Nicholas A. Soter

Eosinophilic pustular folliculitis in the acquired immunodeficiency syndrome. Treatment with ultraviolet B phototherapy.

EOSINOPHILIC pustular folliculitis is a rare pruritic dermatosis1 that has only recently been reported in patients from the United States.2 3 4 5 6 The eruption is characterized by sterile pruritic...

Allergic Reactions to Tattoo Pigment after Laser Treatment

BACKGROUND Cutaneous allergic reactions to pigments found in tattoos are not infrequent. Cinnabar (mercuric sulfide) is the most common cause of allergic reactions in tattoos and is probably related to a cell‐mediated (delayed) hypersensitivity reaction. OBJECTIVE The purpose of these case presentations is to describe a previously unreported complication of tattoo removal with two Q‐switched lasers. RESULTS Two patients without prior histories of skin disease experienced localized as well as widespread allergic reactions after treatment of their tattoos with two Q‐switched lasers. CONCLUSION The Q‐switched ruby and neodymium:yttrium‐aluminum‐garnet lasers target intracellular tattoo pigment, causing rapid thermal expansion that fragments pigment‐containing cells and causes the pigment to become extracellular. This extracellular pigment is then recognized by the immune system as foreign.

Morphology of atopic eczema

The routine examination of skin biopsy specimens embedded in paraffin and strained with hematoxylin‐eosin has failed to allow differentiation of atopic eczema from other types of eczematous dermatitis. The use of 1‐μm plastic‐embedded sections permits the recognition of in filtrating cell types and blood vessel alterations, thus allowing a refined method to examine cutaneous lesions and permit better definition of cutaneous structures than can be achieved in routinely‐processed specimens.

Acute and chronic urticaria and angioedema

Urticaria and angioedema are clinical manifestations of various immunologic and inflammatory mechanisms, or they may be idiopathic. The respiratory and gastrointestinal tracts as well as the cardiovascular system may be involved in any combination. Patients with urticaria and/or angioedema can be classified based on pathophysiologic mechanisms into those with IgE-dependent or complement-mediated immunologic disorders, those with nonimmunologic disorders in which there is a direct effect on the mast cell or on arachidonic acid metabolism, and those whose condition is idiopathic. Evaluation of patients should focus on a thorough history. Laboratory tests provide minimal additional information. About one half of patients with urticaria alone and 25% with urticaria and angioedema or angioedema alone are free of lesions within 1 year. With urticaria, angioedema, or both, 20% of patients experience episodes for more than 20 years.

A 20-year analysis of previous and emerging allergens that elicit photoallergic contact dermatitis

BACKGROUND Retrospective chart reviews are periodically needed to update allergen series to detect changes in photoallergic contact dermatitis (PACD) over time. OBJECTIVE We sought to evaluate photopatch test results during a 13-year period and extend the observations to 20 years. METHODS A retrospective chart review was conducted in patients who were photopatch tested. RESULTS In all, 76 patients were evaluated. A total of 69 positive photopatch and 45 positive patch test reactions were detected in 30 and 23 patients, respectively. The frequencies of the positive photopatch test reactions were sunscreens 23.2%, antimicrobial agents 23.2%, medications 20.3%, fragrances 13%, plants and plant derivatives 11.6%, and pesticides 8.7%. Of the positive photopatch reactions to antimicrobial agents, 60% were caused by Fentichlor. LIMITATIONS This study was a retrospective chart analysis, and the number of patients was small. CONCLUSIONS Sunscreens and antimicrobial agents were the most frequent allergens eliciting PACD, and there was a decrease in PACD caused by fragrances. The number of reactions to medications increased. This study also demonstrated that pesticides can be a cause of PACD. The detection of reactions to Fentichlor was unexpected and, although they have been attributed in some studies to cross-reactions to sulfanilamides and bithionol, such a robust association was not observed in this study. This study extends our experience of the changes in the allergens that elicit PACD to 20 years.

The use of mycophenolate mofetil for the treatment of autoimmune and chronic idiopathic urticaria: Experience in 19 patients

BACKGROUND There is a paucity of investigation on which to base the treatment of chronic urticaria after a patient fails maximum therapy with antihistamines. One prospective, open-label, uncontrolled study suggested that mycophenolate mofetil may be a successful second-line therapy. OBJECTIVE We sought to evaluate the efficacy and safety of mycophenolate mofetil in 19 patients with autoimmune and chronic idiopathic urticaria. METHODS In a retrospective chart review, records of patients with autoimmune and chronic idiopathic urticaria who were evaluated between 2001 and 2009 were analyzed. RESULTS Improvement in urticaria was observed in 89% of patients, specifically 91% of patients with autoimmune urticaria and 88% with chronic idiopathic urticaria. Time to initial improvement ranged from 1 to 9 weeks. In 59% of these patients, complete control of urticaria was achieved, which included 70% of patients with autoimmune urticaria and 43% with chronic idiopathic urticaria. Mean time to complete control was 14 weeks, with a range of less than 1 to 31 weeks. The dose of mycophenolate mofetil at complete control ranged from 1000 to 6000 mg divided twice daily. Mycophenolate mofetil was tapered in 7 of these 10 patients after an average of 7 weeks. Six of the 7 patients tapered then discontinued mycophenolate mofetil with remissions lasting between 2 and 16 weeks up to when the chart review ended. Mycophenolate mofetil was well tolerated with no serious infections or laboratory abnormalities. Gastrointestinal symptoms were most common. LIMITATIONS This was a retrospective chart analysis. The number of patients was relatively small. CONCLUSIONS Mycophenolate mofetil is a useful and well-tolerated second-line therapy for patients with autoimmune and chronic idiopathic urticaria in whom antihistamines and other therapeutic agents have failed.

UVB phototherapy is an effective treatment for pruritus in patients infected with HIV

BACKGROUND Pruritus in patients positive for HIV may be debilitating. OBJECTIVE Our purpose was to evaluate the efficacy of UVB therapy in the treatment of pruritus in patients positive for HIV. METHODS Twenty-one male HIV-positive patients with intractable pruritus (14 with eosinophilic folliculitis and 7 with primary pruritus) were treated three times weekly with UVB phototherapy. Pruritus was quantified with use of a subjective score of 0 (none) to 10 (severe). RESULTS Mean CD4 counts at the initiation of therapy were 91.0 +/- 31.9 cells/microliter. Pruritus scores before and after treatment were 8.6 +/- 0.4 and 2.2 +/- 0.5, respectively (p < 0.001). The mean number of treatments to achieve maximal improvement was 20.7 +/- 2.3, with a cumulative UVB dose of 3399.1 +/- 597.4 mJ/cm2. No significant difference was found between the group with eosinophilic folliculitis and the group with primary pruritus. CONCLUSION UVB phototherapy can produce significant relief of pruritus and improvement in the quality of life in patients positive for HIV.

Chronic actinic dermatitis associated with human immunodeficiency virus infection

Chronic actinic dermatitis is a photodistributed, eczematous dermatitis that preferentially affects elderly men and persists for months to years. Its occurrence in individuals infected with human immunodeficiency virus (HIV) has been described in five patients. We report four additional cases of this uncommon, chronic photodermatosis associated with HIV infection. In two of the patients, photosensitivity was a presenting disorder leading to the diagnosis of HIV infection. All patients were men of skin type VI with a mean age of 50 years, all had decreased minimal erythema doses to ultraviolet B, three of the four patients had decreased minimal erythema doses to ultraviolet A and all had CD4 cell counts of < 200 times; 106/L.

Efficacy of ultraviolet B phototherapy for psoriasis in patients infected with human immunodeficiency virus

To evaluate the efficacy of ultraviolet B (UVB) phototherapy for the treatment of psoriasis in patients infected with human immunodeficiency virus (HIV), the response of 14 patients was compared to that of matched seronegative control individuals. All patients were evaluated prior to treatment (baseline) and after 21 treatments for the extent of total body surface area (TBSA) involvement and the quantification of scale, erythema, and thickness of plaques using a scale of 0 (absent) to 4 (severe). The only concomitant medication allowed was salicylic acid in petrolatum. The cumulative score for scale, erythema, and thickness improved 1.9± 0.5 [mean± standard error of mean (SEM)] in the HIV group and 2.4± 0.3 in controls. There was 40.9± 7.3 % reduction of TBSA involvement in the former and 38.4± 7.6 % reduction in the latter group. None of the differences was statistically significant. There was no statistically significant difference in the response to therapy among various stages of immunosuppression in the HIV group. There was also no deterioration of immune status in this group. UVB phototherapy is an effective treatment for psoriasis in patients infected with HIV. The response is identical to that of matched control individuals.

Methotrexate in the treatment of pemphigus vulgaris: experience in 23 patients

The standard treatment for patients with pemphigus vulgaris has long consisted of high‐dose glucocorticoids. Studies regarding the use of methotrexate in pemphigus vulgaris date back to 1968, but few have quantitatively described a steroid‐sparing effect conferred by methotrexate.