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Setting: Academic-driven, community-recruited patients from 4 counties in England and 1 county in Scotland after information has been widely distributed to general practitioners (GPs), local pharmacies, primary schools, and parents’ meetings. Patients: Young people aged 2 to 15 years with head lice infestation. Intervention: Each participating GP was assigned an individual randomization list at the start of the trial. Patients were randomized to (1) home use of the Bug Buster kit (4 sequential applications combed on wet, conditioned hair at 3-day intervals) or (2) a single application of a pediculicide (either 0.5% aqueous malathion or 1% aqueous permethrin). Main Outcome Measure: Presence of head lice 2 to 4 days after end of treatment: day 5 for the pediculicides and day 15 for the Bug Buster kit. Results: A total of 133 patients were randomly assigned to treatment with Bug Buster kit (62 patients) or pediculicide (71 patients). One patient was excluded for also using an insecticide, and 6 participants were lost to follow-up. At the time of evaluation, 32 (57%) of 56 patients were cured in the Bug Buster kit group vs 9 (13%) of 70 in the pediculicide group, and 5 (17%) of 30 and 4 (10%) of 40 for malathion and permethrin, respectively (relative risk, 4.4; 95% confidence interval, 2.3-8.5; number needed to treat, 2.26). The significant difference remained after extreme case analysis. Authors’ Conclusions: The Bug Buster kit is the most effective over-the-counter treatment for head lice infestation in the community compared with pediculicides.

To identify the prognostic factors of bullous pemphigoid (BP).Prospective study of patients with BP included in a randomized, controlled trial.Twenty dermatology departments in France. Patients One hundred seventy patients with BP initially treated with a 40-g/d dosage of clobetasol propionate cream (testing sample) and 171 patients initially treated with oral corticosteroids at a dosage of 0.5 or of 1.0 mg/kg per day, depending on the extent of BP (validation samples).The end point was overall survival during the first year after BP diagnosis. From the testing sample, associations of clinical and biological variables with overall survival were assessed using univariate and multivariate analyses. Selected predictors were included in a prognostic model. To verify that these predictors were not dependent on the treatment used, the model was then validated independently on the 2 series of BP patients treated with oral corticosteroids.Median age of the BP patients included in the testing sample was 83 years. The 1-year Kaplan-Meier survival rate was 74%. From univariate analysis, the main deleterious predictors were demographic factors (ie, older age and female sex), associated medical conditions (ie, cardiac insufficiency, history of stroke, and dementia), and low Karnofsky score, which is a measure of the patient's general condition. No factors directly related to BP, in particular extent of cutaneous lesions, were shown to be related to the patients' prognosis. From multivariate analysis, only older age (P = .02) and low Karnofsky score (P.001) appeared independently predictive of death. From the Cox model including these 2 predictors, the predicted 1-year survival rates were 90% (95% confidence interval [CI], 85%-96%) for patients 83 years or younger with Karnofsky score greater than 40, 79% (95% CI, 69%-90%) for patients older than 83 years with Karnofsky score greater than 40, 65% (95% CI, 50%-86%) for patients 83 years or younger with Karnofsky score of 40 or less, and 38% (95% CI, 26%-57%) for patients older than 83 years with Karnofsky score of 40 or less. Kaplan-Meier survival distributions of patients from the validation samples appeared clearly separated according to these 4 categories and were in close agreement with corresponding predicted 1-year survival rates obtained from the testing sample.The prognosis of patients with BP is influenced by age and Karnofsky score. These predictors are easy to use and should facilitate the management of BP.

Objective To critically appraise the body of literature concerning treatment of lichen planus (LP). Design Review of MEDLINE and BIOSIS databases to identify articles published with at least an English abstract before March 1998 that examined treatment of LP. Main Outcome Measures Forming a primary database on which most recommendations are based. We thus selected 83 clinical trials or small series of patients in the medical literature that referenced clinical data on patients treated for LP. Results There are no large randomized trials with definitive results in the medical literature examining the efficacy of the various drugs or physical treatments of LP. There are only 3 level B trials (small randomized trials with uncertain results because of moderate to high α or β error) that address efficacy of treatment in LP, ie, 1 with acitretin in cutaneous LP and 2 with topical corticosteroids in mucosal LP. The remainder of the published trials are observational and are not always prospective. Many of the recommendations of the experts are based on their personal experience. Conclusions Although LP may be associated with substantial morbidity and altered quality of life, especially the erosive mucosal LP, definitive clinical trials have not been performed. Acitretin is the first-line therapy in cutaneous LP. The efficacy of systemic corticosteroids and psoralen plus UV-A therapy has not been established with a high level of proof. Topical corticosteroids are the first-line therapy in mucosal erosive LP. Other treatments, such as topical cyclosporine or extracorporeal photochemotherapy, remain to be evaluated. European-US cooperation is warranted to perform large randomized controlled trials in cutaneous and mucosal LP.

Graft-versus-host disease (GvHD) includes inflammatory and/or fibrosing manifestations that may arise at various times after transplantation of any organ containing lymphoid cells. For the dermatologist, the importance of GvHD is real and current. Indeed, because it has become easier to perform bone marrow transplantation (EMT), the indications of BMT have become broader, making follow-up of patients receiving grafts a widespread practice. Nonetheless, GvHD remains a frequent complication of BMT and its principal target organ is the skin. Furthermore, recent innovations, such as grafting of umbilical cord blood and the mobilization of peripheral blood progenitor cells, will be the source of new questions concerning the development of GvHD under these conditions. Finally, because of its analogies with other spontaneous idiopathic skin diseases, GvHD constitutes a model that may lead to a better understanding of the pathophysiological features of these diseases. In this review, the cutaneous aspects of GvHD are emphasized.

Laurence Le Cleach, MD; Ludovic Trinquart, MCS; Dominique Penso-Assathiany, MD; Olivier Chosidow, MD, PhD; Department of Dermatology, Hopital Henri-Mondor, Assistance Publique–Hopitaux de Paris, Creteil (Drs Le Cleach, Penso-Assathiany, and Chosidow), Centre Cochrane Francais, Hotel-Dieu, Paris (Drs Le Cleach and Chosidow and Mr Trinquart), French Satellite of the Cochrane Skin Group, Creteil (Drs Le Cleach and Chosidow), and Universite Paris-Est-Creteil, Val de Marne (Dr Chosidow), France

A 65-year-old woman presented with a several-day history of tender necrotic lesions on her extremities. The lesions were preceded by erythema of her right great toe that did not respond to -lactam antibiotic therapy for presumed staphylococcal paronychia. Her medical history was remarkable for aplastic anemia status post induction therapy with antithymocyte globulin, methylprednisolone, and cyclosporine. Physical examination revealed multiple erythematous, edematous nodules with central necrotic eschars on the patient’s extremities; the largest one, measuring 3.5 cm, was located on her right wrist (Figure 1). Also, there was periungual erythema with associated vesiculation on her right great toe (Figure 2). Laboratory studies at the time of evaluation were notable for a white blood cell count of 1400/μL, with an absolute neutrophil count of 700/μL (to convert values to 10/L, multiply by 0.001). A punch biopsy specimen was obtained from the lesion on the right thigh (Figure 3) for histologic evaluation and culture studies. What is your diagnosis?

We read with interest the case of ''Recurrence of Pemphigus Vulgaris Associated With Interleukin-2 Therapy'' reported by Prussick et al1in a recent issue of theARCHIVES. Indeed, pemphigus vulgaris (PV) and various autoimmune disorders reported during interleukin-2 immunotherapy are diseases in which interleukin-2 might play a key role. Interestingly, these diseases are rare events during interleukin-2 immunotherapy, as discussed by Gaspari in his editorial.2In our own series of 25 patients with metastatic melanoma,3we observed mucocutaneous lesions in 15% of 78 cycles of interleukin-2 infusion. Nine biopsy specimens were studied and did not reveal histologic or direct immunofluorescence patterns of autoimmune bullous skin diseases. Nevertheless, we took a step toward Gaspari's ''unanswered questions'' concerning vitiligo and interleukin-2 therapy. Indeed, we had the opportunity to observe four cases of vitiligo in patients treated with interleukin-2 alone for metastatic melanoma out of our previous series of 25

Background Candida peritonitis (CP) is generally considered to be a severe disease, but its impact on outcome in critically ill patients remains unknown. Hypothesis The predictive factors of mortality due to CP can be determined by study of a population of patients with CP. Design A retrospective review of a prospective surgical intensive care unit (ICU) database of patients (January 1, 1994, through December 31, 2000). Setting University hospital in Paris, France. Patients Eighty-three patients with generalized CP. Main Outcome Measures Demographic and microbiologic data and outcome were collected, and nonsurvivors were compared with survivors. Results Overall ICU mortality due to CP was 43 (52%) of 83 patients. In a stepwise multivariate logistic regression, the following 4 variables were independently associated with mortality: APACHE II (Acute Physiology and Chronic Health Evaluation II) score on admission of at least 17 (odds ratio [OR], 28.4; 95% confidence interval [CI], 5.7-142.5; P P = .003), upper gastrointestinal tract site of peritonitis (OR, 7.7; 95% CI, 1.7-34.7; P = .007), and results of direct examination of peritoneal fluid that were positive for Candida (OR, 4.7; 95% CI, 1.2-19.7; P = .002). Conclusions These results confirm the severity of CP in ICU patients and emphasize the prognostic value of direct examination of peritoneal fluid for Candida in this context.

Background Mycobacterium marinum is a nontuberculous mycobacterium responsible for skin infections. Although cases have been seldom reported, no series of M marinum infection has been recently reported and the treatment is not standardized. Methods A national survey was conducted on culture-confirmed M marinum infections that occurred in France from January 1, 1996, to December 31, 1998. Clinical characteristics and therapeutic data were analyzed, and the minimum inhibitory concentrations of 11 antibiotics were determined against the causative isolates. Results Sixty-three cases of M marinum infection were studied. In 53 (84%) of the patients, inoculation was related to fish tank exposure. The site of infection was mainly the upper limb (in 60 [95%] of the 63 patients), and infection was spread to deeper structures in 18 (29%) of the patients. All patients were treated with antibiotics (median time, 3½ months), and 30 (48%) underwent surgery. Various antibiotic regimens were prescribed, and the initial regimen was modified in 22 (35%) of the patients. Clarithromycin, cyclines, and rifampin were the most commonly prescribed antibiotics. Cure was observed for 55 (87%) of the patients. Failure was related to deep structure involvement (3 of 45 vs 5 of 18 patients; P = .04) but not to any antibiotic regimen. All strains showed the same susceptibility pattern without acquired resistance. The 90% minimum inhibitory concentrations of rifampin and rifabutin were far lower (0.5 and 0.06 µg/mL, respectively) than the 90% minimum inhibitory concentrations of clarithromycin (2 µg/mL) and the cyclines (minocycline, 4 µg/mL; and doxycycline, 8 µg/mL). Conclusions Mycobacterium marinum infections are emerging infections related to fish tank hobby. Because of the severity of the cases with spread of infection, clinical awareness of M marinum infection and its associated risk factors is important so that the diagnosis can be made and therapy can be initiated promptly.