Marcia S. Driscoll

Delusional parasitosis: A dermatologic, psychiatric, and pharmacologic approach

Delusional parasitosis is a syndrome in which the patient has the false belief that he is infested by parasites. Although this is a psychiatric disorder, patients usually seek care from dermatologists. DP has various causes. It may occur as the sole psychologic disturbance, or it may be associated with an underlying psychiatric disorder or physical illness. A dermatology-psychiatry liaison is advocated for establishing a viable differential diagnosis and selecting appropriate therapy. The antipsychotic agent pimozide is currently the most effective treatment when DP occurs as an encapsulated delusion. Pimozide therapy requires careful monitoring because this drug has several potentially serious adverse effects, and relapse often occurs on discontinuation of the drug.

Melanoma epidemic: Facts and controversies

The presence of a true melanoma epidemic has been a controversial topic for the past decade. A dramatic increase in the incidence of cutaneous malignant melanoma in developed countries is well documented, but mortality rates have not risen as rapidly. This has generated much discussion about whether there is a true increase in disease, or more of an apparent phenomenon that may be explained by multiple biases and other factors. The increase in incidence may be due to aggressive surveillance with increased detection of melanomas that are histologically worrisome but biologically benign. This argument, however, does not account for increased incidence of both thin and thicker melanomas. The controversy lies in the interpretation of these facts. This contribution reviews epidemiologic studies from the United States and worldwide to summarize the arguments for and against the debate about whether a melanoma epidemic exists.

Do hormones influence melanoma? Facts and controversies.

The issue of whether hormones influence malignant melanoma (MM) has been controversial for many years. Although early case reports demonstrated a negative effect of hormones, recent evidence has not supported a potential role for hormones in MM. We address whether exogenous and endogenous hormones influence a womans risk for MM or affect her prognosis if diagnosed with MM. Multiple epidemiologic studies show the use of oral contraceptives or hormone replacement therapy does not appear to increase a womans risk for MM. Pregnancy does not appear to influence a womans risk of MM, nor does pregnancy appear to affect prognosis in the woman diagnosed with MM. When counseling the woman who is diagnosed with MM during pregnancy or during the childbearing years, future use of oral contraceptives or hormone replacement therapy is not contraindicated; counseling concerning future pregnancies should be done on a case-by-case basis, with emphasis placed on established prognostic factors for MM.

Does pregnancy influence the prognosis of malignant melanoma

The effect of pregnancy on the clinical course of malignant melanoma (MM) is unclear. Early clinical and laboratory evidence suggested a relation between hormones and MM and subsequently between pregnancy and MM. We reviewed the literature on MM and pregnancy to address three questions: What is the effect on prognosis if an MM is diagnosed during pregnancy? What is the effect of previous pregnancies on the prognosis of MM? What effect does a subsequent pregnancy have on the prognosis of MM? On the basis of a limited number of controlled studies, it does not appear that being pregnant before, after, or at the time of diagnosis of stage I MM influences the 5-year survival rate. However, caution in interpreting these data must be taken because it is possible that the duration of follow-up and size of the study populations are not sufficient to observe a true effect.

Melanoma in pregnancy.

Since the early 1950s clinicians have been concerned about the impact of pregnancy on malignant melanoma (MM). Case reports and case series described a grave prognosis for women diagnosed with MM during pregnancy. Today MM in pregnancy takes on enhanced significance as more women delay childbearing into their 30s and 40s, and the incidence of MM during pregnancy may be expected to increase. In addition, relative immunosuppression during pregnancy theoretically may favor the potential for MMs to behave more aggressively. This article compiles the most recent clinical, epidemiologic, and laboratory studies to guide clinicians in addressing the issue of melanoma in pregnancy. Herein we address the prognosis, characteristics, evaluation, treatment, and how to counsel women diagnosed with MM during pregnancy, including the potential consequences for the fetus. Overall, our analysis reveals that there is no effect on survival in women diagnosed with localized MM during pregnancy; likewise, pregnancies prior or subsequent to a diagnosis of MM do not impact prognosis. Strong epidemiologic evidence shows no enhanced risk of developing MM associated with oral contraceptive pill use. Although a smaller number of studies have addressed hormonal replacement therapy and risk of MM, these studies do not suggest a higher risk of MM. As for the fetus, risk of metastasis to the placenta and/or fetus is extremely low, and seems to occur exclusively in women with widely metastatic MM.

Nevi and melanoma in the pregnant woman

Multiple difficult questions arise when a pregnant woman presents to the dermatologist with a changing melanocytic nevus or melanoma. Our review of the literature provides some insight into these issues. We recommend that a changing pigmented lesion in the pregnant woman should be biopsied promptly and can be safely performed. Women who have dysplastic nevus syndrome require closer monitoring during pregnancy. For the pregnant woman with a confirmed, localized melanoma, prognosis does not appear to be affected by pregnancy. Likewise, limited data indicate that pregnancy before or after a diagnosis of melanoma does not affect prognosis. Wide local excision may be performed safely, but if sentinel lymph node mapping and biopsy is indicated, the technique and safety of this procedure in the pregnant woman remains controversial. There appears to be no absolute contraindication to the prescription of oral contraceptive pills or hormone replacement therapy in someone who has been previously diagnosed with melanoma if no reasonable alternative exists.

Long-term oral antibiotics for acne: Is laboratory monitoring necessary?

BACKGROUND The role of laboratory monitoring in patients receiving long-term oral antibiotics for acne vulgaris has not been clearly defined. OBJECTIVE The purpose of our study was (1) to evaluate the literature for objective evidence on the value of routine laboratory monitoring of the asymptomatic patient receiving oral antibiotics for acne and (2) to determine the utilization of laboratory monitoring of these patients by Connecticut dermatologists. METHODS We surveyed Connecticut dermatologists by phone and inquired about the laboratory monitoring performed in patients receiving long-term oral tetracycline, minocycline, or erythromycin for acne. RESULTS Eight published studies reported a total of 777 patients who had laboratory monitoring at various frequencies while receiving oral antibiotics for acne. Only one adverse drug reaction (ADR) was detected in a patient in whom mild hyperbilirubinemia developed. Of the 75 Connecticut dermatologists who participated in our survey, 48 (64%) perform some laboratory monitoring; 29% do so routinely, and 35% under special circumstances. CONCLUSION Our literature review does not support routine laboratory monitoring in all patients who receive long-term oral antibiotics for acne; rarely does such screening detect an ADR and thus does not justify the cost of such testing. A relatively small proportion of Connecticut dermatologists check laboratory tests more frequently than appears necessary; in our opinion, laboratory monitoring should be limited to patients who may be at higher risk for an ADR.

Nutrition and the deleterious side effects of nutritional supplements.

The potential adverse effects associated with some of the more common oral vitamin supplements--vitamins A, D, and E and niacin (forms include nicotinic acid and nicotinamide), and mineral supplements--zinc, copper, and iron, used in dermatology are manifold. Although the dermatologist may be familiar with adverse effects of vitamins A and D, less well-known adverse effects, such as hematologic and neurologic effects from zinc, are presented.

Efficacy of Intravenous Cidofovir in the Treatment of Giant Molluscum Contagiosum in a Patient With Human Immunodeficiency Virus

Molluscum contagiosum virus (MCV) is a DNA virus in the Poxviridae family that may cause extensive and voluminous lesions often resistant to topical therapies in patients with AIDS and other immunocompromised patients. We present a case of eruptive giant molluscum that caused remarkable deformity in a patient with AIDS. Intravenous (IV) cidofovir was used as therapy, resulting in dramatic improvement.

Pregnancy and melanoma

Malignant melanoma is the most common malignancy during pregnancy, and is diagnosed during childbearing age in approximately one-third of women diagnosed with melanoma. The impact of hormonal changes during pregnancy and from iatrogenic hormones on melanoma is controversial. Women undergo immunologic changes during pregnancy that may decrease tumor surveillance. In addition, hormone receptors are found on some melanomas. In spite of these observations, the preponderance of evidence does not support a poorer prognosis for pregnancy-associated melanomas. There is also a lack of evidence that oral contraceptives or hormone replacement therapy worsens melanoma prognosis.