American Academy of Dermatology

Meeting reDort III II

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American Academy of Dermatology Thirty-ninth Annual Meeting, New York, NY, Dec. 6-11, 1980 Harry L. Arnold, Jr., M.D., and Rees B. Rees, M.D. Honolulu, HI, and Santa Rosa, CA

More than 9,000 registrants, more than 6,000 of them M.D. 's and nearly 4,000 of them members, attended the first New York City meeting of the Academy since we met there Dec. 6, 1941, the day before Pearl Harbor. President Alfred W. Kopf presided; Gordon W. Sauer was vicepresident, and W. Mitchell Sams, Jr., was chairman of the Council on the Annual Meeting. LILA GRUBER MEMORIAL CANCER RESEARCH AWARD LECTURES Private life of the epidermal cell

Howard Green, M.D., professor of cell biology at Massachusetts Institute of Technology, spoke on keratinocyte physiology as studied in tissue culture. "Keratins" are not unique to epidermal keratinocytes and occur not only in all stratified squamous epithelia, but also in epithelium of the trachea, bladder, gut, ducts, and the collecting tubules of the kidneys. The epidermis produces large molecular keratins (76,000 daltons), but other stratified squamous epithelia do not. Cultured keratinocytes do not synthesize these larger molecules. As cells migrate outward in the epidermis, new messages instruct them to build both heavier and lighter keratins. Only by recombinant gene technology will we ever be able to tell whether multiple genes are involved in this process. After the outwardly migrating keratinocyte dies, a marginal band of electron-dense material forms inside the cell membrane, which is even less soluble than keratin. Matoltsy first noted this development more than 30 years ago. About 120 ,i, (12 nm) thick, the species-specific protein is totally insoluble in denaturing and reducing agents, and survives even boiling in ionic detergents. Its polypetide precursor is called involucrin, a com484

pound unique to epidermis. None of it is formed below the upper two thirds of the prickle layer, and it is peripheral in the cell from the start. Cross-linking (by transglutaminase) is initiated in suspension cultures. A calcium-transporting ionophore accelerates its formation, from 20 to 60 hours to 5 to 40 minutes. Cross-linking of keratins is a completely different process, which involves disulfide bonds and is independent of transglutaminases. Controlling cancer: Destruction or subduction?

Eugene J. Van Scott, M.D., professor of dermatology at Temple University, spoke of alternatives to destruction in the control of cancer. After nearly 30 years, he said, destructive chemotherapy is still a disappointment. And deoxyribonucleic acid (DNA)-damaging " c u r e s " are both toxic and mutagenic. Are there other ways? Antimetabolites are not mutagenic, as DNA binders are. (See Harris CC: J Natl Cancer Inst 63:275, 1979). Today, the risk of a second cancer 20 years later, in children who are 5-year survivors of cancer, is 8% to 16%, and the risk of acute leukemia after recovery from plasma cell myeloma is 17.4% at 50 months. Basal cell carcinomas, said Van Scott, may fail to form a tough cell membrane (involucrin) and so fail to stop growing; there is no maturation of the cells. As Pinkus showed in rats, in 1977, transplantation to new tissue sites restores terminal differentiation. In the November, 1980, issue of the Journal of the National Cancer Institute, Kubilos et al confirmed the results of Pinkus's crucial experiment. Podophyllin induces huge thickening of the granular layer in nom-ml skin, psoriatic lesions, 0190-9622/81/100484+ 16501.60/0 9 1981 Am Acad Dermatol

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Abbreviations used ACLE ALM BP DLE DT HG IFK LE LGV LMM LP MCTD MF NM PCT PLE PUPPP SCLE SLE SSS UCTS

acute cutaneous lupus erythematosus acral lentiginous melanoma bowenoid papulosis discoid lupus erythematosus desmoplastic trichoepithelioma herpes gestationis inverted follicular keratosis lupus erythematosus lymphogranuloma venereum lentigo maligna melanoma lymphomatoid papulosis mixed connective tissue disease mycosis fungoides nodular melanoma porphyria cutanea tarda polymorphous light eruption pruritic urticarial papules and plaques of pregnancy subacute cutaneous lupus erythematosus systemic lupus erythematosus superficial spreading melanoma undifferentiated connective tissue syndromes

These pyridines can effect complete resolution in psoriasis and also in erythematous MF lesions, when administered to local test areas. We are entering a new era of new compounds, which appear to work quite differently from the cytotoxic compounds used chemotherapeutically so far.

DISEASES OF THE GENITALIA Peter J. Lynch, Tucson, AZ, moderated this symposium on Monday afternoon.

Vulvar dermatoses Alexander W. Young, of New York, works closely with gynecologists in a vulvar disease clinic in New York. Noninfectious, nonneoplastic cutaneous vulvar dermatoses consist mainly of contact dermatitis and intertrigo. Distinct, however, is lichen sclerosus et atrophicus. He does not use topical testosterone, but eliminates irritants. Syringomas, he said, may be itchy in this area, as are all but 5% of lesions of Bowen's disease, which is becoming increasingly common in women in their twenties and thirties.

Erythroplasia of Queyrat and buccal mucosa--and also in basal cell carcinomas! Polychlorinated naphthalene induces heavy cornification of the mouse vaginal epithelium. Methylcholanthrene in olive oil induces heavy cornification in monkey hair follicles. Acetyl phenylglycolic acid provokes comification too. Cornification in a cancer means a low-grade malignancy. The most heavily cornifying epidermal tumor, the keratoacanthoma, is self-healing. Both retinoids and the alpha-hydroxy acids suppress keratinization and thus help separate overly coherent cells in the stratum corneum. An antagonist to these might therefore work against cancers. Robert C. Gallo at the National Cancer Institute has found a type C (RNA) retrovirus in blood and lymph nodes in mycosis fungoides (MF), which may be the source of a T cell growth factor he finds in this disease. Now 3.6-substituted pyridines have been added to the retinoids, steroids, nitrogen mustard, methotrexate, PUVA, UVB, and x-rays, in combating both psoriasis and MF.

Richard B. Odom, of San Francisco, described topical chemotherapy with 5-fluorouracil (5-FU) for this disease. Older treatments (amputation, fulguration, curettage, cryosurgery, local resection, irradiation, and Mohs' technic) were all unsatisfactory for obvious reasons. Odom has had good results with 5% 5-FU cream or liquid, applied twice daily for 3 to 5 weeks, using a long prepuce or a condom to provide occlusion. Lidocaine ointment or jelly is used to relieve pain, which may be severe. Allergic contact dermatitis occasionally occurs. The cure rate is high; patients remain ambulatory; virtually all normal tissue is spared; function is preserved; and cost is low. Long posttreatment observation is mandatory.

Penile cysts Richard G. Asarch, of Des Moines, said that penile cysts occur anywhere along the median raphe, and are of various types: epidermal inclusion cysts, urethral diverticula, dermoid cysts, or apocrine cysts. Excision with primary closure is the treatment of choice, but the contents should be

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cultured: Neisseria gonorrhoeae has been found occasionally!

Tumors of the vulva Constance M. Ridley, of London, England, author of the beautifully written book, The Vulva* listed some of the many neoplasms of the vulva: hidradenoma, basal cell carcinoma, carcinoma metastatic from the ovary, malignant melanoma, adenocarcinoma, tumors of Bartholin's glands, squamous cell carcinoma, and intraepidermal carcinoma of Paget's type and of Bowen's type. Metastases of squamous cell carcinomas to the regional glands can be difficult to assess. The clitoris, for example, drains to nodes deep in the pelvis. Radical vulvectomy is the treatment of choice for these malignant tumors. X-ray and chemotherapy are relatively ineffective. Predisposing factors include lichen sclerosus et atrophicus, which has only a small chance of malignant degeneration, but one should keep checking. Lesions may arise de novo. Preexisting intraepidermal carcinoma may degenerate into frank invasive malignancy. For intraepidermal (Bowen's) carcinoma, she uses liquid nitrogen, topical 5-FU, or a CO~ laser. Immunosuppression and pregnancy may aggravate vulvar cancers. Herpes simplex is not as important a factor in inducing genital malignancies as some have suggested. Dr. Friedrich found thirteen cases of warts of the genitalia in which malignancy supervened. Look for malignant lesions elsewhere when Bowen's disease of the vulva is present. Extramammary Paget's disease, in the middleaged or elderly, may have a banal appearance clinically. Origin may be from the epidermis, Bartholin's glands, or the cervix. Treatment is excision in toto, and one may find a deep underlying carcinoma. Such patients have an increased incidence of malignancy elsewhere, such as in the breast.

Fox-Fordyee disease William A. Card, of Chicago, discussed FoxFordyce disease, which was first described in 1902. Shelley and Hurley, in 1956, renamed it *Philadelphia, 1975, W. B. Saunders Co.

apocrine miliaria. Treatments of the past which have failed include hormones, surgery, and dermabrasion. Pregnancy has an adverse effect. Caro found temporary benefit with the use of tretinoin (Retin-A 0. i% cream or gel) topically. Relapses occur, but the lesions respond on reapplication (Giacobetti, Caro, and Roenigk: Arch Dermatol 115:1365, 1979).

Secondary syphilismcan you recognize it? Thomas A. Chapel, of Detroit, asked whether you could diagnose secondary syphilis. In the Detroit area, there seems to be suspicion in about 95%, and diagnoses are 85% accurate. Sixty-two percent of such patients have seen an M.D. without being diagnosed. Only 35% of physicians outside his institution (Wayne State University) made an accurate diagnosis. CUTANEOUS TUMORS Marvin Chernosky, of Houston, TX, moderated this symposium on Monday afternoon.

Malignant melanoma: A different view A. Bernard Ackerman, of New York, challenged the accepted view that there are four types of melanoma: superficial spreading (SSM), lentigo maligna (LMM), acral-lentiginous (ALM), and nodular (NM). The same lesion by every criterion, said Ackerman, may be labeled LMM if it occurs on sun-damaged skin of the face, or SSM if it occurs on the trunk, or ALM if it is on a fingertip. How can you distinguish the types, then? You cannot! Neither will histologic criteria make it possible. Dendrites are prominent in ALM, but only in early in situ lesions are they distinctive, and they may be seen in melanomas anywhere in the skin. Pagetoid cells are not unique to so-called SSMs: they may be found in melanomas in any site. And every so-called nodular melanoma had to begin perfectly flat, in level I, in order to become a nodule. Any melanoma may develop a nodule. The diagnostic histologic criteria, said Ackerman, are: 1. Broad, asymmetric, poorly circumscribed lesions 2. Nests (theques) of various sizes and shapes, with much confluence into sheets

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3. Scattering of melanocytes at all levels of the epidermis 4. Extension of abnormal melanocytes within the epidermis beyond the main lesion 5. Mitotic figures and necrotic meIanocytes, and melanocytes with atypical nuclei

Activation of nevi in patients with malignant melanoma Stephen B. Tucker, of Houston, said that time has confirmed Allen and Spitz's 1953 report of unusual changes in nevocytic nevi in patients with malignant melanoma. Junctional nesting and lack of sharp margination of lesions are increased in benign moles in patients with melanoma as compared to controls. Many criteria for melanoma may be found in such moles, but cellular atypia is lacking.

Bowenoid papulosis James H. Graham, of the Armed Forces Institute of Pathology in Washington, DC, said that bowenoid papules of the genitalia (as many in females as in males!) come and go, and also go and come. In their male patients, 32% of lesions were on the penis, 22% on the shaft, 5% on the glans, and 4% on the prepuce. Lesions may, he said, resemble lichen planus, granuloma annulare, seborrheic keratosis, or epidermal nevus. In bowenold papulosis (BP), the cellular atypia usually spares the follicular infundibulum but involves the acrosyringium and even the sweat duct; whereas in true Bowen's disease, the follicular infundibulum is regularly involved but the acrosyringium is almost always completely spared, and never severely involved. Virus-like bodies have been identified in the horny layer. BP is, said Graham, a benign reactive process, probably caused by a virus, with malignant cytologic features but no capacity to invade or metastasize.

Immunologic surveillance and epidermal malignancies Edgar " B e n " Smith, of Galveston, TX, said that light causes skin cancers by inducing formation of DNA dimers, by prolonging the S phase of the cell cycle, and by damaging chromosomes. Initially the effect is inhibition, and then it is proliferation.

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There are many animal studies to show that immune mechanisms do inhibit skin cancer, and the increased incidence of cancer in immunosuppressed humans is high enough to bear this out. It is not yet clear whether T cells are diminished in cases of skin cancer, except in patients with large, aggressive tumors. Dinitrochlorobenzene (DNCB) reactivity in sun-damaged skin is much reduced over that in undamaged skin. Even acute sunlight exposure produces this effect. Probably the mechanisms are several: reduction of T cell function, wiping out of Langerhans cells, promotion of suppressor T cells, and production of prostaglandins. The effects cannot yet be quantified, he thinks. C O N N E C T I V E TISSUE D I S E A S E

Denny L. Tuffanelli, of San Francisco, moderated this symposium on Tuesday morning.

Undifferentiated connective tissue syndromes (UCTS) E. Carwile LeRoy, of Charleston, SC, prefers the term UCTS to such terms as " e a r l y , " "overlapping," " m i x e d " (MCTD), or "ill-defined." (See LeRoy EC et al: Arthritis Rheum 23:341, 1980.) "Puffy hand" syndrome is common to MCTD and UCTS. In UCTS, two features predictive of scleroderma are (1) morphologic and flow abnormalities of the microvascular bed and (2) an antiendothelial cytotoxin in serum and plasma. " M i x e d " and "overlap" syndromes, he considers, are simply early UCTS and may eventuate in SLE, scleroderma, or Sjrgren's syndrome. UCTS excludes the benign and reversible connotations o f MCTD.

Childhood dermatomyositis Richard K. Winkelmann, of Rochester, MN, categorized this as a primary inflammatory muscle disease of central girdle muscles, with swelling, tenderness, pain, and weakness. Malignancy is rare in children with dermatomyositis. Edema of lips and eyelids and extensor extremities, often with mottled erythema of the face, may be seen initially. Lichenoid papules often occur on the knuckles, with lichenoid or poikilodermatous histology. Weakness is prominent in most cases, but clinical manifestations may be confined

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to the skin, and indomethacin alone may alleviate them. Either an acute or a chronic course characterizes 80% of the cases, but some cases run a relapsing course, especially if steroid therapy is used. Virus infections, cancer (rarely), or any reactions may trigger the onset; sunburn does so less often in children than in adults. In the Banker type, vascular changes predominate: infarcted livedo with leukocytosis, anemia, and destructive vascular disease. Death from gastrointestinal or pulmonary infarcts may occur. In the Brunsting type, in contrast, the course is slowly progressive, without dysphagia, anorexia, or fever. The response to steroids, poor in the Banker type, is good in the Brunsting type. (See Paehman and Cooke: J Pediatr 96:226, 1980.) Calcium deposits often occur and, if painful, should be excised. Acanthosis nigricans may be a result of high-dose estrogens or long-term steroid therapy with oral prednisone. Ruiz-Maldonado finds cytotoxic agents helpful in childhood dermatomyositis if they are used from the start and not saved for desperate straits. Azathioprine, as in adults, has been ineffective in Winkelmann's cases. Plasmapheresis might be worthwhile in the Banker type, in which steroids are not helpful. In the Brunsting type, mortality is only 10% with steroids alone. Therapeutic options in connective tissue (CT) disorders Denny Tuffanelli spoke first of lupus erythematosus (LE), reminding us that in LE patients with acne, tetracycline and diazides should be avoided. Antimalarials may be useful; of these, hydroxychloroquine (Plaquenil) is first choice and then chloroquine if hydroxychloroquine fails. Watch out for arrhythmias, especially in children. Pigmentation of the palate, shins, or retina may occur; have the fundi checked initially, and every 3 months or so during treatment. Protection against sunlight is fundamental. If hair loss occurs, intralesional steroids may be helpful. Newer treatments are thalidomide (not in the United States: the FDA feels American physicians cannot be trusted with it), dapsone, plasmaphere-

sis, and nonsteroidal anti-inflammatory agents such as indomethacin (Indocin), ibuprofen (Motrin), and others. Watch for the combination of porphyria cutanea tarda (PCT) with LE! In scleroderma, dimethyl sulfoxide's (DMSOs) position is not yet settled. Azulfidine (salicylazosulfapyridine), penicillamine, phenytoin (Dilantin), immunosuppressives, or plasmapheresis (extremely expensive) may all be helpful; steroids are not usually useful, and may do harm. In Raynaud's, avoidance of smoking and cold are of paramount importance. Tranquilizers, reserpine, prazosin (Minipress), and Nitro-Bid (2% nitroglycerin ointment) may all help. Linear morphea in children, in the face or on a limb, may lead to catastrophic disfigurement despite anything one can do. LE subsets: Immunologic m a r k e r s James M. Gilliam, of Dallas, TX, justified his refined "splitting" of SLE on the ground that it may show us the way to better prognostic and genetic indicators. His subsets are serologic, clinical, and pathologic. The serologic subsets are identified by the finding of anti-DNA antibodies, antihistone antibodies, or a series of anti-ENA antibodies: antiRNP, anti-Sm, anti-SSA (Ro), anti-SSB, and anti-Ma. ANA itself is not helpful in this exercise. Clinical subsets are lupus nephritis, central nervous system lupus, and cutaneous I.E, which is divided into discoid (DLE), subacute or acute cutaneous (SCLE or ACLE), and LE profundus. SCLE is extensive but nonscarring, and no serious central nervous system or renal disease occurs. HLA-DRw3 is three times more common (77%) than in controls, and B8 almost 21/2 times, which is interesting genetically but of course useless in individual cases. RECENT ADVANCES Rudolph Baer's luncheon for distinguished professors from abroad was attended by Professors Klaus Wolff (newly appointed professor at Vienna), Charles M. Lapi~re (Lirge, Belgium), Otto Braun-Falco (Munich), Ronald Marks (Cardiff, Wales), Rubem David Azulay (Rio de Janeiro), and Atsushi Kukita (Tokyo, Japan).

Volume 5 Number 4 October, 1981 Azulay's case presentation was one of classical Oriental sore produced not by Leishmania tropica but by Leishmania braziliensis, to show that it is the immune state of the patient, not the species of Leishmania, that determines the clinical pattern as between the usual eastern disease, "cutaneous leishmaniasis," and the usual Brazilian one, "mucocutaneous leishmaniasis." Klaus Wolff said that PUVA had given them "very good" results in palmoplantar psoriasis, clearing in 4 to 6 weeks without, or 1Y2 to 2 weeks with, the help of oral aromatic retinoid. Relapse occurs quickly, however, as was confirmed by Braun-Falco's experience. Braun-Falco uses 8-methoxypsoralen topically with UVA. Braun-Falco and Wolff have both had encouraging results in lichen sclerosus et atrophicus with heparin-hyaluronidase ointment. Wolff has found 2% testosterone ointment effective on the genitalia but not on the trunk. Ketoconazole, still wearily plodding through the seemingly endless mire of FDA requirements, is effective in 50% of cases of toenail onychomycosis in Lapi~re's experience and in that of Kukita and Braun-Falco, who added that transient nausea in about 20% of cases was the only side effect they had observed. Recurrences are common after treatment is stopped. Azulay has found it effective in systemic mycoses, paracoccidioidomycosis, and candidiasis, but ineffective in blastomycosis and lobomycosis. The dose is 200 mg a day by mouth. Alopecia totalis is helped by anything that chronically irritates the scalp, in Azulay's experience. Braun-Falco had found anthralin (to the point of irritation) and PUVA (in only 30%) effective. Wolff prefers to try not to treat them, but if he must he likes short courses of steroid (oral prednisone?), or inflammation induced by application of dibutyl ester of squaric acid, not DNCB. Lapi6re uses steroids first, then 0.001% DNCB in absolute acetone, then PUVA. Neither Marks nor Wolff believes DNCB carries any serious mutagenic risk, though it is forbidden in Germany on this ground. Kukita's case report was on nevus of Ota, of which some 200 cases are now on record in Japan. Solid carbon dioxide for 1 or 2 seconds with

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moderate pressure, every 2 weeks for 6 months, may be helpful in lightening the pigmentation, but Covermark may still be necessary for concealment. Marks, Lapi~re, and Wolff all find intralesional steroids fairly helpful in lichen pilaris; Wolff had found aromatic retinoid helpful in one case. Braun-Falco likes chloroquine and INH, but not steroids. Persistent pruritus had baffled every panelist. No panelist had seen BP of the perianal area, nor had any seen invasion occur in the usual genital lesions. Is chloroquine dangerous, in polymorphous light eruption (PLE) or in lupus? The Japanese government has banned its use, Kukita said. Azulay uses it a great deal, and funduscopy is done every 2 months. He has seen no retinal lesions from it for many years now. He gives 200 mg of hydroxychloroquine once or twice on alternate days, stopping for a short rest after 1 month. Braun-Falco gives chloroquine, 250 mg twice a day for 1 month, then once daily. He has never seen retinopathy. Marks, who uses hydroxychloroquine, especially in DLE, has never seen it either. Wolffuses it a great deal, in SLE and DLE, and in PLE to permit tanning, and has seen no eye damage yet. Lapi~re desensitizes, in PLE, with PUVA. Acne fulminans is managed by Marks with systemic steroids, by Braun-Falco with dapsone, by Lapi~re with tetracycline, and by Wolff with various combinations of all three. Azulay uses steroids and tetracycline, or PUVA. What is cimetidine useful for? Marks likes it in chronic urticaria and dermatographia. Wolff and Braun-Falco were not impressed with it. It is not allowed in Belgium, Brazil, or Japan! Azulay has found thalidomide (100 to 200 mg a day) effective in variegate porphyria, and in PLE with no side effects. No other panel member had any suggestions. Mastocytosis responds well to PUVA, Wolff said. Marks doubted that disodium cromoglycate would be absorbed--though Soter says it works. None has had any experience with 17-alpha estradiol (in place of 17-beta estradiol, to avoid feminizing side effects) to retard the progression of male alopecia.

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Marks, Braun-Falco, and Azutay all recommended looking at brushings from household pets for Cheyletiella parasitovorax, in patients with seeming scabies with lesions on the trunk that look like insect bites. Treatment requires separation from the source, as patients are not colonized, and de-miting pets with lindane, or rotenone powder, or both. Braun-Falco presented a case of a red 3-cm plaque on the cheek, with a dense lymphocytic infiltrate of cytologically fibroblastoid/histiocytoid appearance and, on electron microscopy, many cells with inclusions and many xanthomalike cells, like Helwig's atypical fibroxanthoma. He thought the risk of metastasis about 1%. No panel member was enthusiastic about hormones (notably cyproterone) for hirsutism, though four had tried it. Depression, said Wolff, is a bad side effect. For herpes, Marks had found Acyclovir (Zovirax) effective. It is a metabolic antagonist, made by Burroughs Wellcome & Co. It does not prevent recurrences.

INFECTIOUS DISEASES On December 10, Charles Heaton, of Cincinnati, OH, conducted a symposium on infectious diseases, particularly nosocomial chlamydial infections.

Chlamydtal infections Calvin Linnemann, Cincinnati, OH, said that chlamydial infections have few skin manifestations. For the past 10 years they have been the chief cause of venereal infections. Now one is able to grow the organisms in the laboratory. Chlamydia, which have both DNA and ribonucleic acid (RNA), are classified with the bacteria; they formerly were called "Bedsonia." There are two life cycles and there are only two species: psittaci and

trachomatis . Chlamydia trachomatis can be sexually transmitted. The organisms are sensitive to sulfonamides; Chlamydia psittaci, however, is resistant. The organisms stain with iodine because they contain large amounts of glycogen. One can obtain results of examination within 2 hours. There are serotypes, such as L-l, L-2, L-3, which cause

lymphogranuloma venereum (LGV) and A, B, Ba, and C, which cause trachoma. However, trachoma comes about only as a result of repeated infection. There are also types D, E, F, G, H, I, J, and K! In the life cycle of the organism it is easy to see cytoplasmic inclusions in the cells of the host. There is a reticulate form which gives rise to elementary bodies; these are the replicating forms. Various involvements include: ocular LGV, urethritis, cervicitis, epididymitis, and salpingitis. Conjunctivitis in neonates is phlyctenular, but resolves spontaneously. Conjunctivitis can persist in adults. In LGV, inguinal adenopathy is the sine qua non of diagnosis, because the genital primary lesion may be very difficult to find. The adenopathy is very often subjected to surgery by mistake. In urethritis of gonococcal origin one sees many neutrophils with gram-negative diplococci in their cytoplasm. In chlamydial urethritis there is a thin, watery discharge. What is the incidence of this sort of infection? In Seattle, 40% of nongonococcal urethritis was found to be due to Chlamydia. Gonorrhea and nongonorrheal urethritis parallel each other. The managerial social level has the highest level o f nongonococcal urethritis; those in the lower economic strata are more likely to have gonorrhea. Epididymitis due to Chlamydia has been delineated in the past five years. In cervicitis there are follicular changes. Possible other involvements include urethritis, skenitis, bartholinitis, perihepatitis, and perinatal deaths. Prematurity predisposes to these deaths. Postpartum endometritis may occur and the syndrome may resemble Reiter's disease closely. Proctitis may occur. Standard treatment consists of tetracyclines (including minocycline and doxycycline, which need be given only once or twice a day). Erythromycin is a good alternative. Clinical mycoses William G. Merz, Ph.D., Baltimore, MD, spoke on unusual manifestations of clinical mycoses. He gave a rather dismal picture of the effectiveness of griseofulvin by mouth. In one Trichophyton rubrum infection, a year's treatment with griseofulvin was ineffective. The questions of resistance, compliance, and malabsorption are

Volume 5 Number 4 October, 1981 relevant in such cases. Griseofulvin sensitivity tests are far too complicated for the physician to carry out. Ketoconazole is the drug of the future. Organisms resistant to griseofulvin are often sequestered in the hair follicle. The host may have a nonspecific lack of resistance or there may be immunodeficiency. Autoimmune disease predisposes to resistant infections, and transferrin may be abnormal. Giving iron may be helpful. In the autoimmune diseases the patients may cross-react with their own blood substances, especially in blood type A. In the immune-compromised host, Cryptococcus accounts for 10% of the infections. Candidiasis accounts for 10% to 15%. Candidiasis is more often due to Candida tropicalis than to Candida albicans. It occurs in 20% to 25% of oncology patients who are being given antitumor and immunosuppressive drugs. In acute and chronic myelocytic leukemia and Hodgkin's disease, there may be a complete absence of inflammatory cells in the biopsy specimen. Amphotericin B, combined with miconazole, is currently the treatment of choice in such infections. Both Mucor and Aspergillus are rare opportunistic causes of mycosis. Primary cutaneous infections with aspergillosis may occur in aplastic anemia.

Zoonoses Barbara Kummel, D.V.M., Philadelphia, PA, spoke on infections acquired from animals. The most common is Microsporum canis, acquired from cats or dogs. Animals need 50 to 100 mg of griseofulvin per pound for weeks to years in order to be cured, and this is prohibitively expensive. Microsporum gypseum infections occur in dogs and horses, Microsporum nahum in the pig, and Trichophyton mentagrophytes occurs mostly in small pets and in wild animals. Trichophyton verrucosum is a common cause of infection in cattle and also in cats who sleep in barns where the cattle are. Trichophyton equinum occurs in horses. Mite infestations are transient in humans. These are from the following: Sarcoptes scabiei in dogs, Trixacarus caviei in the guinea pig, and Cheyletiella in cats. All of these may cause pruritic eruptions in humans. T. caviei looks like Sarcoptes scabiei.

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Flea bite dermatitis provides a livelihood for veterinarians: 90% of dogs carry fleas, and, contrary to information disseminated in the past, the season is not important. One must treat the environment as well as the dog, and it is best to have the fleas exterminated in the environment twice, two or three weeks apart, corresponding to the life cycle of the flea. Sporotrichosis was found in a cat in New Jersey, and 5 weeks later the owner, a woman, acquired the infection. In such cases the animal should be eliminated.

Canine scabies in man Steven A. Estes, Cincinnati, OH, spoke on canine scabies in humans, which occurs principally on the ankles and elbows, it is difficult to find the mite. The infestation can be potentiated by steroids or azathioprine, and then the female mite can be collected in large quantities. Topicycline and Wood's light may be used to find the burrows. The dog scabies mite can survive for 96 hours in humans, but it is not known whether the complete life cycle can occur.

Wart forms and papillomavirus subtypes Mitchell Bender, of Minneapolis, MN, said that human papillomaviruses are DNA viruses. They are intranuclear and have a protein capsid and double-stranded DNA in the core. The current classification of human papillomaviruses is as follows: types 1, 2, and 4 cause common and plantar warts; type 3, flat warts; type 5, epidermodysplasia verruciforrnis; type 6, anogenital; type 7, butcher warts in meat handlers (this is not fully proved as yet; and type 8, laryngeal--also not proved. Type 5 is oncogenic. Laryngeal warts in infants presumably disappear at about the age of 12. Laryngeal warts may result in invasive squamous cell carcinoma at some late date. Type 5 lesions are redder, more inflamed, and more likely to become malignant. This type can be distinguished even with light microscopy. Autogenous vaccines may be oncogenic. With anogenital warts, attempts have been made to hybridize the viral DNA with that of types

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1 and 2, without success, Perhaps five different types of wart virus cause anogenital warts. BP was described by Wade, Ackerman, and Kopf in 1978 and caused by HPV. Pigmented penile papules are probably the same as BP. Verrucous carcinoma of Buschke and Lowenstein is feebly invasive and is presumably caused by wart virus. Newer concepts of wart therapy Franklin Pass, Minneapolis, MN, spoke on curing warts. Destructive measures are not good for multiple warts. Induction of immune regression is the best approach. Dr. Mary Bunney, of Edinburgh, induces immunity by repeated gentle application of liquid nitrogen or by the use of one part each of salicylic acid and lactic acid in four parts of flexible collodion as a local application each night. In 12 weeks the cure rate of hand warts with either of these technics is quite high. DNCB, 2% in acetone, can be used to sensitize the patient on the outer upper arm. It requires 2 weeks to develop sensitivity. Then 0.1% DNCB in petrolatum is repeatedly applied to the warts. Twenty-eight of 237 individuals with warts could not be sensitized. The average treatment requires 3 months, with a range of 0 to 10 months. Among 209 patients, 70% had total regression of warts; with mosaic and plantar warts the figure was only 48%, and for anogenital warts, 38%. Hemorrhage and necrosis occur in warts from virus-specific lgG antibody formation. TOPICAL REMEDIES BEFORE TOPICAL

STEROIDS Marion B. Sulzberger, of San Francisco, said at the outset of this Tuesday morning standingroom-only forum, directed by Peter N. Horvath, of Washington, DC, that presteroid medications were generally not as effective as steroids, but that many of them were effective in special situations. One advantage of the old preparations was that they often contained three, four, or five ingredients that had to be written out, so that every prescription at least seemed to be made specifically for a particular patient. In addition, their use had to be explained in detail, so there was

Journal of the American Academy of Dermatology more time spent with the patient than is required for prescribing or dispensing a tube o f steroid cream. As to actual presteroid medications, there were tars in a wide variety: coal tars, pine tar, birch tar, tar from shales, ichthammol, liquor carbonis detergens, Tumenol, and others, all used in a variety of vehicles as lotions, paints, ointments, or pastes. There were chrysarobin, anthrarobin, and Castellani's paint. Benzoyl peroxide (introduced by Peck and Chargin in 1931) was used in Quinolor ointment, still one of the most effective antibacterial preparations. Vleminckx's solution (liquor calcis sulfurata) is still valuable in acne, although little used today. Iodochlorhydroxyquin 3% with 1% hydrocortisone had the advantage of never inducing bacterial resistance. Rees B. Rees, of Santa Rosa, CA, mentioned the great efficacy of Quinolor ointment in rosacea and acne, and, as Sulzberger had mentioned, sycosis barbae. He pointed out that it is desirable, as Dobson said recently, to avoid topical steroids in psoriasis; or if they are used, combine them with agents such as tars, or anthralin, which offer a better chance of a lasting remission. A shake lotion which can be used occasionally in severe atopic dermatitis consists of 0.25% menthol, 1% phenol, 3% resorcin, and 10% each of liquor carbonis detergens (USP), and benzocaine (beware of sensitization!) in calamine lotion (NF), dispensed in a wide-mouthed bottle, shaken well, and applied very thinly two to four times a day, preferably with a paint brash. P. Raymond Oliver, of Zimbabwe-Rhodesia, recommends a scalp preparation for psoriasis: 0.25% anthralin, and 3% salicylic acid, in 90 ml each of liquor carbonis detergens and mineral or peanut or cottonseed oil. It is rubbed in nightly for 1 month, shampooing as desired. After the scalp clears, once a month may be enough. Alibour water, an antibacterial solution for infected eczema or for eyelid dermatitis, is made of copper sulfate 0.6 gm, zinc sulfate 2 gin, in i00 ml of camphor water, and diluted 1 : 16 to 1:25 for use as cold wet packs. Miscellanous "pearls": Crisco can be used for diaper dermatitis, hydrogen peroxide for external

Volume 5 Number 4 October, 1981 otitis, and modified Goeckerman regimen for nummular eczema and hand dermatitis. I N T E R N A L M E D I C I N E IN DERMATOLOGY Jeffrey P. Callen, Louisville, KY, moderated this symposium on Tuesday morning.

Pruritic dermatoses of pregnancy Stephen i. Katz, Bethesda, MD, said it is often impossible to classify these dermatoses precisely. Various names have been suggested: prurigo gravidarum, prurigo gestationis, herpes gestationis, papular dermatitis of pregnancy, prurigo annularis, impetigo herpetiformis, pruritic urticarial papules and plaques of pregnancy (PUPPP), and one of the commonest, toxemic rash of pregnancy. Idiopathic jaundice of pregnancy, which is rare, occurs during the third trimester, clears within two weeks' postpartum, is exacerbated by exogenous estrogens, and recurs in subsequent pregnancies. In papular dermatitis of pregnancy, reported by Spangler in the Journal of the American Medical Association in the 1960's, a generalized excoriated papular eruption occurs in the middle trimester. Katz cannot confiml Spangler's finding of increased urinary chorionic gonadotropin, but estrogen and estriol are low in the urine; giving them, however, is contraindicated. Katz doubts that fetal mortality is increased. Steroids help. Herpes gestationis (HG) resembles pemphigoid more closely than it does dermatitis herpetiformis. IgG and C3 occur in the basement zone; electron microscopy shows it to be in the lamina lucida. Biopsy of perilesional skin should be done. HG factor is found in the serum in three fourths of patients. Half have a postpartum flare. Of thirtysix patients studied by them, nine had premature delivery and three had stillbirths. PUPPP occurs on the abdomen, buttocks, and thighs, in the third trimester, usually in primigravidas. There is no risk to the baby. No C3 is found, and recurrence in subsequent pregnancies is rare.

Erythema multiforme and Stevens-Johnson syndrome Joseph J. Chanda, Melbourne Beach, FL, agrees these are identical but splits them into mild,

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severe, and very severe. Causes are drugs, infections, cancer, collagen disease, pregnancy, sunlight, x-rays, ingestants, and inhalants. They are rare after the age of 60 except in malignancy. A proclrome of fever and arthralgia may occur. The disease lasts 2 or 3 weeks and seldom recurs. Systemic steroids are effective, but only if given early.

Porphyria cutanea tarda (PCT) David R. Bickers, of Cleveland, OH, said that screening tests are unreliable if negative. A genetically determined deficiency of uroporphyrinogen decarboxylase may either cause, or underlie, acquired cases of PCT, precipitated by alcohol, estrogens, hexachlorobenzene, or benzodioxans, Excessive stainable iron in hepatocytes characterizes all cases, but its source is unknown. Five or six phlebotomies of 500 ml during a 2-week period may be enough to reduce hemoglobin to i0 to 11 gin/100 ml and alleviate the symptoms. It may take 6 months for remission to occur, and repetition in a year or less may be required.

Review of internal medicine literature Gabriel G. Gruber, of Louisville, KY, presented brief reviews of dermatologic items from internal medicine literature. K. W. Jacobson et al (JAMA 243:644, 1980) found laboratory and x-ray tests unrewarding in chronic urticaria. N. A. Soter (N Engl J Med 302:604, 1980) found reduced pulmonary function in patients with cholinergic urticaria. J. E. Gadek (N Engl J Med 302:542, 1980) found C1 inhibitor obtained from pooled plasma effective in hereditary angioedema. R. M. Fusaro et al (JAMA 244:1456, 1980) found oral beta carotene useful in hereditary PLE. Streptococcal pyoderma, leading to nephritis, may be a complication. B. C. Shultz et al (JAMA 243:1836, 1980) confirmed reports of relief of pruritus in renal failure by use of UVB, and Pederson JA et al (Ann Intern Med 93:446, 1980) relieved itching in ten of eleven hemodialysis patients with activated charcoal, with no ill effects. L. G. Lure et al (N Engl J Med 302:392, 1980)

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cured thrombocytopenia by splenectomy in nine patients with Wiskott-Aldrich syndrome, and six of them lived over 11 years after surgery. [Harold M. Johnson did this in SLE, 27 years ago (Arch Dermatol 68:699, 1953).] D. E. Hammerschmidt (N Engl J Med 302: 1191, 1980) reported platelet dysfunction caused by eating Szechuan hot bean curd (ma-p don-fu). The clinical consequences were trivial. N. A. Fenske et al (JAMA 244:1103, 1980) concluded that idiosyncrasy and large doses were probably responsible for the pigmentation that may follow use of minocycline. R. A. DeRemee et al (Ann hTtern Med 92:361, 1980) found serum angiotensin-converting enzyme activity useful for confirming a diagnosis of sarcoidosis and following its course. R. J. Rapoport et al (Am J Med 68:325, 1980) found cutaneous vascular immunofluorescence correlated well with histologic findings of vasculitis but not with the severity of the disease. T. Abel e t a [ (Ann Intern Med 93:407, 1980) found cyclophosphamide worked well in patients with disease caused by circulating immune complexes, including rheumatoid vasculitis. P. Phanuphak et al (Am J Med 68:479, 1980) reported attempted allergic hyposensitization for atopic respiratory disease causing vasculitis in six of twenty patients with polyarteritis nodosa, and three of them died. Five had received less than 16 mg of allergenic protein. H. Mildrom et al (Ann Intern Med 92:467, 1980) reported mucocutaneous lymph node syndrome in an adult. E. A. Baueret al (NEnglJMed 303:776, 1980) found phenytoin helpful in epidermolysis bullosa dystrophica. D. L. Trump et al (JAMA 243:1461, 1980) found amyloidosis and multiple myeloma in a patient with epidermolysis bullosa acquista.

Antimalarial drugs: A practical approach Denny Tuffanelli said that hydroxychloroquine, 200 mg once or twice a day, is less effective than chloroquine, but probably safer. Start with it, but switch over in 3 to 5 months if the results aa'e not good. The drugs are useful in vasculitis, scleroderma, PLE, DLE, and systemic LE. Car-

Journal of the American Academy of Dermatology

diac arrhythmias may occur, especially in children; pruritus, gastrointestinal upsets, pigmentation, hemolysis (initially), and retinopathy may be side effects. CLINICOPATHOLOGIC CONFERENCE A. Bernard Ackerman, of New York, and Robert Freeman, of Dallas, TX, were co-moderators of this symposium.

Lymphomatoid papulosis: What is it? Warren Macaulay, of Fargo, ND, said that Samman (1964), Dupont (1965), Verallo and Haserick (1966), and Pihol Aguade et al (1967) had all reported this disorder as "Mucha-Habermann disease with pseudolymphoma" or some such name before he, with the help of Hermann Pinkus and James F. Madison, reported his case as "lymphomatoid papulosis" in January, 1968. Up to that time the majority of pathologic diagnoses had been "malignant lymphoma." Is it merely that Mucha-Habermann syndrome occasionally occurs with highly atypical, succulent-looking, abnormal lymphocytes? Americans and English have often said " y e s , " but many Europeans agree that lymphomatoid papulosis is a separate entity. Macaulay's position is that lymphomatoid papulosis (LP) is the prototype of a spectrum which he has named the rhythmic (because lesions come and go) paradoxical (because the clinical course is so benign) eruptions. The eruptions range from very chronic "undifferentiated lymphoma" (Dupont) through "histiocytic lymphoma" of long duration (Samman), through LP, to "mycosis fungoides with a prolonged course" (Fine, Barnett, and others), to Hodgkin's disease lasting 10 to 20 years (Szur). There are other variants, as well: one called "giant pseudomalignant granuloma" was reported in J AM ACAD DERMATOL3:292, 1980 by Sina et al. Vitor Weinman, of New York, studied forty cases of LP, some of over 20 years' duration. Characteristic is a dense, deep, wedge-shaped infiltrate with edema, purpura, and mixed large, small, and atypical lymphoid cells. Neutrophils are present from the start within the lumen of many vessels, and between collagen bundles. Plasmacytoid cells and mitotic figures are fre-

Volume 5 Number 4 October, 1981

quently seen. Eosinophils are also seen. Convoluted nuclei, and even multinucleate cells, occur. Atypical cells in the epidermis are not larger than in the dermis, as in MF, but are the same size or smaller. Spongiotic vesicles may occur. Weinman thinks lymphomatoid papulosis a specific entity, almost always nonfatal, though as many as 10% may eventuate in malignant lymp h o m a - - a n outcome that cannot be predicted from the histopathology. Edward Wilson-Jones, of London, England, believes that neutrophils and eosinophils are inconspicuous and may be absent altogether, and he distinguishes five forms of LP according to the degree and intensity of cellular atypia. He considers LP to be on a sort of borderline between an autoimmune disorder, pityriasis lichenoides et varioliformis acuta, and a neoplastic one, namely, lymphoma. It seemed like a streamlined version of Macaulay's view. Ackerman rejected, however, the view that neutrophils and eosinophils may be lacking; every published case of LP, and every one he has seen, had both at every stage [by definition?]. He considers LP to be distinct from Mucha-Habermann syndrome at every stage of its evolution. Bowen's disease: How do you define it? Edward J. Krull, of Detroit, MI, had more questions than answers, but Arkadi Rywlin, Miami, FL, said he conceived of Bowen's disease as consisting of hyperplasia with cellular atypia (reversible) or carcinoma in situ (irreversible), lying between simple hyperplasia at the benign end, and invasive carcinoma at the other. But one cannot distinguish between the reversible and the irreversible phase histologically, he said. He takes the lonely position that if the lesions are induced by chronic arsenical intoxication, it is not Bowen's disease; but for Graham, an astonishing 80% of cases of Bowen's disease are caused by arsenic. Preservation of a normal basal layer, Rywlin said, is usual, with atypia limited to the prickle layer; involvement of the basal layer usually means an actinic keratosis, to him. But there are mixtures: a bowenoid actinic keratosis, so called. James H. Graham, of Washington, DC, said that the acrosyringium is always spared in Bow-

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en's disease, though often it is straightened out; hair follicles, in contrast, are always involved. The basal layer, he believes (unlike Rywlin), is usually involved. In about 5% of lesions, focal invasive carcinoma is seen, and of these lesions, metastasis has occurred or will occur in about one-third! Kurt Stenn of New Haven, CT, agreed that a bowenoid actinic keratosis shows atypia from the base to the top, whereas an ordinary actinic keratosis usually has its atypia in the deeper portion. In actinic keratoses, few germinative cells are hit; in bowenoid patterns, all of them are altered. Desmoplastic trichoepithelioma (DT) Martin H. Brownstein, of New York, coined this term to designate a benign lesion which has been mistaken repeatedly for basal cell carcinoma in young persons, girls more than boys. It mimics a morpheiform basal cell carcinoma. It is not, however, a trichoepithelioma (Cancer 40:2979, 1977). Basaloid strands and horn cysts close by follicles characterize the histologic picture. The usual site is the face or the nose. Robert Freeman agreed that morpheiform basal cell carcinoma is the commonest misdiagnosis in DT, although the admixture of follicular elements should warn one off. Brownstein explained that he named this lesion "desmoplastic trichoepithelioma" because nearly all of the early reports of it were under the name "trichoepithelioma. "Wilson-Jones said that Whimster named it "scarring follicular nevus."

Inverted follicular keratosis (IFK) Elson B. Hclwig, of Washington, DC, said that the typical IFK is about 5 m m in diameter, rough or smooth, hyperkeratotic, most often on the face but sometimes on the trunk or extremities; of weeks' to years' duration; commoner in Caucasians; rarely pigmented; often showing a central keratin-filled depression; and characterized by numerous "squamous eddies." Ackerman rejected the view that the IFK is an entity. "Squamous eddies" are, he said, merely cross-sections of acrosyringia as they spiral through hyperplastic epithelium, and the so-called IFK is mostly exophytic, not " i n v e r t e d " as the name in-

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dicates. Most IFKs, he believes, are merely traumatized or irritated warts, and some are irritated seborrheic keratoses. [He did not convince Helwig, or Pinkus.] CLINICAL CONTROVERSIES Richard B. Odom, of San Francisco, organized and conducted this Wednesday afternoon symposium for the third time, with Harry L. Arnold, Jr., Honolulu, as co-moderator.

Suntan parlors: A photobiologist's view John H. Epstein, of San Francisco, said that there are about 2,000 of these salons now operating; most, in the United States, provide UVB with Westinghouse FS bulbs, peaking at 313 nm. The acute hazards are from new (and thus stronger) bulbs, poor supervision, careless timing, risk of aggravating photosensitive diseases, and (from UVA especially) photosensitization. Chronic damage or aggravation of existing sun damage is also a risk. Misleading claims are common: lamps are said not to emit "harmful rays"; it is said that "everyone can tan"; and it is claimed that "tan is possible without injury." The UVA salons are still chiefly in Europe. So far there are no firm data on damage to dermal collagen; only vessel damage is documented.

The lindane (Kwell) conundrum James E. Rasmussen, of Ann Arbor, MI, rejected the aUegation that lindane (Kwell) lotion is dangerous in normal use against scabies. The reports of toxicity, he said, are almost exclusively from industrial poisoning, plus a few cases of gross overuse of the lotion. Of twenty-six reported toxic reactions, only six proved "probable" (none was "certain"), and only three of these followed proper use. Animal studies showed toxicity at a level equivalent to 30 gm of lindane internally daily for 35 years in an adult human. The only practical alternative therapy, crotamiton (Eurax) is at best 56% effective as opposed to lindane's 97%, even after 5 days' use. Sulfur is far less effective, and its toxicity is not negligible. To use lindane as safely as possible, Rasmus-

Journal of the American Academy of Dermatology

sen suggests no preliminary bath, and a single application washed off after 6 to 8 hours. Milton Orkin, of Minneapolis, MN, said that seizures are being reported to the FDA, mostly in infants and children, and we know nothing of possible subclinical toxicity. Lindane is certainly effective but not, in his view, the treatment of choice. He feels more comfortable with sulfur in young patients and pregnant women; for pediculosis he uses a pyrethrum preparation, such as RID.

Home phototherapy for psoriasis John A. Parrish, of Boston, MA, said that topical tar raises the proportion of psoriatics responding to UVB from 80% improvement in 80% of patients, to 90% clearing; and simple lubricants are almost as effective as tar. Increasing doses, producing continuous erythema, are necessary; and twenty to thirty exposures, at two to seven weekly, are usually required. Tar produces a helpful phototoxic response, and lubricants enhance penetration of light into the skin. Aggressive UVB therapy is about as effective as PUVA, he said. Convenience and cheapness are the main advantages; risk of bums, electrical or mechanical hazards, and early relapse (within a month as a rule) are the main drawbacks. The long-term damage has not yet been assessed.

Intramuscular steroids in dermatology Rees B. Rees, of Santa Rosa, CA, spoke on Kenalog intramuscularly. In the past there has been much concern about interference with the integrity of the hypothalamic-pituitary-adrenal axis. This occurs with any systemic use of corticosteroids and, indeed, with extensive use of potent topical corticosteroids. However, this bugaboo seems not to be very important clinically. On the other hand, all of the other complications of corticosteroid therapy are to be feared either with parenteral repository corticosteroids or with oral corticosteroids. The dogma is still that oral corticosteroids are best given all at once in the morning, to follow the diurnal or circadian rhythm. The alternate-day regimen has been strongly advocated as avoiding

Volume 5 Number 4 October, 1981

many of the complications, but the difficulty of withdrawal of corticosteroids with alternate-day technic and the incidence of posterior subcapsular cataracts and osteoporosis are not diminished by using this approach. On the other hand, with repository corticosteroids, there is no need for gradual withdrawal, as nature accomplishes that by herself, and osteoporosis has not been observed. Cataract is very rare. Rees still uses more oral prednisone than triamcinolone acetonide (Kenalog) intramuscularly, but he gives the tablets to the patients himself because of some unfortunate experiences in the past in which unauthorized refills were given to several patients, in some over a period of several years. Triarncinolone acetonide intramuscularly may work in situations in which oral prednisone fails. This may be true in some cases of atopic dermatitis and volar psoriasis, to mention just two. Also, it has been shown that when one switches to alternate-day therapy with prednisone, diminishing of kidney function may occur in renal transplant patients, a clear indication that the approach may not be as efficacious as having corticosteroids uninterruptedly in the body over a reasonably long period of time. Special disadvantages of giving triamcinolone acetonide intramuscularly include the formation of sterile abscesses when the injection is not given deeply enough. This can be overcome by using a 1 89 19-gauge needle and giving the injection deep in the upper, outer quadrant. There may be interference with the menstrual cycle in women ("dysfunctional uterine bleeding"). This has been described as occurring in as many as one out of three women in the menstrual age. It is therefore best either to diminish the dose or to give it only when the patient is taking a birth control pill or if she has had a hysterectomy. Another clear indication for reducing the dose or withdrawing triamcinolone acetonide intramuscularly is the development of ecchymoses on the forearms in areas already sun-damaged. This is slowly reversible (to the extent it was caused by the drug) when the drug is stopped. Triamcinolone acetonide intramuscularly should be given as infrequently as possible, certainly not

American Academy of Dermatology 497

more often than every 4 to 6 weeks, if that can be accomplished. Fortunately, in many, many cases, injections can be given as infrequently as two or three times a year. Frances J. Storrs said, "Where there's a will there's a won't"; the question of parenteral steroids, she said, is like a religious war, with true believers on each side. She objects to long-term therapy with triamcinolone acetonide on the ground that its safety has not yet been critically documented, as that of alternate-day prednisone has. She thinks alternate-day prednisone usually does work and is associated with "fewer infections" (than daily prednisone, presumably, since almost none have been noted by anyone with triamcinolone acetonide) though with no reduced risk of cataracts--or, she might have added, osteoporosis. The HPA axis depression, she insisted, outlasts the usual 4-week interval between doses of triamcinolone acetonide.

Hemangiomas: W h e n to intervene William L. Weston, of Denver, CO, urged us to defend babies by resisting the temptation in ourselves and others to excise or irradiate raised hemangiomas which were not present at birth. The only indications for intervention are airway obstruction, platelet trapping, obstruction to vision, obstruction of a vital orifice, or heart failure. Prednisone, 1 to 2 mg/kg/day for 4 to 6 weeks, may be effective. Curettage vs excision for basal cell carcinomas Samuel J. Stegman, of San Francisco, acknowledged the effectiveness of both approaches, but pointed out that a more informative pathologic specimen is obtained by excision than by curettage, and that (especially in florid or oily skin) the cosmetic result may be somewhat better following excision. John M. Knox, of Houston, TX, likes curettage and electrodesiccation--twice, for improved recurrence statistics--for the great majority of basal cell carcinomas; for the smaller ones, he said, the cosmetic result is often extremely good: hard to match, let alone beat, by excision. The conven-

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i e n c e - - n o preliminary b i o p s y - - a n d the lower cost, with no need for sutures, are a consideration as well, especially if the volume of practice is large. THERAPEUTICS Frances J. Storrs again moderated this excellent windup program on the final morning of the meeting. The lindane (Kwell) conundrum James S. Rasmussen, as he had done the afternoon before, explained why he considers lindane (Kwell) to be not only by far the most effective antiscabietic, but at least as safe as the alternatives. The mite, he said, is never resistant to lindane. Malignant melanoma: Current management Arthur J. Sober, of Boston, MA, despite Ackerman's skepticism, still classifies melanomas as SSM, L M M , A L M (especially in blacks and Orientals), and NMM; and though elevation, ulceration, and bleeding have some correlation with level, the critical measurement is the thickness, with 99% free of disease after 5 years if the thickness is 0.75 m m or less, 92% at 1.69 m m , 67% at 3.6 mm, and 37% at over 3.6 mm. For LMM, a 1-cm margin of excision is enough; for N M M 0.75 mm thick or less, 2 cm; for thicker lesions, 4-5 cm. There is little advantage in lymph node dissection except in the thickest category. They follow patients every 3 months for 2 years, every 6 months for 7 more, and then annually. He believes BCG adjuvant therapy is useless. He advises excision of giant congenital nevi for prophylaxis. Diphenylhydantoin (Dilantin): New tricks by an old dog Nancy B. Esterly, of Chicago, IL, said there are over fifty diseases that phenytoin can help, according to anecdotal reports. (See Watson et al: JAMA 233:1385, 1975.) It is notably useful in alcohol withdrawal, and for leg pain in Fabry's disease. Side effects such as ataxia and nystagmus are dose-related. Eruptions from it seem to be idiosyncratic. Hirsutism and gum hypertrophy may

occur. Pseudolymphoma has been reported, mainly in blacks. It has been said to be useful in pruritus ani, glycogen storage diseases, leg ulcers, scleroderma, linear scleroderma, recessive dystrophic epidermolysis bullosa, and other disorders. Nickel: Hips and hand eczema Desmond Burrows, Belfast, Ireland, believes about 10% of women with hand eczema are allergic to nickel. The burning question is: "Is diet helpful?" Well, a low-nickel diet contains an irreducible 470 mg or so of nickel, as opposed to 900 mg in a normal diet; and as one might expect, diet makes little or no difference. Dosing with nickel seems capable of aggravating eczema in the nickel-sensitive, although even this is uncertain. Disulfiram (Antabuse) does not work well either. Does a hip prosthesis sensitize its wearer to nickel? Probably only very rarely if at all. Preoperative testing is unnecessary. Psoriasis and cancer Kenneth M. Halpr~n, of Miami, FL, said we have not yet used PUVA long enough to know whether it can cause cancer or not; so far, it has not been a carcinogen, but it has probably been a cocarcinogen: a promoter. Stern, Roenigk, and Honigsmann have all reported the same incidence of cancers in PUVA-treated patients as in matched controls: about 0.1% to 0.5%. Either previous arsenic, or previous x-i'ay therapy, has characterized all the patients who got carcinomas during or after PUVA therapy. By 1995, if PUVA is really an effective cocarcinogen, the cancer rate in P U V A patients ought to start rising. Ketoconazole in the griseofulvin-resistant case Jon M. Hanifin, of Portland, OR, said most griseofulvin failures are attributable to poor absorption, noncompliance, or deficient drug delivery. Partial responses and early recurrence are seen mainly with T. rubrum, and may be due to too low a dose, too short a course, nail loci, or shoe reinfection. Reported cure rates for tinea pedis have been 40% and 58%, and not all the failures are due to griseofulvin resistance, though it does rarely occur.

Volume 5 Number 4 October, 1981

Ketoconazole, a piperazine imidazole administered orally, 200 mg two or three times a day, is probably only fungistatic at the achieved tissue levels, but that is sufficient for all fungi and yeast forms except for sporotrichosis and actinomycosis. Of twenty resistant cases, 67% had cleared after 8 weeks on ketoconazole. All but three were wholly clear at 14 weeks. Side effects are few and trivial: mild nausea, prevented by taking with meals; epistaxis (two), and photophobia in bright light (one). Oral retinoids and acne, 1980

John S. Strauss, of Iowa City, IA, said there is no disagreement: retinoids work! The median dose is 0.5 mg/kg daily for 12 weeks; it lowers sebum production dramatically and clears ache as well; 1 mg/kg clears 88% of patients. The remission lasts 2 weeks or so. Not only the amount of sebum drops but also the proportion of cholesterol returns to its high prepubertal level. The percent reduction of cysts is the same at all dose levels from 0.1 to 1 mg/kg. Etretinate (Ro 10-9359) is more effective than isotretinoin (13-cis-retinoic acid), though sebum reduction is four to six times better with the latter! Acne does not require the high doses that other keratinizing disorders do. It will be at least 11/2 to 2 years before these compounds are released for general use. ADMINISTRATIVE AFFAIRS Certificates of honorary membership were presented to Walter C. Lobitz, Jr., Rudolph L. Baer, and Naomi M. Kanof.

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The four new members of the Board of Directors, replacing retiring directors Marvin E. Chernosky, Marie-Louise T. Johnson, John S. Strauss, and Harry L. Wechsler, are Leonard C. Harber, Henry W. Jolly, Jr., Stephen B. Webster, and John J. Voorhees. The Dermatologist of the Year award went to Royal M. Montgomery and Lawrence C. Goldberg, and the Finnerud award was conferred on Wiley M. Sams, Sr. For the first time in the history of the Academy, an organization not connected with it, the A1fred-Marchionini Foundation, was given time for the presentation of an award, the Alfred Marchionini Gold Medal, to its eleventh recipient, Marion B. Sulzberger. The presentation was made by Prof. Theodor Nasemann, of Hamburg, in recognition of Dr. Sulzberger's outstanding contributions to international dermatology in the humanitarian spirit which was so characteristic of the great Munich dermatologist and humanitarian, Alfred Marchionini. At the meeting's end, the gavel was turned over to the new president, Harold O. Perry, by the outgoing president, Alfred W. Kopf, and James H. Graham was inducted as vice-president. John H. Epstein is now the president-elect. The meeting in 1981 is to be in San Francisco, CA.