a rosacea-like eruption for the first time and one also had perioral dermatitis. All of these responded to treatment and remained clear. Another patient had a severe exacerbation of rosacea following use and withdrawal of 1% hydrocortisone cream. Two female adults developed atrophy and telangiectasia of the eyelids following long-term application of 1% hydrocortisone cream. The severity of the complications reported was generally less than that found following use of more potent topical corticosteroids. However, the complications experienced by these patients would suggest that therapy with any effective topical corticosteroid should be intermittent. Particular care should be used in susceptible individuals and in vulnerable areas such as the eyelids.

Wandering fixed drug eruption: A mucocutaneous reaction to acetaminophen

Two patients are presented with a fixed drug eruption to acetaminophen characterized by recurring erythematous, circular plaques of the skin and oral mucosa along with multiple sites of deep (postinflammatory) hyperpigmentation clinically characteristic of fixed drug eruption. The involved sites did not necessarily flare with each exposure, nor did activity always appear in the same sites with each flare. Eventually some sites apparently became completely refractory. This caused the eruption to seem to wander. Patch testing with 1% acetaminophen in alcohol (300 mg/30 ml alcohol) confirmed the causative agent in one patient. Although patch testing was negative in the other patient, oral reexposure caused a flare. Acetaminophen appears to be an uncommon cause of fixed drug eruption, with a tendency for lesions to appear at the same or at different sites in flares, perhaps because of a prolonged refractory period and the tendency to become completely refractory in some locations.

The effect of quenching agents on contact urticaria caused by cinnamic aldehyde

Inhibition (quenching) of contact sensitization by cinnamic aldehyde (CA) reportedly occurs from eugenol (E) and d-limonene (d-L). Experimentally the former inhibited nonimmunologic contact urticaria (NICU) from CA in seven of eleven test subjects, which prompted a search for possible mechanisms, including chemical interaction, altered absorption, and anti-inflammatory activity, and competitive inhibition. Mixtures of CA and E and CA and d-L showed no chemical changes or intermolecular bonding. Absorption was not increased by cellophane tape stripping, and neither E nor d-L inhibited urticaria formation following stimulation of skin of five subjects with dermographism. Competitive inhibition at the receptor level may best explain the quenching phenomenon observed. Additional factors are presented that complicate the already numerous caveats in interpreting test results in NICU.

Perfume sensitivity in adult females: A study of contact sensitivity to a perfume mix in two groups of student nurses

The incidence of contact sensitivity to a perfume mix was investigated in two groups of student nurses by questionnaire and patch testing. Twenty-nine of ninety gave a history of dermatitis on exposure to fragrances or perfumed cosmetics. Fifteen of eighty-five showed a positive patch test reaction to a perfume mix comprising 2% concentrations of eight different perfume ingredients, and twelve of the fifteen had a positive history. Chi-square analysis of the data indicates that the results of the two methods of measurements are significantly related (p < 0.0001).