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This case report describes the migration of a fluocinolone acetonide implant to the anterior chamber 1 year after it was placed.

Importance A randomized clinical trial comparing fluocinolone acetonide implant vs systemic corticosteroids and immunosuppression for treatment of severe noninfectious intermediate, posterior, and panuveitides did not result in a significant difference in visual acuity at 2 and 4.5 years; longer-term outcomes are not known. Objective To compare the association between intravitreous fluocinolone acetonide implant vs systemic therapy and long-term visual and other outcomes in patients with uveitis. Design, Setting, and Participants Nonprespecified 7-year observational follow-up of the Multicenter Uveitis Steroid Treatment (MUST) randomized clinical trial comparing the alternative treatments. Follow-up was conducted in tertiary uveitis subspecialty practices in the United States (21), the United Kingdom (1), and Australia (1). Of 255 patients 13 years or older with intermediate, posterior, or panuveitis (active within ≤60 days) enrolled in the MUST trial between December 6, 2005, and December 9, 2008, 215 consented to ongoing follow-up through at least 7 years postrandomization (last visit, February 10, 2016). Interventions Participants had been randomized to receive a surgically placed intravitreous fluocinolone acetonide implant or systemic corticosteroids supplemented by immunosuppression. When both eyes required treatment, both eyes were treated. Main Outcomes and Measures Primary outcome was change from baseline in best-corrected visual acuity in uveitic eyes (5 letters = 1 visual acuity chart line; potential range of change in letters read, −121 to +101; minimal clinically important difference, 7 letters), analyzed by treatment assignment accounting for nonindependence of eyes when patients had 2 uveitic eyes. Secondary outcomes included potential systemic toxicities of corticosteroid and immunosuppressive therapy and death. Results Seven-year data were obtained for 161 uveitic eyes (70% of 90 patients assigned to implant) and 167 uveitic eyes (71% of 90 patients assigned to systemic therapy) (77% female; median age at enrollment, 48 [interquartile range, 36-56] years). Change in mean visual acuity from baseline (implant, 61.7; systemic therapy, 65.0) through 7 years (implant, 55.8; systemic therapy, 66.2) favored systemic therapy by 7.2 (95% CI, 2.1-12) letters. Among protocol-specified, prospectively collected systemic adverse outcomes, the cumulative 7-year incidence in the implant and systemic therapy groups, respectively, was less than 10%, with the exceptions of hyperlipidemia (6.1% vs 11.2%), hypertension (9.8% vs 18.4%), osteopenia (41.5% vs 43.1%), fractures (11.3% vs 18.6%), hospitalization (47.6% vs 42.3%), and antibiotic-treated infection (57.4% vs 72.3%). Conclusions and Relevance In 7-year extended follow-up of a randomized trial of patients with severe intermediate, posterior, or panuveitis, those randomized to receive systemic therapy had better visual acuity than those randomized to receive intravitreous fluocinolone acetonide implants. Study interpretation is limited by loss to follow-up. Trial Registration clinicaltrials.gov Identifier:NCT00132691

Objective: To establish the efficacy of topical corticosteroid nasal spray treatment of severe olfactory loss associated with severe nasal and sinus disease. Design: Efficacy before and after open-label trial of topical corticosteroid nasal spray used exclusively in the headdown-forward position. Setting: Taste and smell clinic of a university teaching hospital and research facility. Patients: Taste and smell clinic patients with anosmia or severe hyposmia associated with paranasal sinus disease and nasal polyposis including 39 of 45 patients recruited from 1988 to 1994 who completed the topical corticosteroid treatment course and returned for subsequent testing. Intervention: At least 8 weeks of treatment with flunisolide (Nasalide), 2 sprays in each nostril twice a day, with concurrent antibiotic treatment of any bacterial infection. Main Outcome Measures: Subjective olfactory symptoms, objective olfactory function tests, and otolaryngological evaluation (including endoscopic examination). Results: Olfactory scores significantly improved following treatment ( P P Conclusion: Topical corticosteroid nasal spray administered in a head-down-forward position is an effective treatment of severe olfactory loss associated with severe nasal and sinus disease. Arch Otolaryngol Head Neck Surg. 1997;123:367-372

To determine whether adverse effects such as elevated intraocular pressure and cataracts, which are lower with dexamethasone when compared with fluocinolone acetonide or triamcinolone acetonide, may be explained in part by the differences in drug lipophilicity and partitioning of these drugs into the trabecular meshwork and lens.The n-octanol/phosphate-buffered saline (pH 7.4) partition coefficient (log distribution coefficient [D]) and bovine/human ocular tissue partition coefficients were determined for triamcinolone, prednisolone, dexamethasone, fluocinolone acetonide, triamcinolone acetonide, and budesonide at 37°C.The log D of the corticosteroids ranged from 0.712 to 2.970. The ranges of tissue:PBS partition coefficients following drug incubation at 0.4, 2.0, and 10.0 μg/mL were 0.35 to 1.56, 0.30 to 2.12, and 0.30 to 1.95, respectively, for the bovine lens, 0.87 to 4.18, 0.71 to 4.40, and 0.69 to 5.86, respectively, for the human lens, and 2.98 to 9.48, 2.41 to 9.16, and 1.71 to 9.96, respectively, for the bovine trabecular meshwork. In general, tissue partitioning showed a positive correlation with log D. Dexamethasone, with lipophilicity less than triamcinolone acetonide and fluocinolone acetonide, exhibited the least amount of partitioning in the trabecular meshwork and lens among these 3 corticosteroids commonly used for treating diseases at the back of the eye.Binding of corticosteroids to the trabecular meshwork and lens increases as drug lipophilicity increases.Less lipophilic corticosteroids with limited partitioning to the trabecular meshwork and lens may result in reduced incidence of elevated intraocular pressure and cataracts.

Patient 1 is a 42-year-old white man who has had alopecia areata (AA) for 17 years. His father also has extensive AA. Early in the course of the disease, the patient intermittently received prednisone, 15 to 30 mg/d for 2 years, with 1 year being the longest duration of continuous treatment followed by an additional 7-month taper. The patient also received topical fluocinolone acetonide 0.1% (Synalar; Medicis, Scottsdale, Ariz) solution and intralesional triamcinolone acetonide (Kenalog; Bristol-MyersSquibb, New York, NY) injections for most of the duration of the disease. He typically receives intralesional triamcinolone, 10 mg/mL to his scalp and 3 to 5 mg/mL to his eyebrows, every 4 to 10 weeks. Intralesional triamcinolone was helpful, with remissions lasting 2 months. Sulfasalazine administered failed secondary to drug eruption. He has never received contact sensitizers. Patient 2 is a 37-year-old white man who has had alopecia universalis for 14 years. For the first 2 years, he received intermittent courses of prednisone, starting at 40 mg/d and tapering off for 1 to 2 weeks, together with topical corticosteroids and intralesional triamcinolone, 5 mg/mL. The prednisone led to transient hair regrowth with rapid relapse after he finished the course of steroids. The patient subsequently received squaric acid dibutyl ester 0.01% applied twice per week to his scalp in conjunction with tretinoin 0.01% gel (Retin-A; Ortho Neutrogena, Skillman, NJ). He continued to receive intralesional injections of triamcinolone, 5 mg/mL to his eyebrows and scalp, every 4 to 8 weeks. The patient began to respond after 3 months of treatment with squaric acid and had nearly total regrowth of hair on his scalp after 6 months. However, the squaric acid treatments became less effective during the next year and were discontinued. For the next 9 years, the patient received intralesional triamcinolone 5 mg/mL to his eyebrows every 4 to 8 weeks, which resulted in transient hair regrowth. His scalp went untreated and remained completely devoid of hair. A 3-month trial with tacrolimus 0.1% ointment applied twice daily to his scalp had no effect. Patient 3 is a 22-year-old Asian woman who has had alopecia universalis for 3 years. Her prior treatments include prednisone for 5 months with a maximal dose of 40 mg daily to which she had a transient response. She did not respond to diphenylcyclopropenone 2% applied weekly for 3 months. She had no response to sulfasalazine, 2 g twice daily for 1 year. She also received intralesional triamcinolone, 5 mg/mL, to her eyebrows for 11⁄2 years, which resulted in transient hair regrowth. Patient 4 is a 14-year-old white girl who has had AA for 3 years. She also has hypothyroidism, which was diagnosed 1 year ago, but has had symptoms of hypothyroidism for 5 years. Her prior treatments included class I topical corticosteroids twice daily for 3 years with no improvement and intralesional triamcinolone, 10 mg/mL, for 11⁄2 years with transient hair regrowth. A course of prednisone, 60 mg daily, tapered off for 4 weeks resulted in minimal sparse regrowth of pigmented terminal hair and improvement of her eyebrows. Treatment with diphenylcyclopropenone 0.1% to 0.5% for 9 weeks resulted in contact dermatitis but minimal sparse regrowth of pigmented terminal hair. She was unable to tolerate further treatments because of the contact dermatitis.

OBJECTIVE To review the effect of the fluocinolone acetonide implant in subjects with autosomal dominant neovascular inflammatory vitreoretinopathy (ADNIV), an inherited autoimmune uveitis. METHODS A retrospective case series was assembled from patients with ADNIV who received fluocinolone acetonide implants. Visual acuity and features of ADNIV, including inflammatory cells, neovascularization, fibrosis, and cystoid macular edema, were reviewed. RESULTS Nine eyes of 5 related patients with ADNIV with uncontrolled inflammation were reviewed. Follow-up ranged from 21.7 to 56.7 months. Visual acuity at implantation ranged from 20/40 to hand motion. Preoperatively, 8 eyes had vitreous cells (a ninth had diffuse vitreous hemorrhage). Eight eyes had cystoid macular edema, 7 had an epiretinal membrane, and 3 had retinal neovascularization. Following implantation, vitreous cells resolved in all eyes and neovascularization regressed or failed to develop. Central macular thickness improved in 4 eyes. During the postoperative course, however, visual acuity continued to deteriorate, with visual acuity at the most recent examination ranging from 20/60 to no light perception. There was also progressive intraocular fibrosis and phthisis in 1 case. Four eyes underwent cataract surgery. Six of the 7 eyes without previous glaucoma surgery had elevated intraocular pressure at some point, and 3 of these required glaucoma surgery. CONCLUSIONS The fluocinolone acetonide implant may inhibit specific features of ADNIV such as inflammatory cells and neovascularization but does not stabilize long-term vision, retinal thickening, or fibrosis. All eyes in this series required cataract extraction, and more than half required surgical intervention for glaucoma. Further studies may identify additional therapies and any benefit of earlier implantation.

Objective To assess the safety and efficacy of combined cataract extraction, posterior chamber intraocular lens placement, pars plana vitrectomy, fluocinolone acetonide intravitreal implant (Retisert), and Ahmed valves with pars plana tube (CPR-PT) in eyes with chronic, posterior, noninfectious uveitis. Methods Retrospective study of patients who underwent CPR-PT. Outcome measures included visual acuity, intraocular pressure, inflammation, and complications. Results Eight eyes were included, with a mean follow-up of 18 months. Mean visual acuity improved from 1.89 to 0.14 logMAR (Snellen, counting fingers at 2 ft [0.6 m]) to 20/30; P = .01). Mean intraocular pressure remained stable at 16 to 17 mm Hg (P = .35). The number of glaucoma medications per eye decreased from 2.9 to 0.25 (P = .01). Systemic prednisone therapy was discontinued in all patients by 9 months postoperatively. Inflammation was well controlled in all eyes. Conclusion The CPR-PT procedure allows rapid visual rehabilitation without major short-term complications.

Objective To determine whether adverse effects such as elevated intraocular pressure and cataracts, which are lower with dexamethasone when compared with fluocinolone acetonide or triamcinolone acetonide, may be explained in part by the differences in drug lipophilicity and partitioning of these drugs into the trabecular meshwork and lens. Methods The n-octanol/phosphate-buffered saline (pH 7.4) partition coefficient (log distribution coefficient [D]) and bovine/human ocular tissue partition coefficients were determined for triamcinolone, prednisolone, dexamethasone, fluocinolone acetonide, triamcinolone acetonide, and budesonide at 37°C. Results The log D of the corticosteroids ranged from 0.712 to 2.970. The ranges of tissue:PBS partition coefficients following drug incubation at 0.4, 2.0, and 10.0 μg/mL were 0.35 to 1.56, 0.30 to 2.12, and 0.30 to 1.95, respectively, for the bovine lens, 0.87 to 4.18, 0.71 to 4.40, and 0.69 to 5.86, respectively, for the human lens, and 2.98 to 9.48, 2.41 to 9.16, and 1.71 to 9.96, respectively, for the bovine trabecular meshwork. In general, tissue partitioning showed a positive correlation with log D. Dexamethasone, with lipophilicity less than triamcinolone acetonide and fluocinolone acetonide, exhibited the least amount of partitioning in the trabecular meshwork and lens among these 3 corticosteroids commonly used for treating diseases at the back of the eye. Conclusion Binding of corticosteroids to the trabecular meshwork and lens increases as drug lipophilicity increases. Clinical Relevance Less lipophilic corticosteroids with limited partitioning to the trabecular meshwork and lens may result in reduced incidence of elevated intraocular pressure and cataracts.

Three patients with chronic, noninfectious uveitis requiring immunosuppressive therapy underwent fluocinolone acetonide (FA) implant exchange complicated by dissociation of the medication reservoir from its anchoring strut. In 2 patients, the medication reservoir descended into the vitreous cavity and required pars plana vitrectomy with intraocular foreign body removal techniques for its retrieval. The use of viscoelastic or perfluorocarbon to elevate the device was helpful in the safe removal of the FA implant device. Surgeons performing FA implant exchange should be aware of this potential complication and anticipate the possible need for vitreoretinal instrumentation and personnel. Patients undergoing FA explantation or exchange should be counseled regarding this potential complication prior to surgery.

OBJECTIVE To report the incidence and management of elevated intraocular pressure (IOP) in patients with uveitis treated with the fluocinolone acetonide (FA) intravitreal implant. DESIGN Pooled data from 3 multicenter, double-masked, randomized, controlled, phase 2b/3 clinical trials evaluating the safety and efficacy of the 0.59-mg or 2.1-mg FA intravitreal implant or standard therapy were analyzed. RESULTS During the 3-year follow-up, 71.0% of implanted eyes had an IOP increase of 10 mm Hg or more than baseline and 55.1%, 24.7%, and 6.2% of eyes reached an IOP of 30 mm Hg or more, 40 mm Hg or more, and 50 mm Hg or more, respectively. Topical IOP-lowering medication was administered in 74.8% of implanted eyes, and IOP-lowering surgeries, most of which were trabeculectomies (76.2%), were performed on 36.6% of implanted eyes. Intraocular pressure-lowering surgeries were considered a success (postoperative IOP of 6-21 mm Hg with or without additional IOP-lowering medication) in 85.1% of eyes at 1 year. The rate of hypotony (IOP

REPORT OF A CASE A 19-month-old white boy was evaluated for erythematous papules and hair loss over the entire scalp of 4 to 5 months' duration. Erythematous papules of the scalp developed at about 15 months of age, followed by pronounced loss of hair. He had mild pruritus and was initially treated with 0.01% fluocinolone acetonide solution without improvement. He was in the 60th percentile for weight and 88th percentile for height. He had varicella at 7 months of age and a his- tory of recurrent otitis media. He was not receiving any medications. His father has androgenetic alopecia; otherwise, the family history was unremarkable for hair loss. The boy's 5-year-old brother had normal scalp hair. Examination of the scalp revealed 1- to 2-mm erythematous follicular papules and fractured hairs of variable lengths measuring 3 to 10 mm over the entire scalp ( Figure 1 ). The eyebrows and eyelashes were normal.

• Six generic formulations of five topical steroids were compared for bioequivalence with their trade-name counterparts using an in vivo vasoconstriction assay. Two of six generic formulations were found to show significantly less vasoconstriction than the respective trade-name topical steroids. The issue of generic equivalence of topical steroids is discussed, with particular emphasis on the vagaries of the vasoconstriction assay. ( Arch Dermatol. 1991;127:197-201)

• A flunisolide-containing intranasal spray and matching placebo were used in an eight-week, double-blind parallel study in 67 patients with perennial rhinitis. Seventeen patients who did not benefit from treatment with the placebo then switched to flunisolide for a six-week open trial. Flunisolide-treated patients showed greater improvement in both duration and severity of symptoms, as well as a greater preference for flunisolide; 75% of patients either had "mild" symptoms or were asymptomatic and 67% stated that they experienced "substantial" or "total" control of symptoms. No serious side effects were encountered. Chief side effects in both drug and placebo groups were brief, mild, nasal burning and stinging on spray application. The drug exhibited no adverse effects on adrenal function (morning plasma cortisol levels). ( Arch Otolaryngol 105:649-653, 1979)

Patients with oral vesiculoerosive diseases frequently require corticosteroid treatment to induce healing and reduce pain. Because of the adverse effects associated with systemic use, topical application of 0.05% fluocinonide in an adhesive base was investigated. The study group was comprised of 89 patients with erythema multiforme, lichen planus, benign mucous membrane pemphigoid, or pemphigus. In the double-blind phase involving 15 patients, seven responded completely and eight partially to the topical ointment. In the open study that included 74 patients, 35 had complete disappearance of signs and symptoms, while 39 experienced partial benefit. There were no adverse side effects. All 89 patients were observed for three to 35 months and each patient's condition continued to respond to the treatment when its use was required.

To the Editor.— Because of reports 1,2 of chloroquine-induced ototoxicity in the fetus, abortion was performed for a woman receiving this therapy for discoid lupus erythematosus. Report of a Case A 27-year-old white woman had been under treatment for widespread superficial disseminated discoid lupus erythematosus, present since July 1966. The eruption was well controlled by fluocinolone acetonide ointment (Synalar) applied locally. There was no evidence of systemic involvement. In April 1968, following normal delivery of a healthy child, her second, the patient had several episodes of urticaria for which no cause could be found. The lupus erythematosus became more severe, and by October 1968 there was considerable scarring. Treatment was started with hydroxychloroquine sulfate (Plaquenil [Britain]; Plaquenil sulfate, comparable to US product), 200 mg three times daily for two weeks, then 200 mg twice daily. The condition was well controlled on this dosage, but it flared up when treatment

• Because clinical improvement of psoriasis vulgaris was recently observed after the prolonged application of tape, 26 patients with symmetric plaque-type psoriasis were enrolled in a prospective bilateral comparison study evaluating the clinical efficacy of the adhesive hydrocolloid occlusive dressing (HCD). The majority of localized plaques of psoriasis achieved improvement (41%, 14/34) or resolution (47%, 16/34) with the prolonged application of HCD; also, HCD was therapeutically superior to twice-daily applications of fluocinolone acetonide cream, and was comparably effective as erythemogenic ultraviolet B treatment. Although the therapeutic mechanism is not completely understood, occlusive dressings have great potential in the management of limited psoriasis vulgaris. ( Arch Dermatol 1987;123:1046-1052)

To the Editor.— Two cases of granuloma gluteale infantum (GGI) were treated with a flurandrenolide-impregnated tape. The cutaneous lesions flattened rapidly, but the erythema was more persistent. The lack of response to a noncorticosteroid-containing tape in the second case suggests that the response was attributable to the antiinflammatory effect of the medication. The prolonged use of the tape that contained flurandrenolide produced atrophy at the site of application. Report of Cases.—Case 1.— A baby girl was treated with 0.025% fluocinolone acetonide ointment for diaper dermatitis at the age of 3 months. Initially responding to therapy, the dermatitis exacerbated after treatment was discontinued. In January 1974, a red tumor appeared within the diaper contact area, and orally given antibiotics were without effect for a presumed secondary pyodermia. The tumors increased in size the number during an episode of diarrhea that lasted for ten days. The patient was referred to us

Alopecia mucinosa is classified into two categories. 1 One is the idiopathic or primary variety, which is benign and without associated disease. The second is the form seen in association with lymphoma, usually mycosis fungoides. Reviews of series of patients with alopecia mucinosa 2,3 suggest that when small numbers of lesions are present, and particularly when these are limited to the head and neck, the course will be benign. We report a case in which this was not so. Report of a Case A 41-year-old woman was seen in April 1976 because of three enlarging facial plaques of nine months' duration. In 1973 she had been hospitalized for a generalized eczematous dermatitis. Patch tests at that time showed 2+ reactions to nickel, chrome, balsam of Peru, and a caine mixture. It was also believed that she had atopic dermatitis. That episode of eczematous dermatitis was controlled with fluocinolone acetonide and

A previously unrecognized pharmacological event, acute tolerance to the vasoconstrictive action of topically applied glucocorticosteroids, has been discovered in human skin. Thus, potent topical glucocorticosteroids will cause vasoconstriction when first applied to human skin but with subsequent applications the production of vasoconstriction rapidly diminishes. However, after a rest period of a few days, the same initial vasoconstrictive effect may be produced again, but this will also disappear if the steroid is again continued topically. These observations have important applications to optimum timing in the clinical topical use of glucocorticosteroids for maximum therapeutic advantage.

• The relative efficacy of fluocinonide and betamethasone benzoate gels in treating the symptoms of psoriasis was evaluated in 335 patients, of whom 263 were analyzable. By means of a paired comparison design in which both drugs were examined simultaneously in the same patient, many potential sources of variation were eliminated. In addition, the analysis took into account the difficulties of pooling results in a multicenter trial. Imposing a rigorous grouping structure on the results from individual clinics minimized differences between clinics and demonstrated consistently high, statistically significant results in favor of fluocinonide gel even when several different statistical approaches were used. Local adverse reactions related to drugs were experienced by few patients. ( Arch Dermatol 112:1729-1733, 1976)

To the Editor.— Some authors link psoriasis with the presence of autoantibodies and the absence of T suppressor cells. 1 Plasmapheresis by way of elution of such autoantibodies may serve as a possible mode of therapy in psoriasis. Subsequent to the observation of Dau 2 of the clearing of psoriasis after plasmapheresis, as well as our own observations of the clinical and immunologic effects of peritoneal dialysis on psoriasis, 3,4 we decided to perform plasmapheresis and to evaluate its effect on the immunologic system in a patient with psoriasis. The result of this treatment was a complete lack of response of the psoriatic lesions, with no notable influence on the immunologic system. Report of a Case.— An 18-year-old man had been suffering from generalized, plaque-type psoriasis since the age of 17 years and had been treated only with fluoridated corticosteroid ointments (0.025% fluocinolone acetonide) under occlusive dressings. This mode of

To the Editor.— We were recently contacted by telephone to renew a prescription for fluocinolone acetonide ointment. The patient indicated he had been using the medication to treat atopic dermatitis on his face and arms, and that it had been prescribed by another physician. When we learned he had been applying the fluorinated steroid to his face daily for 16 years, we insisted he come down to our office and expected to see a horrendous case of steroid rosacea, steroid acne, perioral dermatitis, telangiectasia, and skin atrophy. When he arrived, we had trouble believing our eyes. He had no side effects whatsoever! The patient was a 31-year-old black man whose facial skin showed even pigmentation and normal texture. His atopic dermatitis was under excellent control. How can one explain the complete absence of side effects in this case? The effects of prolonged use of fluorinated steroids on the face have

• Trade name glucocorticoid formulations triamcinolone acetonide, fluocinolone acetonide, and betamethasone valerate were compared with their generic equivalents because of increasing substitution of generic formulations for trade name formulations. The vasoconstrictor assay was the method used for these comparisons. Large differences were found between generic and trade name formulations containing the same steroid in the same concentration in both cream and ointment vehicles. If generic substitutions are to be used for trade name formulations, the physician must be aware that significant differences in therapeutic effectiveness may be expected. (Arch Dermatol1987;123:1312-1314)

• A bioassay for the evaluation of certain adverse effects of various corticosteroids was performed. Twenty-eight daily topical applications of corticosteroids to young rats produced reduction in body-weight gain, atrophy of the skin as determined by double skin-fold thickness micrometer measurement, and mild to severe telangiectasia. This animal model demonstrates corticosteroid-induced skin atrophy and telangiectasia and the correlation of the degree of atrophy and telangiectasia to body-weight change. Nine corticosteroids were evaluated by this method and are listed in terms of increasing severity of side-effects as follows: 1.0% hydrocortisone cream, 0.1% betamethasone valerate cream, 0.025% betamethasone benzoate cream, 0.05% flurandrenolide cream, 0.05% fluocinonide cream, 0.1% dexamethasone cream, and 0.03% flumethasone pivalate cream. Triamcinolone acetonide cream, 0.5%, and 0.2% fluocinolone acetonide cream resulted in death of the animals prior to completion of 28 days of topical application. ( Arch Dermatol 112:1115-1117, 1976)

To the Editor.— Since its description in 1957 by Frumess and Lewis as a "light-sensitive seborrheid," perioral dermatitis (PD) has continued to be a perplexing entity. 1 Many causes have been postulated, including sunlight sensitivity, birth control pills, emotional stress, fluorinated steroid creams, Candida albicans , and rosacea. We have gathered clinical and historical data implicating fluoride dentifrices as an important etiologic factor in this dermatosis. The following two cases support this observation. Report of Cases.—Case 1.— A 63-year-old woman developed PD in mid-1971 that persisted for 24 months. There were exacerbations and remissions even though she was initially treated for one month with 0.025% fluocinolone acetonide cream and then intermittently with a mixture of 1% hydrocortisone, coal tar, and diiodohydroxyquin (Cor-Tar-Quin) and 250 mg of tetracycline hydrochloride four times a day. In August 1973, it was ascertained that she had been using a fluoride dentifrice for as long

To the Editor.— Contact dermatitis has rarely been reported in more than one member of a family. Three different families in which allergic contact dermatitis developed in several members at the same time have been observed. Report of Families.—Family 1.— A husband and wife each used a spray containing tribromohydroxytoluene on their right foot for pruritus. This spray had been used by both patients on other occasions without adverse effects. On this occasion, however, an acute, blistering eruption developed in both within a 24-hour period (Figure). After the condition had been treated with topical 0.025% fluocinolone acetonide and was quiescent, patch tests were performed. In this way, allergy to the spray was confirmed. Family 2.— Three siblings, aged 9, 6, and 5 years, acquired pruritic, erythematous streaks on their limbs after playing in the garden. Patch tests were done after the eruption had subsided. The patch tests were

Two patients with epidermolysis bullosa hereditaria dystrophica treated with fluocinolone acetonide 0.2% cream and observed for eight months and five months, respectively, are presented. The results, though preliminary, are encouraging with respect to the rapid healing of individual bullous lesions so treated and also to the gradual but definite increase in tolerance of friction and trauma which has been observed in the treated areas. The local use of highly concentrated corticosteroid preparations is offered as a promising therapeutic modality in management of this discouraging and disabling chronic bullous disease for which so little effective therapy has been available.

An evaluation of fluocinolone acetonide applied topically in the treatment of discoid lupus erythematosus is presented. Bilateral comparison of 0.025% fluocinolone acetonide cream to the cream base alone demonstrated the effectiveness of this program. In 59 patients an attempt was made to control this disease with topical fluocinolone acetonide as their only treatment. Forty three patients could be controlled in this fashion. Eleven patients responded partially, but for optimal response required a systemic supplement. Five patients did not show any improvement following topical fluocinolone acetonide applications. Noteworthy, is a group of 37 patients followed through two summer seasons. Twenty-four of these patients could be controlled with topical applications but reapplication the following summer was required. Three patients in this group cleared and remained clear. Six patients followed through two summers required a systemic supplement, while four in this group did not respond to therapy.

Desonide cream, 0.05%, is a new nonfluorinated topical steroid cream. A doubleblind clinical evaluation of 133 patients demonstrates it to be as effective as 0.025% fluocinolone acetonide cream in the treatment of steroid responsive dermatoses with no statistically significant preponderance for either steroid.

Betamethasone and 23 of its esters and ortho-esters, assayed topically on healthy human subjects, had vasoconstrictor activities ranging from 0.1% to 400% of that of a standard steroid, fluocinolone acetonide. Compared with the standard in ointments, betamethasone 17,21 - methyl - ortho - valerate and betamethasone 17-valerate showed promising activity in the occlusion treatment of psoriasis. It is concluded that, despite its low precision, the vasoconstriction assay is of value for screening potential topically active anti-inflammatory steroids. Vasoconstriction assays should be designed to allow for differences in sensitivity between subjects and between sites of steroid application.

The action of the corticoid drugs has been investigated in regard to their antimitotic activity on human skin. For topical studies two 4-mm biopsies were taken from the forearms of each volunteer to allow use of the paired comparison method; a separate control group was used for oral studies. The results indicated that orally administered triamcinolone and topically administered triamcinolone acetonide inhibited mitotic activity of the epidermis. Topically administered 0.2% fluocinolone acetonide proved equally potent, although no effect was seen when 0.025% was used. No mitotic inhibition was observed after topical administration of hydrocortisone acetate. Repeated injections of corticotropin, however, resulted in a significant fall in mitotic activity. The antimitotic activity of the corticosteroids seems to be related to their therapeutic efficacy. This may supplement the vasoconstrictor assay for pertinence to those diseases with increased cell turnover.

Two additional patients with thalassemia minor and ankle ulcers are reported, bringing the total number reported to ten. A genealogic study of the thalassemic trait in their family was traced. From a review of the literature it appears that all previous patients with thalassemia and leg ulcers had thalassemia minor. The composite affected patient is a 26-year-old Italian-decended woman with splenomegaly and a hemoglobin of about 8 gm/100 ml. The pathogenesis of the ulcers is nonspecific. Treatment is that of a stasis ulcer.

Regrowth of hair in patients with alopecia areata and alopecia totalis has been demonstrated following intralesional injection or systemic administration with corticosteroid drugs.1-4Intralesional injection is painful and may be followed by atrophy, and systemic administration is often accompanied by the undesirable effects of these drugs. The successful treatment of psoriasis and other dermatoses by maceration with fluocinolone acetonide cream under thin plastic films5caused us to consider the use of this technique for the treatment of alopecia. The following case illustrates the regrowth of hair in a patient with alopecia totalis treated by this technique. Report of Case The patient, a 34-year-old housewife, was referred to us in April, 1962, because of alopecia of many years' duration. She had first noticed loss of hair behind her left ear in July, 1956. She became pregnant and in the second month of gestation the alopecia spread to involve her

RETROSPECTIVELY, that form of pemphigus which has come to be known by the eponym of Senear-Usher syndrome or more formally as pemphigus erythematosus,* was first presented by Ormsby and Mitchell1as a case for diagnosis at a meeting of the Chicago Dermatological Society in 1921. In 1925, before the American Dermatological Association, Senear and Usher analyzed 11 similar cases and described the salient features of the condition which has since borne their names.2Their original description was of a dermatosis involving chiefly or exclusively the head and trunk. The clinical picture embraced features of both lupus erythematosus and pemphigus. The lesions were present on the trunk, usually in the areas involved in seborrheic dermatitis; they were flaccid bullae that ruptured readily and, on their sites, developed scales and crusts that were thick and dry or greasy. Since this original description, many articles have been written about the clinical

Eighty patients with varying types of inflammatory dermatoses were treated with a liquid solution containing fluocinolone acetonide 0.01% dissolved in propylene glycol. * While the over-all results were not as good as those reported for the 0.025% vanishing cream preparation, it was particularly effective for some patients whose dermatoses involved the scalp and other hairy areas and for some with intertriginous involvement.

In vitro and in vivo quantitative measurements indicate that dimethylsulfoxide (DMSO) enhances human percutaneous absorption of certain chemical agents.

To the Editor.— Topical corticosteroids are widely used in skin diseases, and the roster of changes they suppress is extensive. The changes they provoke are rather few but they may cause acneiform eruption, itching, irritation, hypertrichosis, burning sensation, striae, dryness, folliculitis, secondary bacterial infection, hypopigmentation, atrophy, maceration, or miliaria. Occlusive dressings with topical steroids may accentuate the above problems. Report of a Case.— This 14-year-old boy appeared in April 1969, with a red, moist, macerated dermatitis of the distal phalanx of the left index finger, present for five months. For cosmetic reasons, he had kept the area covered almost continuously with a "Band-aid." Skin scrapings and culture for fungi were negative. The lesion was treated with full strength flurandrenolide ointment, but was improved in July. Fluocinolone acetonide cream,.2% three times a day, with Saran Wrap occlusion overnight was then prescribed. The next month the dermatitis was gone, and so was

Within a few minutes after application to the surface of human skin, hydrocortisone and fluocinolone acetonide in the presence of dimethylsulfoxide (DMSO) are established in a protected reservoir in the stratum corneum. This reservoir remains over a 16 day period and is resistant to washing of the skin surface with soap, water, and alcohol.

Strict control of experimental variables yields a vasoconstrictor assay of extreme sensitivity and high precision that can be used to develop important information relating chemical structure and vasoconstriction following topical application to normal skin. In this assay fluocinolide has about five times the potency of the standard fluocinolone acetonide while triamcinolone acetonide and betamethasone valerate have approximately the same activity as fluocinolone acetonide. Hydrocortisone with only one thousandth the activity of fluocinolone acetonide is at the lower limit of sensitivity of the assay.

It has been the general experience that intralesional injection of suspensions of certain corticosteroids will consistently induce complete involution of lesions of psoriasis, 1-3 the effect being purely local. The same compounds have had little effect when applied as ointment or lotions. The effectiveness of intralesional injection is based on the injection of a suspension which creates a depot of crystals insoluble in tissue, and inhibition of the lesion continues (apparently) until the crystals are no longer present. In essence, this is a form of tissue-depot therapy. Intralesional injection, however, has certain limitations and disadvantages: It is time consuming, uncomfortable for the patient, and atrophy, usually reversible, of the skin and subcutaneous tissue is often a sequel. A method which is free of these limitations and objections would be highly desirable. Twelve patients with chronic patches of typical psoriasis have been used to study the possible effectiveness of an alternate

To the Editor.— In a recent letter (225:1658, 1973), ( Arch Dermatol 107:870-871, 1973) Kligman directed criticism at a double-blind evaluation that showed that 0.05% desonide cream, topically applied to inflammatory skin disorders, was as effective as 0.025% fluocinolone acetonide cream. He alleged that the doubleblind study had yielded a spurious result because (1) it had included too many skin diseases that respond too easily to treatment and (2) he concluded from his own unpublished observations that desonide was inferior to fluocinolone acetonide (both in unstated concentrations). Details of his study were not provided for objective scrutiny by the reader. Phillips et al 1 reported 0.05% desonide cream to be superior to 0.025% fluocinolone acetonide cream when applied to stabilized psoriasis, a disease that indeed does not respond easily to treatment. This report was based in part on our own testing of desonide on psoriasis via a study with a double-blind