Search

Patient informational/instructional sheets can be used not only to assist in providing patients with baseline ma- terial regarding their condition, but also aid in physicians communicating a treatment protocol. Educational material re- garding acne, adult acne, perioral dermatitis, and isotretinoin is included for perusal and discussion. Within this frame- work, one learns the unifying concept of the Propionibacterium acnes biofilm, methods to maximize production of ben- zoyl peroxide radicals (the active biological form of this compound), unplugging ability of oral antibiotics, and low-dose isotretinoin therapeutics. Caring for patients involves a number of critically impor- tant elements including being sympathetic, understanding, supportive, and educating them about their condition and their treatment regime. Regarding that latter point, there are diverse methods that can be utilized to convey to patients information concerning their individual skin condition and therapy. One method would be patient informational sheets to assist in providing patients with baseline material regard- ing their condition and treatment. Of course, they should be written in language which most patients will find easy to comprehend, and offered after greeting the patient and per- forming a history and physical examination. In the case of acne and related conditions, it is also helpful to introduce the topic by using diagrams explaining that bacteria within the hair follicle unit produce toxins that cause inflammation, and that treatments will be directed at these bacteria, or their food source, the sebaceous gland. Without further ado, figures 1 through 5 are the initial instructional sheets used in Sylvania, Ohio for the following conditions: acne, adult acne, perioral dermatitis, and isotreti- noin. Please note there is an additional sheet for females who opt for accutane, due to all the additional steps required to obtain this drug for this sex. Of note, these informational sheets selected for discussion are for patients who either have no insurance or insurance which provide limited drug coverage. Certainly, with patients with standard insurances, trade name products become more economically feasible and informational sheets would be easily modified to reflect one's preferred therapies with this expanded therapeutic ar- mamentarium. Physician-written instructional sheets parallel the clinical teachings and beliefs of the individual disease state. Thus, the remainder of this paper will discuss the mate- rial contained within these information sheets, and offering justification of the beliefs expressed within them.

Background: Seborrheic dermatitis affects approximately 2 to 5% of the populace. Interestingly, the term 'seb- orrheic dermatitis' is somewhat a misnomer as there is no direct quantitative relationship between the degree of sebaceous activity and susceptibility to seborrheic dermatitis. Method: A pilot study was performed to initiate assessment of patient satisfaction with oral minocycline and topical keto- conazole for seborrheic dermatitis, and in so doing, set a stage for discussion for a novel assessment on the pathophysiol- ogy of this condition. Results: Clinical improvement of seborrheic dermatitis occurred with oral minocycline and topical ketoconazole. In terms of all parameters studied, the condition improved with therapy and all patients desired to continue with the treatment regimen. Conclusions: One could speculate that the clinical benefit of seborrheic dermatitis with antibiotics is likely via its effect on the microbiology within the sebaceous unit as well as on the alterations which thereby occur to the composition of the sebaceous secretions as they pass through the pilosebaceous unit. After being secreted, human sebum can be altered by various factors including secretion of hyaluronidase, proteases, and lipases by P. acnes. A closer examination of the al- teration in sebum content both in the seborrheic condition and in treatment therapies warrants further investigation.

Background Concerns have arisen over the development of antibiotic-resistant organisms due to the prolonged use of oral and topical antibiotics in acne vulgaris. We have previously demonstrated that benzoyl peroxide used in consort with a chemical with an accessible tertiary amine, such as an allylamine, increases radical activity and biological effect. Objectives The purpose of this pilot study was to assess the efficacy of two nonantibiotic topical remedies for mild to moderate acne, with one of the agents being a combination of benzoyl peroxide with butenifine, an allylamine. Methods In an open-label, patient-satisfaction, 8-week comparative study, 23 patients demonstrating mild to moderate facial acne were given randomly either benzoyl peroxide in Proactiv Solution or the combination of benzoyl peroxide with an allylamine. Results The allylamine–benzoyl peroxide combination therapy outperformed Proactiv Solution during each 2-week stage of evaluation in terms of reduction of comedones, inflammatory lesions, and degree of oiliness. There was a marked preference for the allylamine–benzoyl peroxide combination in terms of patient satisfaction. Conclusions Benzoyl peroxide used in consort with antimicrobial agents that contain an accessible tertiary amine, such as erythromycin, has previously been shown to increase radical activity and biological effect. Trials of short duration with small numbers of patients do not adequately inform practitioners about whether the combination of allylamines with benzoyl peroxide is a viable alternative to topical antibiotic therapy for acne. Nevertheless, the higher satisfaction with the allylamine–benzoyl peroxide combination certainly warrants further investigation.

Summary Background Dermatophyte infections can be polymicrobial. Topical antifungal therapies offer limited coverage of yeasts and Gram-positive and Gram-negative bacteria. Moreover, the increased usage of these topical antimicrobial agents has resulted in the development of resistant cases. Benzoyl peroxide (BP), used in concert with antimicrobial agents containing an accessible tertiary amine, has previously been shown to increase radical activity and biological effect. Objectives To determine the applicability of using the tertiary amine terbinafine in concert with BP in dermatophyte and mixed skin infections by means of in vitro testing. Methods In this preliminary in vitro study, the effect of BP, alone and in combination with terbinafine, was tested against Candida albicans, Pseudomonas aeruginosa and Staphylococcus aureus isolates following a checkerboard modification of the National Committee for Clinical Laboratory Standards M27-A2 and M7-A6. The individual minimum inhibitory concentrations of terbinafine, BP, and the combination, were determined against each isolate. Results The combination of BP with terbinafine led to additive activities against the majority of Candida albicans isolates tested and additionally expanded the bacterial coverage of terbinafine. Conclusions The combination of antifungal agents bearing a tertiary amine with BP may have benefit in polymicrobial infections, given its wider antimicrobial coverage. Further appreciation of this mechanism of catalysis of BP radical formation by certain antimicrobials and other tertiary amine-containing compounds may lead to the discovery of improved treatments for several dermatological conditions.

Intertrigo is a superficial inflammatory dermatitis involving juxtaposed skin surfaces subjected to friction, heat, moisture, and maceration. In response to encouraging reports of topical sucralfate's effect on epithelialization of wounds as well as its bacteriostatic property, a clinical trial evaluating its possible role as a topical agent for intertrigo was initi- ated. For expected beneficial effects, zinc oxide and ketoconazole were added with sucralfate to the vehicle. The study was an open-label comparison designed to examine patient satisfaction with topical sucralfate vs the patients' prior thera- pies for their condition. At the conclusion of our pilot study, patients completed a survey questionnaire so that we could assess the value of this product in clinical usage. By all parameters queried, patient satisfaction was very high with this product for their condition. It is conjectured that such a formulation might be useful also for diaper rashes, diaper wipes, blisters, and open skin sores.

Current concerns about persistent visual abnormalities after the use of isotretinoin may lead the Federal Aviation Administration to further restrict its use in pilots or future pilots.

A 33-year-old male experienced three episodes of urticaria precipitated by exposure to a hidden source of ampicillin. Each occurrence coincided temporally with his girlfriend taking ampicillin for a chest cold and/or allergies. We postulate that he was exposed to ampicillin in the body fluids of his sexual partner.

Scabies continues to be a major public health problem. Recent findings reveal that these mites produce substances that modulate the host's immune response resulting in the latency period prior to symptoms. In terms of treatment, two cases of ivermectin resistance have come to fore in Australia in patients treated over fifty times with the agent. Additionally, work in the development of vaccination of hosts with antigenic midgut proteins of mites to control ectoparasitic infestations continues.

Head lice infestation is a common and growing problem, primarily affecting school-aged children. There are growing numbers of treatment failures due to the emergence of treatment-resistant lice to the popular over-the-counter products that have been used for the past several decades. Resistance has also decreased the efficacy of lindane, a prescription pediculicide that has been commonly used for several generations. Malathion, recently reintroduced in the US as a prescription pediculicide, has been associated with some treatment resistance depending upon its formulation. Other insecticidal treatments, such as ivermectin, will have to be developed further, given the limited options presently available for the treatment of head lice. Given the number of anecdotal and market-driven reported studies on head lice, assessment of topical lice therapies requires standardised in vitro testing. Based on concerns about safety and decreasing efficacy due to resistance, a reassessment of the general topic of pediculicides for head lice is warranted.

Background Pinworms are the most common helminth infection in the USA and Western Europe, with prevalence rates in some communities of as high as 30–50%. Pinworms generally live in the gastrointestinal tract, and helminth infestations have been noted in over one-quarter of acute appendectomies on histologic examination. Results & Conclusions Although transmission is often attributed to the ingestion of infective eggs by nail biting and inadequate hand washing, inhalation and ingestion of airborne eggs also occur. The female Enterobius vermicularis migrates nightly to the perianal area to deposit her eggs, but some worms find their way into adjacent orifices, most commonly the female genitourinary tract, producing an array of symptoms. More consideration of this entity is justified in patients presenting with genitourinary complaints not responding to normal therapies. In the treatment of pinworms affecting genitourinary organs, treatment with possibly two oral agents, namely mebendazole and ivermectin, and a topical therapy for the eggs may be warranted.

Head lice infestation is a common and growing problem that primarily affects school-aged children. Most cases of head lice are diagnosed and treated by nonphysicians. Misdiagnosis may lead to treatment when no lice are present. Treatment failure may lead to repeated use of and improperly applied pediculicides, potentially resulting in overexposure to pesticides. These treatment failures are primarily due to the emergence of treatment-resistant lice. In regions where resistant lice are common, patients may self-treat numerous times with over-the-counter pediculicides before seeking treatment from a physician. Resistance has decreased the efficacy of lindane, a prescription pediculicide that has been used for decades. In addition, the Food and Drug Administration recently warned of potentially serious adverse effects associated with lindane and recommended strict controls for its use. Malathion, recently reintroduced in the United States as a prescription pediculicide, has not been associated with treatment resistance or notable adverse effects, although it is flammable due to its alcohol base. Because of concerns about decreasing efficacy due to resistance and safety concerns about over-the-counter products and some prescription pediculicides, a reassessment of pediculicide safety is warranted. The safety and efficacy of commonly used over-the-counter and prescription pediculicide products are discussed, along with the safety and efficacy of other treatments, such as ivermectin, that are not indicated for the treatment of head lice but are being used increasingly.

Background There is clinical uncertainty concerning the effectiveness of the new topical immunomodulators vs. the conventional use of topical steroids for the treatment of atopic dermatitis. Objectives To assess patient satisfaction with these two prescription topical remedies for atopic eczema. Methods In an open-label, 2-week, comparative study, 10 patients demonstrating atopiform dermatitis were given tacrolimus and 0.1% hydrocortisone butyrate in a 70% oil-in-water base to apply to the eczema on opposite sides of the body. After 2 weeks of applying the agents twice daily to their respective sides of the body surface, the study subjects completed a 12-question survey to assess their opinions of the two products. Results There was a preference for the nonfluorinated topical steroid over tacrolimus in this cursory head-to-head study. There were no withdrawals from the study or side-effects reported with either product. Conclusions Trials of short duration with small numbers of patients do not adequately inform practitioners regarding the use of these topical remedies. However, the higher satisfaction of patients with 0.1% hydrocortisone buyrate in a 70% oil-in-water base over tacrolimus certainly warrants further investigation.

Contrary to previous reports, azithromycin has now been associated with arrythmias and sudden cardiac deaths. There is a need for careful consideration of these risk factors with this drug especially when prescribing for the elderly. A more thorough screening of cardiovascular risk prior to starting azithromycin may also be warranted.

Background: Benzoyl peroxide is the most widely used topical agent for acne since the 1960s. Concomitant treatment of benzoyl peroxide with oral, or topical antibiotics diminishes the multiplication of antibiotic-resistant strains of Propionibacteria acnes. Besides being antibacterial, the chemical also functions as a peeling agent, has comedolytic activity, reduces free fatty acid levels, and is touted to be sebosuppressive. Objective: The purpose was to determine the ability of topically applied benzoyl peroxide to suppress lipogenesis of the sebaceous glands. Methods: The data were obtained employing an animal model for human sebaceous glands, namely, the flank organs of female golden Syrian hamsters. Results: Our results reveal no inhibition of lipogenesis in sebaceous glands by topical application of benzoyl peroxide. Conclusion: Despite many functions beneficial in acne therapy, benzoyl peroxide does not possess sebosuppressive capabilities. With the advent of water-soluble organic peroxides revealing similar antimicrobial activity to benzoyl peroxide, all therapeutic parameters (save for sebosup-pression) will need to be assessed to weigh the benefits of these second-generation acne-fighting peroxides.

Heparin is an injectable anticoagulant that prevents coagulation. There are presently high and low molecular heparins as well as synthetic pentasaccharide inhibitors. Given its ubiquitous use in sensitive medical states, there is a high concern for safety with this drug. Heparin can induce several distinct immune-mediated reactions. There are several options to consider when heparin al- lergy occurs including use of direct thrombin inhibitors such as lepirudin and bivalirudin. Of significant relevance, one must make sure that what appears to be heparin allergy is not, in reality, a reaction to a pre- servative. Benzyl alcohol is used as a solvent and preservative in many products including high and low molecular weight heparin and heparin lock flush solution. Allergic contact dermatitis from benzyl alcohol is well known and is on many lists of recommended patch test lists for preservatives. Heparin is a highly-sulfated glycosaminoglycan that is an injectable anticoagulant that prevents clot formation. Thus, the agent is used in patients for thrombotic disorders or in situation in which blood clots are otherwise eminent. Such instances include deep vein thrombosis, pulmonary emboli, myocardial infarctions, and strokes. Heparin is a biological substance that works by activating antithrombin III and thereby blocking thrombin from clotting blood. Heparin can be used by injection, or can be used on medical devices to prevent similar clot formation. There are now more highly processed products available referred to as low molecular weight heparin. They also are administered subcutaneously, but given their predictable clinical results, do not require strict monitoring. Examples include enoxaparin (Lovenox and Clexane), certoparin (San- doparin), ardeparin (Normiflo), parnaparin (Fluxum), tinza- parin (Innohep and Logiparin), dalteparin (Fragmin), revi- parin (Clivarin), and nadroparin (Fraxiparin). These agents have fewer side effects and have more predictable plasma levels. Additionally, there are synthetic pentasaccharide inhibi- tors of factor Xa. Fondaparinux (Arixtra) and Idraparinux are examples of these synthetic five sugars in heparin that form the high affinity biding site to antithrombin III. These agents are also administered subcutaneously.

Darier’s disease is inherited in an autosomal dominant fashion.1 Nevertheless, half of affected persons have no family history of the condition. Darier’s disease presents with scattered, greasy, keratotic papules on the face, neck, chest, back, and extremities that coalesce forming plaques. It is exacerbated by heat and sweating, and usually worsened by exposure to sunlight.1 The cause of the distorted keratinization is dissolution of desmosomal plaque proteins, specifically, desmoplakin I and II, plakoglobin, and desmoglein.2 The result of this defect is a deficiency in the tonofilament/desmosome attachment, leading to tonofilament clumping and vesicle formation. Because oral isotretinoin is effective in this condition,3 the new topical acetylenic retinoid tazarotene was tried in a patient.

Background. Topical anesthetics are widely used to diminish the sensation of pain from various medical cutaneous procedures. Any topical agent that reduces the desired effect has clinical ramifications. Materials and Methods. Topical 6% benzocaine cream was applied to both inner forearms of five persons and covered with a bandage. One of the arms was additionally treated simultaneously with 5% benzoyl peroxide. The areas were tested with a pinprick examination every 10 minutes for the ensuing hour. Results. There was an estimated 75% increased perception of pain on the forearm to which benzoyl peroxide was applied in consort with the topical anesthetic at all examination times. Conclusions. Benzoyl peroxide chemically reacts with topical anesthetics such as tetracaine, procaine, pramoxine, prilocaine, and lidocaine, causing a significant reduction in their numbing effect. Clinically, make sure that the skin area to be topically anesthetized is devoid of any previous treatment with benzoyl peroxide or insist that the skin is thoroughly washed prior to application of the anesthetic. CRAIG G. BURKHART, MPH, MD, AND CRAIG N. BURKHART, MSBS, MD, HAVE INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS.

Head lice are caused by the host-specific, ectoparasitic insect Pediculus humanus capitis De Geer and remain a common human infestation. As a response to increasing resistance of head lice to present insecticidal agents, additional agents must be pursued. Inasmuch as nicotine has been used for controlling poultry lice, an in vitro study assessing its possible usage for human head lice was performed. Nicotine proved not to be an efficient insecticide, although it may facilitate removal of adult lice because it induces muscle twitches that may affect the insect's normal grip on hair follicles.

Summary Superficial fungus infections are seen in animals and humans alike. Prescription and most over-the-counter treatments act on the fungal cell wall. Whereas in humans, allylamines and azoles are now available along with griseofulvin for oral treatment of dermatophyte infections, these newer agents are not presently licensed for use in animals. At our horse farm, three ground 250 mg tablets of terbinafine given orally for 10 days proved curative in two horses with culture-positive fungal infections of their skin. Terbinifine (LamisilŖ), the only approved oral allylamine for human use, constitutes a new class of anti-dermatophyte medications that provide superior effectiveness with an extremely high safety profile.1,2 The drug blocks squalene epoxidase in the synthesis of ergosterol,2,3 which along with protein and phospholipid molecules, composes fungal cell membranes. Without functional ergosterol, membranes become permeable and stiffen. Terbinifine, unlike the other oral antifungals, itraconazole and griseofulvin, is fungicidal without acting via the cytochrome P-450 enzyme system.2 Neither terbinifine or itraconazole is licensed for veterinary use. Given the superior results of the newer oral antifungals in human dermatophyte infections, we opted to test terbinifine's effectiveness on horses.

Presently, the Civil Aviation Authority in the United Kingdom completely contraindicates pilots from flying while on isotretinion [1]. Additionally, following a month off the drug, an English pilot is required to have formal ophthalmologic assessment by the Civil Aviation Authority. The guidelines for flight surgeons in Canada restricts pilots to A3 category in which pilots using isotretinoin are restricted to fly with or as copilot only. The Federal Aviation Administration in the United States has restrictions that persons on the drug are not approved for night flying, but is presently reviewing if more restrictions are appropriate.

We noted the interchange between Franz et al 1 and Downs 2 in recent issues of theArchivesconcerning the available topical scabietic agents that are currently used. However, with the Food and Drug Administration's approval of ivermectin (Stromectol, Merck & Co Inc, West Point, Pa) in November 1996, a new era of scabietic therapeutics began. Ivermectin is an anthelmintic used extensively in veterinary medicine for a wide range of nematode, insect, and acarine parasites, including Sarcoptes scabiei in animals. 3 We use this drug routinely every 2 months for all the Arabian horses on our farm to control any potential parasitic infection. In fact, ivermectin is sold over-the-counter at farm supply stores, tack shops, grain elevators, and via stock catalogs for animal use. The drug has also been used in more than 6 million people for diseases, including onchocerciasis, strongyloidiasis, loiasis, bancroftian filariasis, and cutaneous larva migrans. There already

To the Editor.— Herpes gestationis is an intensely pruritic, subepidermal, bullous dermatosis of pregnancy. The eruption involves the abdomen, with frequent extension to the chest, back, and extremities. The onset of herpes gestationis is usually in the fifth or sixth month of pregnancy. Herpes gestationis is reported to contribute to an increased incidence of fetal mortality. 1 The cause of the condition is unknown, although immunologic factors seem to play a prominent role. 2,3 Reports in the literature describe the role of pyridoxine hydrochloride in the possible cause and treatment of herpes gestationis many years ago. 4,5 A major textbook continues to quote these references. 6 The use of pyridoxine in the treatment of a patient with herpes gestationis is discussed herein. Report of a Case.— A 26-year-old woman was seen in the Dermatology Clinic of the Medical College of Ohio, Toledo, with an intensely pruritic and extensive vesiculopapular and

To the Editor.— Pitted keratolysis is a noninflammatory bacterial infection characterized by discrete crateriform pits of the stratum corneum on the plantar surface. The causative microorganism has been shown to be a Corynebacterium . 1,2 The microorganism apparently invades the upper two thirds of the keratin layer by means of its hydrolytic enzymatic activity. 2 Environmental factors are important in inducing the overgrowth of Corynebacterium . Hyperhidrosis is almost universally present in patients with pitted keratolysis. 3,4 Continuous foot moisture during three-day military field trials caused pitted keratolysis to develop in 53% of 387 volunteers.4 Evidently, skin friction is also important in the pathogenesis of this condition, as weight-bearing plantar surfaces are primarily involved. Various medications, including oral erythromycin, 1 0.1% triamcinolone acetonide, iodochlorhydroxyquin-hydrocortisone cream, flexible collodion, benzoic and salicylic acid ointment, and formaldehyde solution, 5 have been used with limited success for this disease. I am reporting here the successful use

To the Editor.— Various drugs can produce a wide variety of reactions in the skin. Certain drugs are capable of aggravating existing acne or inducing acneform eruptions. What I believe to be the first case of quinidine sulfate-induced acne is reported herein. Report of a Case.— A papular eruption occurred on the chest and back of a 57-year-old man who had a history of premature ventricular contractions soon after the initiation of therapy with quinidine. The eruption continually worsened during the ensuing year with continuation of the quinidine therapy. The patient was receiving no other oral medications. On physical examination, numerous papulopustules were noted scattered on his back and chest, intermixed with an occasional open and closed comedone. There were no cystic lesions or scars. Quinidine therapy was continued. Topical treatment was initiated with an erythromycin solution and a topical benzoyl peroxide preparation. Excellent resolution of the eruption occurred within