Larry E. Millikan

Multiple glomus tumors

894 Glomus tumors (GLTs) or glomus gliomas are benign tumors which often appear as bluish nodules. In our clinic, we have seen a 16-year-old man who had a total of nine bluish soft nodules on his trunk and arms, which, on biopsy, were shown to be GLTs (Figs 1-2). The lesions ranged from 0.2 to 0.6 cm in diameter with the largest ones being somewhat painful. His family history was significant for a younger sister who had seizures secondary to an arteriovenous malformation, but no GLTs. The patients computed tomography (CT) scan of the head was negative for any vascular abnormalities. This patients presentation stimulated us to review the current literature on multiple GLTs and to present a survey of the various cases listed in the literature. •! ; v ,• • 1

Naftifine cream 1% versus econazole cream 1% in the treatment of tinea cruris and tinea corporis

Data from 104 subjects with tinea cruris or tinea corporis were evaluated in this double-blind, randomized study. The subjects applied naftifine cream 1% or econazole nitrate cream 1% to affected areas twice daily for 4 weeks. After 1 week of treatment naftifine had an overall cure rate of 19% compared with 4% for econazole (p = 0.03). A difference in favor of naftifine, although not statistically significant after the first week, persisted throughout treatment. Two weeks after the end of treatment both medications had overall cure rates of approximately 80%. Three percent of the naftifine-treated subjects had side effects compared with 13% of the econazole-treated subjects. In two subjects using econazole, the side effects were severe enough to warrant discontinuation of treatment.

Efficacy and tolerability of topical terbinafine in the treatment of tinea cruris

Thirty men with clinical and mycologic evidence of tinea cruris were enrolled in a controlled, randomized, double-blind trial comparing terbinafine 1% cream and its cream vehicle as placebo. Patients applied the test medications to the affected area twice daily for 2 weeks. Therapeutic response was evaluable in 18 patients after each week of treatment and at a follow-up visit 2 weeks after therapy ended. At each visit, terbinafine was found to be more effective than the cream vehicle in the reduction of the signs and symptoms of infection and in the conversion of culture and microscopy findings to negative or normal. At the end of treatment, therapy was effective in 67% of the nine terbinafine-treated patients compared with only 11% of the nine placebo-treated patients. At the follow-up examination, efficacy rates were 78% in the terbinafine treatment group and 33% in the placebo group--a difference of borderline statistical significance (p = 0.077). Possible reasons for this result may include the higher incidence of chronic disease in the terbinafine group and the large number of patients who were classified as delayed exclusions because of negative initial culture for dermatophytes. No side effects or significant alterations in laboratory or hematologic tests were observed in either treatment group.

Comparison of once- and twice-daily naftifine cream regimens with twice-daily clotrimazole in the treatment of tinea pedis

1. Steere AC, Malawista SE, Bartcnhagen NR, et al. The clinical spectrum and treatment of Lyme disease. Yale J Bioi Med 1984;57:453-61. 2. Berger BW. Erythema chronicum migrans of Lyme disease. Arch DermatoI1984;120:1017-21. 3. Kramer N, Rickert RR, Brodkin RH, et al. Septal panniculitis as a manifestation of Lyme disease. Am J Med 1986; 81:149-52. 4. Eichenfield AR, Goldsmith DP, Benach JL, et al. Childhood Lyme arthritis: experience in endemic area. J Pediatr 1986;109:753-8. 5. Russell H, Sampson JS, Schmid GP, et al. Enzyme-linked immunosorbent assay and indirect immunofluorescence assay for Lyme disease. ] Infect Dis 1984;149:465-70. 6. Duffy J, Mertz LE, Wobig GH, et al. Diagnosing Lyme disease: the contribution of serologic testing. Mayo Clin Proc 1988;63: 1116-21. 7. Gammon WR. Urticarial vasculitis. Dermatol Clin 1985; 3:97-105. 8. Monroe EW, Schulz CI, Maize JC, et al. Vasculitis in chronic urticaria: an immunopathologic study. J Invest DcrmatoI1981;76:103-7. 9. Midgard R, Hofstad R. Unusual manifestations of nervous system Borrelia burgdorferi infection. Arch Neurol J987; 44:781-3. 10. Camponovo F, Meier C. Neuropathy of vasculitic origin in a case of Garin-Boujadoux-Bannwarth syndrome with positive Borrelia antibody response. J Ncurol 1986;233: 69-72.

Infectious etiologies of cutaneous vasculitis

Vasculitis remains an enigma for most physicians in practice. Because it is, by definition, a secondary phenomenon and not a disease suis generis, symptomatic treatment remains the primary goal until we come to the point where we are more likely to pick up probable etiologies and treat accordingly. The case presented here provides a good example of the direction we are going in our understanding of the infectious causes of vasculitis.

Unapproved treatments or indications in dermatology: physical therapy including balneotherapy

More than a decade ago, the author was the AAD representative and liaison with the U.S. Food and Drug Administration (FDA), beginning the new approach to “orphan” drugs and orphan diseases. This was precipitated by the need for an organized study on the efficacy of Dilantin in the various forms of epidermolysis bullosa. At the time, in meeting with the FDA, it was very obvious that, in dermatology, more than two-thirds of treatment regimens and medications used were for diseases and conditions that did not have specific FDA approval. Perhaps in dermatology more than any other specialty, the large number of unapproved usages of both drugs and modalities is the greatest. Several of the specific areas that this involves are listed in the following sections, covering balneology, spas, and physical therapies.

History of Iatrogenic Disease

Perhaps the earliest association of iatrogenics relates to toxicity of the many remedies. Here, primum non nocere (“do no harm”) was not the norm. Many of the early physical modalities—leeches, bleeding, heat, water therapy—all had toxic side effects. Overuse of spas, excessive mineral concentrations, and related treatments also created problems in the nineteenth century. Hunter, in his lectures, graphically documents the complications of therapy for this portion of dermatology and syphilology.1 The complications of physical treatment of the strictures, fistula formation, the use of bougies forming new urethral openings, all are directly related to medical surgical intervention. Injections or systemic therapy for the various venereal diseases had many long-term side effects. Mercury was foremost among them, and Hunter, in his usual style, applied mercury on his skin and noted the mucous membrane side effects with severe oral symptoms that were commonly noted in patients treated with mercurial ointments for their chancres. Perhaps in some of these patients the evolution of acrodynia occurred. It is of interest that in his lectures Hunter has a section (p. 119) on “operations of mercury on the virus.” William Heberden, M.D. (in his commentaries, The History and Cure of Diseases)2 compares his thoughts and concerns with those of Hunter. He documents the widespread use of mercury, the dysgeusia associated and the problems with decreased appetite, wasting, erythema, and acrodynia. His recommended treatment is shown in Table 1. This was said to be beneficial for the problems of acrodynia. The development in the understanding of acrodynia was further documented by Kaposi in his book Pathology and Treatment of Diseases of the Skin.3 Acrodynia was noted by Alibert, with the epidermal symptoms in 1828. In 1829 and 1830, further added symptoms included erythema, vesicles, a pellagra-like picture, progressing to gangrene and “tingling” of the peripheral nervous system. At that time acrodynia was assumed to be analogous to pellagra, a similarly poorly understood syndrome. This was a time of increased use of various serums, both animal and human, progressing to the problem of serum sickness, which became well documented in the nineteenth century. The urticaria component of serum sickness was well known, and it was attributed often in Kaposi’s work to food, berries, and seafoods such as saltwater fish and lobsters. The medications associated with urticaria were quinine, copaiba, and mineral water. The problem of urticaria, documented at the close of the nineteenth century, remains a serious medical syndrome to this day. Other heavy metals were used prior to the advent of antibiotics, along with their concomitant side effects, which could be considered either as toxic reactions or iatrogenic disease. Many of these remedies had a very low therapeutic ratio, thereby greatly increasing the possibility of toxic side effects. At the turn of the twentieth century, Darier’s treatise4 focused on the similar problem of sorting out the disease “de novo” versus toxicities and drug-induced diseases from many treatment modalities. Darier attempted to organize these toxicodermas into internal and external causes, thus helping to broaden the understanding of drugs and disease. In Darier’s approach to toxicodermas, he considered external causes as the most common; this was because there were few systemic medications for skin disease at the time. The medicinal and counter-irritant approach to many skin diseases resulted in many clinical problems, including induced maceration from soaks, with secondary infection; toxic reactions to the antiseptics, such as boric acid, other borates and carbolic acid; and skin changes related to formol and other formalin derivatives. Salol, which is a carbolic salicylic acid combiFrom Department of Dermatology, Tulane University Medical Center, New Orleans, Louisiana. Address correspondence to Dr. L. E. Millikan, Dept. of Dermatology SL73, Tulane University Medical Center, 1430 Tulane Ave., New Orleans, LA 70112-2699. Table 1. Early Therapy for Iatrogenic Skin Disease