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Dermatologic therapy: 1990
Therapv Dermatologic therapy: 1990 Ralph J. Coskey, MD Detroit, Michigan This article reviews significant therapeutic advances that have been reported in the Englishlanguage literature during 1990, Readers should review the original article in full before attempting any new experimental or controversial therapy. (J AM ACAD DERMATOL 1991; 25:271-80.) ACNE AND RELATED CONDITIONS
Topical 4% erythromycin combined with 1.2% zinc acetate solution was compared with its vehicle in the treatment of acne. This combination was more effective than its vehicle and was found to be safe after 1 year of treatment.! This same solution was also compared with topical 1% clindamycin phosphate solution. Both agents were applied twice daily. Mter 6 weeks the erythromycin-zinc preparation was more effective than the c1indamycin preparation in decreasing papules, pustules, and comedones. No serious topical or systemic side effects occurred. The authors believed that the erythromycin-zinc formulation was more effective either because of the 4% concentration of erythromycin or because of the ability of the 1.2% zinc acetate to enhance the product's activity.2 Patients with severe nodular cystic acne were treated with isotretinoin in a dosage mainly of 1 mg/kg/day. Of the 88 patients treated, 84 had complete clearing. One patient became pregnant during therapy. Her infant was born with a ventral septal defect. 3 In another study 172 patients were treated with isotretinoin. These patients were followed up between 12 and 41 months after stopping therapy. Twenty-one percent had relapses. The more severe the acne, the higher the rate of relapse; there were more relapses in the 15- to 20-year-old group than in those of later age. These authors did not find a relation between dosage and relapse rate. 4 In another study four patients with inflammatory bowel disease and severe cystic acne were treated with isotretinoin. Two patients improved without any gastrointestinal side effects. One patient had two From the Dermatology Department, Wayne State University School of Medicine. Reprint requests: Ralph J, Caskey, MD, 23133 Orchard Lake Rd., Farmington, MI 48336.
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episodes of rectal bleeding, related to hemorrhoids, and in the fourth patient a flare of Crohn's disease developed. This article indicates that oral isotretinoin may be used in severe cystic acne in patients with inflammatory bowel disease, who do not tolerate oral antibiotic therapy. 5 ALLERGY
Three patients with solar urticaria were successfully treated with astemizole, 10 mg/day. This dosage increased the minimal urticarial dose elaborated by phototesting to visible light from 2 to 12 times. 6 Twenty-two patients with chronic idiopathic urticaria were treated in a double-blind cross-over study with nifedipine, 10 mg four times daily, or chlorpheniramine, 4 mg four times daily. Partial or total control of itching and hives was noted in 39% of patients receiving nifedipine and 28% of patients receiving chlorpheniramine. Nifedipine was not found to be superior to chlorpheniramine in controlling chronic urticaria. 7 Terfenadine, 60 mg twice daily, was compared with c1emastine, 2 mg twice daily, for their antipruritic effect in atopic dermatitis. These drugs were not more effective than a placebo. These findings support the view that histamine is probably not of importance in the pathogenesis of itch in atopic dermatitis. s COLLAGEN DISEASES AND VASCULITIS
Ten patients with discoid lupus erythematosus or subacute cutaneous lupus erythematosus (SCLE) were treated with interferon alfa-2a. After 4 to 8 weeks marked improvement was noted in the skin lesions of six patients treated with lower doses. Two patients with SCLE received high doses for 12 weeks with complete clearing and one had marked improvement. When treatment was discontinued, relapses occurred. 9 271
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272 Caskey
Eleven patients with severe extensive localized scleroderma were treated with D-penicillamine. Improvement was noted within 3 to 6 months with cessation of active cutaneous lesions in seven patients, skin softening in five, and more normal growth ofthe affected limb in two of three children. In addition, improvement in stiffness and contractures of joints was noted. Dosage was as low as 2 to 5 mg/kg/day given for 15 to 53 months. Nephrotic syndrome occurred in one patient and reversible proteinuria in three other patients,lO Eight patients with refractory cutaneous vasculitis were treated by intermittent plasma exchange. All but one improved. ll Two monoclonal antibodies, Campath-IH and rat CD4, were used to treat a patient with intractable systemic vasculitis. Treatment was well tolerated and the patient remained well a year after therapy. 12 MUCOSAL ERUPTIONS
In a controlled trial, azathioprine (2.5 mg/kg of body weight/day) was given to 25 Turkish men with Beh~t's syndrome without eye disease and 48 with eye disease. 13 All patients also had corticosteroid treatment available to them. Six patients withdrew from the study because ofsevere eye disease but they were receiving placebo. Azathioprine was found to be superior to placebo in prevention of new eye disease in the first group of patients and in the second group in the 14 patients who had disease in only one eye. There were fewer episodes of hypopyon and uveitis in the two patients with eye disease who took azathioprine. In the group who took azathioprine oral-genital ulcers and arthritis occurred less frequently. A double-blind trial was done in 16 patients with symptomatic oral lichen planus. I4 The patients swished and spit out 5 ml of cyclosporine, 100 mg/ ml, three times daily. After 8 weeks cyclosporine produced marked improvement from treatment whereas those who used the vehicle had little change or minimal improvement. When the placebo group switched to cyclosporine, they also improved. The authors did not note side effects and in most cases the blood cyclosporine levels were low or not detectable. Fifty-one patients with venous lakes of the lips were treated with the argon laser. ls Ninety percent obtained excellent results and only one patient had recurrent lesions after 18 months. In another study 43 patients with actinic cheilitis were treated with the carbon dioxide laser. 16 After
follow-up of at least 10 months, 26 patients thought that the lip was cosmetically improved and 40 believed that the function of the lip was improved. DERMATITIS
Clobetasol propionate 0.05% cream was evaluated in the treatment of experimentally induced Rhus dermatitis. 17 It decreased vesiculation at the treated sites and was most effective when applied 12 hours after exposure to Rhus extract. Ten of 12 patients with vesicular hand eczema were given a high nickel diet for 4 days.I8 Hand eczema was aggravated in 10 patients by the eleventh day. The authors suggested that nickel-allergic patients with severe vesicular hand eczema should be given a low nickel diet. Thirty-eight patients with atopic dermatitis were treated with UVB on one side of the body and a combination of UVA and UVB to the other side of the body three times weekly for 8 weeks. 19 Improvement was noted on both sides of the patients' bodies but there were statistically significant differences in favor of the combined UVA and UVB therapy. Thirty patients with mild to moderate atopic dermatitis were treated on one side of the body with a purified coal tar cream and the other side with hydrocortisone 1% cream for 4 weeks. 2o Both treatments were equally effective in reducing symptoms and there was no difference in the patients' preference for treatment. A double-blind, placebo-controlled, cross-over study was done to assess the effect ofpapaverine, 100 mg, four times daily on the severity of pruritus in atopic dermatitis. 21 It was not found to be effective after 4 weeks of therapy. Thirteen patients with severe atopic dermatitis were treated for up to 31 months with oral cyclosporine. 22 Ten patients had a good response, one had a moderate response, and two a slight response. In two of the patients cYclosporine was withdrawn because of increasing plasma creatinine levels. BACfERIAL INFECTIONS
Seventy-two adults with erythema migrans were treated with either amoxicillin, 500 mg, in combination with probenecid, 500 mg, three times a day or doxycycline, 100 mg, twice a day for 21 days.23 Both regimens were equally effective. The authors stated that this regimen should not be used for patients with active central nervous system infection
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becuase the efficacy of oral therapy has not been proved. A randomized study compared mupirocin 2% ointment with oral erythromycin ethylsuccinate in the treatment of impetigo. 24 Mupirocin ointment was as safe and effective as oral erythromycin ethylsuccinate. Mupirocin ointment was used also in the treatment ofsecondarily infected dermatoses in a doubleblind, randomized, vehicle-controlled study.25 It was found to be safe and effective especially for infections caused by Staphylococcus aureus. Forty-seven patients with epidermolysis bullosa were treated with topical mupirocin ointment. 26 In five of these patients cultures from nonhealing wounds revealed S. aureus resistant to mupirocin. A total of 8220 cultures were obtained from inpatients and outpatients in England between 1987 and 1989.27 Of these 7137 grew S. aureus, of which only 0.3% were resistant to mupirocin. Three percent of coagulase-negative staphylococcal isolates were resistant. Sixteen patients with recurring staphylococcal furunculosis had a low serum iron concentration, although they were not anemic. 28 The furunculosis resolved after 3 to 4 weeks of treatment with iron supplements in all but one of the patients. Twenty-four patients with severe interdigital toe web infections not caused by dermatophytes were treated with topical econazole nitrate or its vehicle.29 Ofthese, 88% had a good to excellent response to the active agent. Aerobic flora decreased in 93% in the actively treated group. This study demonstrated that econazole has antibacterial activity and is an effective agent for the treatment of interdigital bacterial infections not complicated by dermatophyte colonization. FUNGUS INFECfIONS An open study was done to evaluate 2% ketoconazoIe cream in the treatment of tinea corporis and tinea cruris. 3o After 30 days, 32 of 35 patients were clinically cleared. Seventy patients with tinea cruris or tinea corporis were treated with naftifine 1% cream or its vehicle once daily for 4 weeks. 3! At the end of 4 weeks, 86% were mycologically cured with naftifine whereas 30% were mycologically cured with the vehicle. In another study 210 patients with tinea pedis were treated with naftifine cream once or twice daily or clotrimazole cream twice daily for 4 weeks. 32
Dermatologic therapy: 1990 273 When seen 2 weeks after therapy was stopped, 81 % of the patients in the naftiiine group and 58% of those in the clotrimazole group had been treated successfully. In two separate studies patients with tinea cruris were treated with topical terbinafine 1%cream twice daily.33, 34 Mter 2 weeks, in both studies, terbinafine was more effective than placebo in 78% of the patients. In two other studies 1% terbinafine cream was used to treat chronic tinea pedis. 35 ,36 Terbinafine was effective clinically and mycologically in 78% of the patients treated for 4 weeks. 35 Oral terbinafine, 125 mg twice daily, was given for the treatment of chronic moccasin-type tinea pedis. Mycologic cure and near to complete clearing of signs and symptoms were obtained in 59% of the patients. 36 In another double-blind study oral terbinafine was compared with ketoconazole in the treatment of patients with dermatophyte infections. 37 Both groups responded equally well after a maximum of 6 weeks. Eleven patients with onychomycosis of the fingernails were treated with terbinafine, 125 mg twice daily, for 6 months or until the infection cleared. 38 At the end of the treatment period all patients were clinically and mycologically normal. The only side effect noted was mild gastric discomfort in one patient. Eighty patients with onychomycosis of the toenails and 23 with fingernail onychomycosis were treated with terbinafine, 250 mg daily.39 The fingernails were treated for 6 months and the toenails for 12 months. Of 89 patients who completed the study, 95% with a fingernail infection and 82% with a toenail infection were cured. The mean time for mycologic cure was 13.4 weeks for fingernail infection and 28 weeks for toenail infections. Gastrointestinal symptoms were the most common cause for patients to withdraw from the study. Terbinafine, 125 mg twice daily, was compared with griseofulvin, 250 mg twice daily, in patients with moccasin-type tinea pedis. 4o After 6 weeks of therapy mycologic and clinical cure or mycologic cure with minimal signs of infection was noted in 12 of 16 patients receiving terbinafine but only 3 of 12 patients treated with griseofulvin. Six to IS months after completion of the study, 94% of terbina:finetreated patients remained clear. Of the patients treated with griseofulvin, 30% remained cured; toenails improved in only 14%. Ninety-four patients with dermatophytosis and 16 with tinea versicolor were treated with itracona-
274 Coskey zole, 100 mg, for 15 to 30 days.41 All patients responded to therapy. In another study oral itraconazole was evaluated in onychomycosis. 42 It was more effective than griseofulvin. With a dosage of 100 mg per day fingernail infections were cured in 9 of 11 patients. Mter 6 to 8 months of treatment, toenail infections were cured in one patient and markedly improved in 14 of 25 patients. PARASITIC INFECfIONS
In three separate studies permethrin 5% cream was found to be extremely effective in the treatment of scabies in adults and children. 43.45 It was more effective than crotamiton 10% cream and slightly more effective than lindane lotion. In addition, it was found to cure cases of scabies resistant to lindane. Permethrin cream has a lower potential for neurologic toxicity and may be preferable to lindane for the treatment of scabies, particularly in young children. In two separate studies albendazole was found to be effective in the treatment of cutaneous larva migrans. 46,47 In onestudy eight patients weretreated with either 400 mg twice a day or 400 mg once daily for 3 days46 and in the other study they were treated with 400 mg daily for 3 days.47 VIRUS INFECTIONS
Thirty-two adults with varicella were treated with acyclovir, 4 gm daily, for 5 days.48 Those treated within 24 to 48 hours ofonset had a milder case than those treated later or not at all. In another study acyclovir was used to treat varicella in otherwise healthy children. 49 Fever was reduced sooner in the patients given acyclovir, they had fewer skin lesions, and they healed sooner. However, acyclovir did not change the rate of complications in this group. In an open study, continuous oral therapy with either ibuprofen or indomethacin reduced the incidence and frequency of recurrent herpes simplex in 9 of 16 patients.50 In another study topical interferon-a was evaluated in recurrent genital herpes simplex. 51 Topical human leukocyte interferon-a, either 104 or 106 IV/ gm in a 1% nonoxynol 9 base, was evaluated. The agents were applied either during the prodromal stage or during the first stage of recurrence. The higher dose ofinteferon-a was more effective than the lower dose with respect to duration of viral shedding as well as reducing time to the end of symptoms. However, there was no difference be-
Journal of the American Academy of Dermatology
tween placebo and the interferon groups in the time to crust formation and healing. A study was done to evaluate the prophylactic effect of oral acyclovir on primary herpes simplex infections in a day-care nursery.52 Twenty-three children treated with prophylactic acyclovir did not have herpetic gingivostomatitis whereas in the second group the disease developed in 18 of 22 not given prophylactic treatment. Podophyllotoxin 0.5% solution was compared with podophyllotoxin 0.5% cream and podophyllin 25% solution in the treatment of condyloma acuminatum. 53 The podophyllotoxins were applied by the patients three consecutive days per week, whereas the podophyllin was applied once weekly by the physician. Therapy ranged from 1 to 6 weeks. Podophyllotoxin was more effective (56% to 79%) than podophyllin (38%). In another study topical idoxuridine, 0.25% or 0.5% twice daily, was evaluated in the treatment of genital warts ofless than 3 months' duration.54 Treatment was not continued longer than 28 days. Three months after the start of treatment the cure rate was 60% with idoxuridine 0.5% cream and 32% with idoxuridine 0.25% cream. Two patients with the acquired immunodeficiency syndrome (AIDS) developed severe ulcerative proctitis caused by herpes simplex virus type 2 resistant to acyclovir.55 However, when high-dose, continuous-infusion acyclovir, 1.5 to 2.0 mg/kg/hr, was given in 6 weeks the eruption resolved. In another study 92 pregnant women with recurrent genital herpes received either acyclovir, 200 mg four times daily, starting 1 week before expected term and 46 women were not treated.56 Acyclovir was given for an average of 10 days. Treated women did not develop a symptomatic recurrence during the treatment period and did not excrete virus at the time of labor. Twelve nontreated women had symptomatic recurrences within 10 days before or at the time of delivery and nine had a cesarean section because of herpes. None of the 92 infants had neonatal herpes. Seven patients who tested positive for the human immunodeficiency virus (HIV) with red blood cell aplasia also had high concentrations of B19 parvovirus in their serum. 57 Six of these patients were treated with intravenous immunoglobulin. In all cases they developed a rapid reduction in the serum virus concentration and full recovery of erythropoiesis.
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Thirty-one men with androgenetic alopecia completed 4V2 to 5 years of treatment with topical 2% and 3% topical minoxidil. 58 Hair growth peaked at 1 year with a slow decline in regrowth over subsequent years. At the end of the treatment time maintenance of nonvellus hairs persisted beyond that seen at baseline. Five percent minoxidil plus 0.5% anthralin was used to treat severe treatment-resistant alopecia areata. 59 Irritant dermatitis developed in all patients. A cosmetic response was seen in 5 of 45 patients who completed the six months study. This was maintained in four of the patients for as long as 84 weeks. Polymyalgia was noted in four healthy men who had used topical minoxidil for 2 to 14 months. 6o The symptoms resolved after 2 to 4 weeks and recurred in two patients who started therapy again. When it was discontinued again the symptoms resolved. Hypertrichosis in remote parts of the body as well as rare cases of nerve or cardiovascular toxicity have also been reported. Topical cyclosporine was evaluated in male pattern alopecia in a double-blind study.61 Hair growth was observed in two of the eight patients who completed the study. Oral cyclosporine was evaluated in alopecia areatao Six patients were treated with 6 mg/kg/day for 12 weeks. 62 Cosmetically acceptable terminal hair regrowth occurred in three of six patients. However, hair loss occurred in all of the patients within 3 months of discontinuation of cyclosporine. METABOLIC DISEASES
A patient with porphyria cutanea tarda on longterm hemodialysis was treated with recombinant human erythropoietin, which mobilizes excess iron stores. 63 Transfusions were not necessary to treat the anemia produced by end-stage renal disease. In addition, small-volume phlebotomies (120 to 180 ml) were performed with a total of 900 ml of blood removed. The clinical course of this patient was improved and plasma porphyrin levels were markedly reduced. In another study two patients with chronic renal impairment complicated by anemia who also had porphyria cutanea tarda were treated with chloroquine, 50 mg twice a week. 64 Both patients improved and the uroporphyrin levels were reduced. Two children with erythropoietic protoporphyria,
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who were only moderately responsive to beta carotene and sunscreens, were also treated with pyridoxine with a dramatic reduction in sun sensitivity.65 A 55-year-old man with lichen myxedematosus of the urticarial plaque and nodular type was treated with chloroquine and had significant clinical improvement. 66 PAPULOSQUAMOUS ERUPTIONS
A randomized, double-blind, paired trial compared c1obetasol propionate ointment and diflorasone diacetate ointment in moderate to severe psoriasis. 67 Clobetasol propionate was significantly more effective in alleviating erythema, scaling, and skin thickening on days 8 and 15. Ten patients with psoriasis were treated with topical capsaicin four times daily.68 Seven patients had marked improvement in itching, scaling, and erythema. An 8-week, double-blind trial of sulfasalazine for the treatment of moderate to severe psoriasis was undertaken. 69 Seven of 17 had marked improvement and seven had moderate improvement. Only one patient who received placebo had moderate improvement. The authors believe this drug may be useful in psoriasis patients in whom methotrexate, etretinate, or PUVA is not indicated but whose disease is too widespread to justify topical corticosteroids. Acitretin in combination with UVB was found to be more effective than UVB alone. 7o Acitretin also decreases the effective accumulative UV dose necessary to treat psoriasis. A supplement in the British Journal ofDermatology summarizes the efficacy of cyclosporine in psoriasis and its side effects.71 •78 A supplement in this JOURNAL also discusses the usage ofcylosporine in dermatology.79.90 Forty-three patients with plaquelike psoriasis had half the body treated with UVB plus an emollient whereas the other side was treated with UVB alone. 91 The half treated with the emollient improved faster. In 40 patients with relapsing plaque-type psoriasis, the effectiveness of cyclosporine plus PUVA was compared with that of etretinate plus PUVA. 92 PUVA in combination with etretinate was more effective. Of 892 men who had been exposed to long-term PUVA therapy, 14 had 30 genital tumors. 93 The
276 Coskey authors recommend genital protection for men when they are treated with PUVA or other types of UV light. Two patients with AIDS and psoriasis were treated with zidovudine. 94 Lesions in one of the patients cleared after 2 weeks and in the other patient after 4 weeks of therapy. Severe extensive lichen planus treated with cyclosporine, 3 mg/kg/day, in seven of eight patients cleared after 10 days to 3 weeks of treatment,95 In another studytwo patients with severe chronic lichen planus had complete clearing after 8 weeks of cyclosporine, 6 mg/kg/day.96 Patients with seborrheic dermatitis of the scalp and culture positive for Pityrosporum ovale were treated in a double-blind, placebo-controlled study with ketoconazole shampoo or placebo twice weekly for 4 weeks. 97 Sixteen of 18 patients treated with ketoconazole became free of lesions or improved compared with 8 of 18 in the placebo group.97 In another study both ketoconazole shampoo and selenium sulfide shampoo were found to be effective in the treatment of dandruff. Ketoconazole reduced greasiness. 98 It was also found that 2% ketoconazole shampoo used once weekly prevented recurrence of dandruff. Eighteen patients with pityriasis rubra pilaris were treated with either isotretinoin, etretinate, or both. 99 Sixty percent of patients treated with isotretinoin achieved sustained resolution. Four patients treated with etretinate had complete clearing; another improved substantially. A patient with lichen nitidus was treated with astemizole, 10 mg/day, for 14 days and the lesions resolved. 100
NEOPLASMS A patient with xeroderma pigmentosum was treated with etretinate, 25 mg daily, for 22 months. WI During this period tumor development was completely suppressed. Seventy-three children with port-wine stains were treated with a flashlamp-pumped pulsed dye laser. 102 Thirty-three had more than 75% lightening after an average of 2.5 treatments, 31 patients had 50% to 74% lightening after an average of 1.7 treatments, and 26% to 49% lightening occurred after two treatments in another 7% of patients. Two patients with metastatic basal cell carcinoma responded to cisplatin chemotherapy.103
Journal of the American Academy of Dermatology
Ten of twelve solitary keratoacanthomas regressed completely after short-term, low-dose, oral isotretinoin therapy.l04 In another study two patients with multiple keratoacanthomas were treated with oral retinoids. 105 Retinoid therapy resulted in regression of larger, more typical lesions but smaller follicular keratoacanthomas were not affected. Sixty-five basal cell carcinomas were treated with intralesional sustained-release interferon alia-2b, 10 million IU per injection. 106 At study week 16, 80% of the evaluable tumors treated with three injections and 52% treated with one injection were cured histologically. In another study nine intralesional injections of two different doses of interferon-')' were evaluated in 29 patients with basal cell carcinoma. 107 One group of 15 patients received interferon-')', 0.01 mg, intralesionally three times a week for 3 weeks and in another group 14 patients received 0.05 mg intralesionally. Twelve weeks after therapy, excision of biopsy specimens revealed no tumor in four of seven patients treated with the higher dose, although only 1 of 15 patients treated with low dose interferon was cured. In another study 172 patients were given interferon alfa-2b or placebo for basal cell carcinoma three times weekly for 3 days for a cumulative dosage of 13.5 million IU l08 Sixteen to 20 weeks later 86% of interferon-treated patients were cured. Ten patients with basal cell carcinoma were treated with sublesional injections of interferon alfa-2b three times a week for 3 weeks (1.5 X 106 units per injection).109 Six treated lesions cleared completely. Fourteen patients with advanced squamous cell carcinoma of the skin or lip were treated with one to four cycles of cisplatin, 5-fluorouracil, and bleomycin. IIO Objective responses were seen in 11 of 13 evaluable patients, of whom four had a completeremission and seven had a partial remission. Sixty-nine patients with mycosis fungoides in the plaque stage were treated with either photochemotherapy (PUVA) or a combination of oral retinoids and PUVA (REPUVA).lll The response rate of PUVA and REPUVA was equal, with complete remission in 73% and 72%, respectively. However, there were fewer PUVA sessions and a lower UVA dosage was obtained when REPUVA was used. One hundred forty-three patients with cutaneous T cell lymphoma were treated with topical carmustine. A complete response was obtained in 86% of
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patients treated with less than 10% involvement of plaques, in 40% of those with extensive plaques, and in 21% of those with erythroderma. 112 The 5-year overall survival rate was 77%; the median survival time was 9.4 years. Photopheresis was used to treat eight patients with cutaneous T cell lymphoma. I13 Four of five patients with erythrodermic disease had either complete or partial clinical remission with photopheresis alone; one patient with extensive plaque disease had a partial remission of 7 months. Two patients with tumor stage disease were treated. One had no evidence ofdisease at 10 months. The second patient had a partial remission of 5 months with local radiation therapy and monthly photopheresis. Sixty patients with disseminated and progressive AIDS-related Kaposi's sarcoma were treated with bleomycin.114 Thirty were treated with intramuscular bleomycin and 30 with slow intravenous infusion. The mean duration of therapy was 5 months. A partial response was observed in 29 patients and the disease was stabilized in 18 patients. Low-dose recombinant interferon alfa-2b was used to treat two patients with Kaposi's sarcoma who did not have AIDS.1 15 Clinical improvement was obtained after a few months in both cases. In another study 43 patients with Kaposi's sarcoma associated with AIDS were treated with interferon-a (4.5,9, or 18 million U jday) and zidovudine, 100 to 200 mg orally every 4 hours. 116 Of 37 patients who were able to be examined, 17 showed complete or partial tumor regression.
VESICULOBULLOUS ERUPTIONS Carbon dioxide laser vaporization of localized, recalcitrant intertriginous plaques was performed in two patients with Hailey·Hailey disease and two with Darier's disease. 117 Only one patient had a recurrence in one treatment site. Two patients with severe pemphigus vulgaris were treated with cyclosporine for 12 and 30 months. I IS A good clinical response was obtained in both cases with no major side effects. The patients have remained free of disease for more than 20 months after stopping cyclosporine. Twenty-six patients with bullous pemphigoid were treated with a combination of chlorambucil and a systemic corticosteroid I 19; 23 completed treatment. The corticosteroid requirement during therapy was reduced by 50% compared with that reported for
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corticosteroid and azathioprine and the mean total duration of treatment was 5 months. Thirty percent of patients had mild transient thrombocytopenia. A patient with acquired epidermolysis bullosa whose disease was refractory to prednisolone, corticotropin, sulfasalazine, and phenytoin was treated with cyclosporine, 6 mg/kgjday.120 The prednisolone could be reduced to 15 mg a day and the blistering decreased dramatically. Twenty patients with striae distensae were treated with topical tretinoin 0.1 % cream. 121 Of the 16 patients who completed the study 15 had significant improvement. A double-blind study evaluated oral pentoxifylline in the treatment of venous ulcers. 122 Complete healing in 23 of 38 patients treated with the active drug and 12 of 42 treated with placebo. A 58-year-old black man with sickle cell leg ulcers of43 years' duration was treated with pentoxifylline, 400 mg three times a day, for 8 months and the ulcer healed. 123 Patients with brittle fingernails and onychoschizia were treated with biotin, 2.5 mgjday.124 Splitting of the nails was decreased and in some of the patients thickness of the nail increased. A patient with 20-nail dystrophy was treated with topical PUVA therapy.125 After 7 months excellent improvement was noted. Twenty-six patients with idiopathic guttate hypome1anosis were treated with liquid nitrogen. 126 The lesions became repigmented in 6 to 8 weeks. A 30-year-old Japanese woman with eosinophilic pustular folliculitis was treated with indomethacin, 25 to 250 mg daily, and went into remission. 127 REFERENCES 1. Schachner L, Eaglstein W, Kittles C, et al. Topical eryth-
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3. 4. 5. 6. 7.
romycin and zinc therapy for acne. JAM ACAD DERMA1990;22:253-60. Schachner L, Pestana A, Kittles C. A clinical trial comparing the safety and efficacy of a topical erythromycinzinc formulation with a topical c1indamycin formulation. JAM ACAD DERMATOL 1990;22:489-95. Buckley D, Rogers S, Daly P. Isotretinoin therapy for acne vulgaris: results in Irish population. Ir Moo J 1990;83:2-5. Chivot M, Midoun H. Isotretinoin and acne: study of relapses. Dermatologica 1990;180:240-3. Godfrey KM, James MP. Treatment of severe acne with isotretinoin in patients with inflammatory bowel disease. Br J Dermatol 1990;123:653-5. Monfreco1a G, Nappa P, Pini D. Solar urticaria in the visible spectrum successfully treated with astemizole. Dermatologica 1990;180:154-6. Liu HN, Pan LM, Hwang SC, et al. Nifedipine for the TOL
278 Caskey treatment of chronic urticaria: a double-blind cross-over study. J Dennatol Treat 1990;1:187-9. 8. Wahlgren CF, Hagennark 0, Bergstrom R. The antipruritic effect of a sedative and a non-sedative antihistamine in atopic dennatitis. Br J DermatoI1990;122:545-51. 9. Thivolet J, Nicolas JF, Kanitakis J, et a1. Recombinant interferon alpha2A is effective in the treatment of discoid and subacute cutaneous lupus erythematosus. Br J Dermatol 1990;122:405-9. 10. Falanga V, Medsger TA. D-Penicillamine in the treatment of localized sclerodenna. Arch Dermatol 1990;126:60912. 11. Turner AN, Whittaker S, Banks I, et al. Plasma exchange in refractory cutaneous vasculitis. Br J Dermatol 1990; 122:411-5. 12. Mathieson PW, Cobbold SP, Hale G, et a1. Monoclonalantibody therapy in systemic vasculitis. N Engl J Med 1990;323:250-4. 13. Yazigi H, Pazarli H, Barnes CG, et al. A controlled trial of azathioprine in Behs:et's syndrome. N Engl J Med 1990;322:281-5. 14. Eisen D, Ellis CN, Duell EA, et al. Effect of topical cyclosporine rinse on oral lichen planus: a double-blind analysis. N Engl J Med 1990;323:290-4. 15. NeumannRA, Knobler RM. Venous lakes (Bean-Walsh) of the lips: treatment experience with the argon laser and IS months follow up. Clin Exp DermatoI1990;15:1l5-8. 16. Zelickson BD, Roenigk RK. Actinic cheilitis: treatment with the carbon dioxide laser. Cancer 1990;65:1307-11. 17. Vernon HJ, Olsen EA. A controlled trial of clobetaso1 propionate ointment 0.05% in the treatment of experimentally induced Rhus dermatitis. J AM ACAD DERMA. TOL 1990;23:829-32. 18. Nielsen GD, Jepsen LV, Horogensen PJ, et al. Nickelsensitive patients with vesicular hand eczema: oral challenge with a diet naturally high in nickel. Br J Dermatol 1990;122:299-308. 19. JekIer J, Larka O. Combined UVA-UVB versus DVB phototherapy for atopic dermatitis: a paired-comparison study. J AM ACAD DERMATOL 1990;22:49-53. 20. Munkvad M. A comparative trial of clinitar versus hydrocortisone cream in the treatment of atopic eczema. Br J DermatoI1989;121:763-6. 21. Berth Jones J, Graham-Brown RAC. Failure of papaverine to reduce pruritus in atopic dermatitis: a double-blind, placebo-controlled cross-over study. Br J Dermatol 1990;123:553-7. 22. Ross JS, Camp RDR. Cyclosporin A in atopic dermatitis. Br J DermatoI1990;122(supp136):41-5. 23. Dattwyler RJ, Volkman DJ, Conaty SM, et al. Amoxicillin plus probenecid versus doxycycline for treatment of erythema migrans borreliosis. Lancet 1990;336:1404-6. 24. McLinn S. A bacteriologically controlled, randomized study comparing the efficacy of 2% mupirocin ointment (Bactroban) with oral erythromycin in the treatment of patients with impetigo. J AM ACAD DERMATOL 1990; 22:883-5. 25. Breneman DL. Use of mupirocin ointment in the treatment of secondarily infected dermatoses. J AM ACAD DERMATOL 1990;22:886-92. 26. Moy JA, Caldwell-Brown D, Lin AN, et a1. Mupirocinresistant Staphylococcus aureus after long-term treat· ment of patients with epidermolysis bullosa. J AM ACAD DERMATOL 1990;22:893-5. 27. Cookson BD, Lacey RW, Noble WC, et aJ. Mupirocin-
Journal of the American Academy of Dermatology resistant Staphylococcus aureus [Letter]. Lancet 1990; 335: 1095-6. 28. Weijmer MC, Neering H, Welton C. Preliminary report: furunculosis and hypoferraemia. Lancet 1990;336:464-6. 29. Kates SG, Myung KB, McGinley KJ, et al. The antibacterial efficacy of econozole nitrate in interdigital toe web infections. J AM ACAD DERMATOL 1990;22:583-6. 30. Wong KS, Tham SN. An open clinical study of 2% ketoconazole cream for treating superficial dermatomycoses. J Dermatol Treat 1990;1:207-8. 31. Jordon RE, Rapini RP, Rex IH, et a1. Once-daily naftifine cream I % in the treatment of tinea cruris and tinea corporis. Int J Dermatol 1990;29:441-2. 32. Smith EB, Wiss K, Hanifin JM, et al. Comparison ofonceand twice-daily naftiline cream regimens with twice-daily c1otrimazole in the treatment of tinea pedis. J AM ACAD DERMATOL 1990;22:116-7. 33. Greer DL, Jolly HW Jr. Treatment of tinea cruris with topical terbinafine. J AM ACAD DERMATOL 1990;23: 800-4. 34. Millikan LE. Efficacy and tolerability of topical terbinaline in the treatment of tinea cruris. J AM ACAD DERMATOL 1990;23:795-9. 35. Savin RC. Treatment ofchronic tinea pedis (athlete's foot type) with topical terbinafine. J AM ACAD DERMATOL 1990;23:786-9. 36. Savin RC, Zaias N. Treatment of chronic moccasin-type tinea pedis with terbinafine: a double.blind, placebo-controlled trial. JAM ACAD DERMATOL 1990;2:804-7. 37. DeWit RFE. A randomized double-blind multicentre comparative study of Lamisil (terbinafine) versus ketoconazole in tinea corporis. J Dermatol Treat 1990;1 (suppl 2):41-2. 38. Zaias N. Management of onychomycosis with oral terbinafine. J AM ACAD DERMATOL 1990;23:810-2. 39. Goodfield MJD. Clinical results with terbinafine in onychomycosis. J Dermatol Treat 1990;1 (suppl 2):55-7. 40. Savin RC. Oral terbinafine versus griseofulvin in the treatment of moccasin-type tinea pedis. J AM ACAD DERMATOL 1990;23:807-9. 41. Roseeuw D, Willemsen M, Kint RT, et a1. Itraconazole in the treatment of superficial mycoses: a double-blind study vs. placebo. Clin Exp Dermatol 1990;15:101-4. 42. Walsoe IDA, Strangerup M, Svejgaard E. Itraconazole in onychomycosis. Acta Derm Venereol (Stockh) 1990;70: 137-40. 43. Schultz MW, Gomez M, Hansen RC, et al. Comparative study of 5% permethrin cream and 1% lindane lotion for the treatment of scabies. Arch Dermatol 1990;126:16770. 44. Yonkosky D, Ladia L, Gackenheimer L, et al. Scabies in nursing homes: an eradication program with permethrin 5% cream. JAM ACAD DERMATOL 1990;23:1133-6. 45. Taplin D, Meinking TL, Chen JA, et al. Comparison of crotamiton 10% cream (Eurax) and permethrin 5% cream (Elimite) for the treatment of scabies in children. Pediatr Dermatol 1990;7:67-73. 46. Jones SK, Reynolds NJ, Oliwiecki S, et al. Oral albendazole for the treatment of cutaneous larva migrans. Br J Dermatol 1990;122:99-101. 47. Orihuela AR, Torres Jr. Single dose of albendazole in the treatment of cutaneous larva migrans [Letter]. Arch DermatolI990;126:39S-9. 48. Feder H. Treatment of adult chickenpox with oral acyclovir. Arch Intern Med 1990;150:2061-5.
Volume 25 Number 2, Part I August 1991 49. Balfour HH, Kelly JM, Suarez CS, et al. Acyclovir treatment of varicella in otherwise healthy children. J Pediatr 1990;116:633-9. 50. Wachsman M, Aurelian L, Burnett JW. The prophylactic use of cyclooxygenase inhibitors in recurrent herpes simplex infections. Br J Dermatol 1990;123:375-80. 51. Shupack J, Stiller M, Knobler E, et al. Topical alpha-interferon in recurrent genital herpes simplex infection: a double-blind, placebo-controlled clinical trial. Dermatologica 1990; 181: 134-8. . 52. Kuzushima K, Kimura H, Shibata M, et al. Prophylactic oral acyclovir in outbreaks of primary hcrpes simplex virus 1 infection [Letter). Lancet 1990;335:1043. 53. Mazurkiewicz W, Jahlonska S. Clinical efficacy of condyline (0.5% podophyllin) in the treatment of external condylomata acuminata. J Dermatol Treat 1990;1:123-5. 54. Happonen HP, Lassus A, Santalahi J, et al. Topical idoxuridine for treatment of genital warts in males: a doubleblind comparative study of 0.25% and 0.5% cream. Genitourin Med 1990;66:254-6. 55. Engel JP, Englund JA, Fletcher CV. Treatment of resistant herpes simplex virus with continuous-infusion acyclovir. JAMA 1990;263:1662-4. 56. Pedersen BS. Acyclovir in late pregnancy to prevent neonatal herpes simplex [Letter]. Lancet 1990;336:756. 57. Frickhofen N, Abkowitz JL, Safford M, et al. Persistent B19 parvovirus infection in patients infected with human immunodeficiency virus type 1 (HIV-I); a treatable cause of anemia in AIDS. Ann Intern Med 1990;113:926-33. 58. Olsen EA, Weiner MS, Amara lA, et al. Five-year follow-up of men with androgenetic alopecia treated with topical minoxidil [Letter]. 1 AM ACAD DERMATOl 1990; 22:643-6. 59. Fiedler ve, Wendrow A, Szpunar Gl, et al. Treatmentresistant alopecia areata. Response to combination therapy with minoxidil plus anthralin. Arch Dermatol 1990; 126:756-9. 60. Colamarino R, Dubost JJ, Sauvezie B. Polymyalgia and minoxidil. Ann Intern Med 1990;113:256-7. 61. Gilhar A, Pillar T, Etzioni A. Topical cyclosporine in male pattcrn alopecia. J AM ACAD DERMATOL 1990;22:251-3. 62. Gupta AK, Ellis CN, Cooper KD, et al. Oral cyclosporine for the treatment of alopecia areata. 1 AM ACAD DERMA· TOlI990;22:242-50. 63. Anderson KE, Goeger DE, Carson RW, et al. Erythropoietin for the treatment of porphyria cutanea tarda in a patient on long-term hemodialysis. Med Intell 1990; 322:315-7. 64. Wright AL, McColl KEL, Hunter lAA, et al. Treatment of porphyria cutanea tarda in renal failure with ultra-Iowdose chloroquine. J Dermatol Treat 1990;1:159-61. 65. Ross lB, Moss MA. Relief of the photosensitivity of erythropoietic protoporphyria by pyridoxine. 1 AM ACAD DERMATOL 1990;22:340-2. 66. Cernea SS, Rivitti EA. Successful treatment of mucinosis with chloroquine. J Dermatol Treat 1990;1:163-5. 67. Jegasothy BV. Clobetasol propionate ointment 0.05% versus diflorasone diacetate ointment 0.05% in moderate to severe psoriasis. Int 1 Dermatol 1990;29:729-30. 6S. Kurkcuoglu N, Alaybeyi F. Topical capsaicin for psoriasis [Letter]. Br J Dermatol 1990;123:549-50. 69. Gupta A, Ellis CN, Siegel MT, et al. Sulfasalazine improves psoriasis: a double-blind analysis. Arch Dermatol 1990;126:487-93. 70. Ruzicka T, Sommerburg C, Braun-Falco 0, et aJ. Effi-
Dermatologic therapy: 1990 279 ciency of acitretin in combination with UY-B in the treatment of severe psoriasis. Arch Dermatol 1990;126: 482-6. 71. Fradin MS, Ellis CN, Voorhees JJ. Efficacy ofcyclosporin A in psoriasis: a summary ofthe United States experience. Br J Dermatal I990; I22(suppl 36):21-5. 72. Meinardi MM, DeRie MA, Bos JD. Oral cyclosporin A in the treatment of psoriasiS: an overview of studies performed in The Netherlands. Br J Dermatol 1990; 122(suppl 36):27-31. 73. Timonen P, Friend D, Abeywickrama K, et al. Efficacy of low dose cyclosporin A in psoriasis: results of dose-finding studies. Br J DermatoI1990;122:(suppl 36):33-9. 74. Powles AY, Baker BS, Valdimarsson H, et al. Br J Dermatol 1990;122(suppl 36);13-9. 75. Halioua B, Saurat JH. Risk:benefit ratio in the treatment of psoriasis with systemic retinoids. Br J Dermatol 1990; 122(suppI36):135-50. 76. Mason J. Renal side-effects of cyclosporin A. Br 1 DermatolI990;122:(supp136):71-7. 77. Feutren G, Abeywickrama K, Friend D, et al. Renal function and blood pressure in psoriatic patients treated with cyclosporin A. Br J Dermatoll990;122(suppI36):5769. 7S. Krupp P, Monka C. Side-effect profile of cyclosporin Ain patients treated for psoriasis. Br J Dermatol 1990; 122(suppI36):47-56. 79. Griffiths CEM. Systemic and local administration of cyc1osporine in the treatment of psoriasis. 1 AM ACAD DERMATOL 1990;23:1242-7. SO. Ho YC, Lui H, McLean DI. Cyclosporine in nonpsoriatic dermatoses. 1 AM ACAD DERMATOL 1990;23:1248-59. 81. Eisen D, Ellis CN. Topical cyclosporine far oral mucosal disorders. 1 AM ACAD DERMATOL 1990;23:1259-64. 82. Fradin MS, Ellis CN, Voorhees J1. Management ofpatients and side effects during cyclosporine therapy for cutaneous disorders. J AM ACAD DERMATOL 1990;23:126575. 83. Mockli G, Kabra PM, KurtzTW. Laboratory monitoring of cyclasporine levels: guidelines for the dermatologist. J AM ACAD DERMATOL 1990;23:1275-9. 84. Bennett WM. Renal effects of cyclosporine. 1 AM ACAD DERMATOlI990;23:1280-7. 85. Messana JM, Rocher LL, Ellis CN, et al. Effects of cyclosporine on renal function in psoriasis patients. 1 AM ACAD DERMATOL 1990;23:1288-93. 86. Valdimarsson H. Immunity during cyclosporine therapy. J AM ACAD DERMATOL 1990;23:1294-300. 87. Watkins PB. The role of cytochromes P-450 in cyclosporine metabolism. J AM ACAD DERMATOL 1990;23:130111. 88. Baadsgaard 0, Fisher Gl, Voorhees JJ, et al. Interactions of epidermal celIs and T cells in inflammatory skin diseases. 1 AM ACAD DERMATOL 1990;23:1312-7. 89. Cooper KD, Yoorhees JJ, Fisher Gl, et al. Effects of cyc1osporine on immunologic mechanisms in psoriasis. 1 AM ACAD DERMATOL 1990;23:1318-28. 90. Fairley lA. Intracellular targets of cyclosporine. J AM ACAD DERMATOL 1990;23:1329-34. 91. Berne B, Blom I, Spangberg S. Enhanced response of psoriasis to UYB therapy after pretreatment with a lubricating base. A single-blind controlled study. Acta Derm Venereol (Stockh) 1990;70:474·7. 92. Petzelbauer P, Honigsmann H, Langer K, et aL Cyclosporin A in combination with photochemotherapy
280 Coskey
93.
94. 95. 96. 97. 98.
99. 100. 101. 102. 103. 104. 105. 106.
107. 108. 109. 110.
(PUVA) in the treatment of psoriasis. Br J Dermatol 1990;123:641-7. Stern RS. Genital tumors among men with psoriasis exposed to psoralens and ultraviolet A radiation (PUVA) and ultraviolet B radiation. N Engl J Med 1990;322: 1093-7. Diez F, del Hoyo M, Serrano S. Zidovudine treatment of psoriasis associated with acquired immunodeficiency syndrome [Letter]. J AM ACAD DERMATOL 1990;22:146-7. Pigatto PD, Chiappino G, Bigardi A, et al. Cyc1osporine A for treatment of severe lichen planus [Letter]. Br J DermatoI1990;122:121-3. Ho VC, Gupta AK, Ellis CN, et al. Treatment of severe lichen planus with cyclosporine. J AM ACAD DERMATOL 1990;22:64-8. Faergemann 1. Treatment of seborrheic dermatitis of the scalp with ketoconazole shampoo: a double-blind study. Acta Derm Venereal (Stockh) 1990;70:171-2. Brown M, Evans TW, Tooley PJH. The role of ketoconazole 2% shampoo in the treatment and prophylactic management of dandruff. J Dermatol Treat 1990;1: 177-9. Borok M, Lowe NJ. Pityriasis rubra pilaris. JAM ACAD DERMATOL 1990;22:792-5. VaughnRY,SrnithJG Jr. The treatment oflichen nitidus with astemizole. JAM ACAD DERMATOL 1990;23:757-8. Berth-Jones J, Graham-Brown RAC. Xeroderma pigmentosum variant: response to etretinate. Br J Dermatol 1990;122:559-61. Reyes BA, Geronemus R. Treatment of port-wine stains during childhood with the flashlamp-pumped pulsed dye laser. JAM ACAD DERMATOL 1990;23:1142-8. Khandekar JD. Complete response ofmetastaticbasal cell carcinoma to cisplatin chemotherapy: a report on two patients [Letter]. Arch DermatoI1990;126:1660. Goldberg LH, Rosen R, Becker J, et al. Treatment of solitary keratoacanthomas with oral isotretinoin. JAM ACAD DERMATOL 1990;23:934-6. Street ML, White JW Jr, Gibson LB. Multiple keratoacanthomas treated with oral retinoids. J AM ACAD DERMATOL 1990;23:862-6. Edwards L, Tucker SB, Perednia D, et al. The effect ofan intralesional sustained release formulation of interferon alfa-2b on basal cell carcinomas. Arch Dermatol 1990;126:1029-32. Edwards L, Whiting D, Rogers D, et al. The effect of intralesional interferon gamma on basal cell carcinomas. J AM ACAD DERMATOL 1990;22:496-500. Cornell RC, GreenwayHT, Tucker SB, et al. Intralesional interferon therapy for basal cell carcinoma. J AM ACAD DBRMATOL 1990;23:694-701. Thestrup-Pedersen K, Jacobsen IE, Frentz G. Intralesional interferon-alfa 2b treatment ofbasal cell carcinoma. Acta Derm Venereol (Stockh) 1990;70:512-4. Sadek H, Azli N, Wendling JL, et al. Treatment of advanced squamous cell carcinoma of the skin with cisplatin, 5-f1uorouracil, and bleomycin. Cancer 1990;66: 1692-6.
Journal of the American Academy of Dermatology 111. Thomsen K, Hammar H, Molin L, et al. Retinoids plus PUVA (REPUVA) and PUVA in mycosis fungoides plaque stage. A report from the Scandinavian Mycosis Fungoides Group. Acta Derm Venereol (Stockh) 1989; 89:536-8. 112. Zackheim HS, Epstein EH Jr, Crain WR. Topical carmustine (BCNU) for cutaneous T cell lymphoma: a IS-year experience in 143 patients. JAM ACAD DERMATOL 1990;22:802-10. 113. Armus·S, Keyes B, Cahill C, et al. Photopheresis for the treatment of cutaneous T cell lymphoma. J AM ACAD DERMATOL 1990;23:898-902. 114. Lassoued K, Clauvel JP, Katlama C, et al. Treatment of the acquired immune deficiency syndrome-related Kaposi's sarcoma with bleomycin as a single agent. Cancer 1990;66:1869-72. 115. Monti M, Barbareschi M, Angius A, et al. Responsiveness of classical Kaposi's sarcoma to recombinant interferon alpha 2b treatment. J Dermatol Treat 1990;1:209-10. 116. Krown SE, Gold JWM, Niedzwiecki D, et al. Interferona with zidovudine: safety, tolerance, and clinical and virologic effects in patients with Kaposi's sarcoma associated with the acquired immunodeficiency syndrome (AIDS). Ann Intern Med 1990;112:812-21. 117. McElroy JA, Mehregan DA, Roenigk RK. Carbon dioxide laser vaporization ofrecalcitrant symptomatic plaques ofHailey-Hailey disease and Darier's disease. JAM ACAD DERMATOL 1990;23:893-7. 118. Alijotas J, Pedragosa R, Bosch J, et al. Prolonged remission after cyclosporine therapy in pemphigus vulgaris: report of two young siblings. J AM ACAD DERMATOL 1990;23:701-3. 119. Milligan A, Hutchinson PE. The use of chlorambucil in the treatment of bullous pemphigoid. J AM ACAD DER. MATOL 1990;22:796-801. 120. Layton AM, Cunliffe WJ. Clearing of epidermolysis bullosa acquisita with cyclosporine [Letter]. J AM ACAD DERMATOL 1990;22:535. 121. Elson ML. Treatment of striae distensae with topical tretinoin. J Dermatol Surg Oneol 1990;16:267-70. 122. Colgan MP, Dormandy JA, Jones PW, et aL Oxpentifylline treatment of venous ulcers of the leg. Br Med J 1990;300:972-5. 123. Frost ML, Treadwell P. Treatment of sickle cell leg ulcers with pentoxifylline. Int J DermatolI990;29:375. 124. Colombo VE, Gerber F, Bronhofer M, et al. Treatment of brittle fingernails a.nd onychoschizia with biotin: scanning electron microscopy. J AM ACAD DERMATOL 1990; 23:1127-32. 125. Sorensen LH, Cramers M, Kragballe K. Twenty-nail dystrophy treated with topical PUVA. Acta Derm Venereol (Stockh) 1990;70:510-1. 126. Ploysangam T, Dee-Ananlap S, Suvanprakorn P. Treatment of idiopathic guttate hypomelanosis with liquid nitrogen: light and electon microscopic studies. J AM ACAD DERMATOL 1990;23:681-4. 127. Kato H. Eosinophilic pustular folliculitis treated with indomethacin [Letter]. Dermatologica 1989; 179:217-23.
Topical 4% erythromycin combined with 1.2% zinc acetate solution was compared with its vehicle in the treatment of acne. This combination was more effective than its vehicle and was found to be safe after 1 year of treatment.! This same solution was also compared with topical 1% clindamycin phosphate solution. Both agents were applied twice daily. Mter 6 weeks the erythromycin-zinc preparation was more effective than the c1indamycin preparation in decreasing papules, pustules, and comedones. No serious topical or systemic side effects occurred. The authors believed that the erythromycin-zinc formulation was more effective either because of the 4% concentration of erythromycin or because of the ability of the 1.2% zinc acetate to enhance the product's activity.2 Patients with severe nodular cystic acne were treated with isotretinoin in a dosage mainly of 1 mg/kg/day. Of the 88 patients treated, 84 had complete clearing. One patient became pregnant during therapy. Her infant was born with a ventral septal defect. 3 In another study 172 patients were treated with isotretinoin. These patients were followed up between 12 and 41 months after stopping therapy. Twenty-one percent had relapses. The more severe the acne, the higher the rate of relapse; there were more relapses in the 15- to 20-year-old group than in those of later age. These authors did not find a relation between dosage and relapse rate. 4 In another study four patients with inflammatory bowel disease and severe cystic acne were treated with isotretinoin. Two patients improved without any gastrointestinal side effects. One patient had two From the Dermatology Department, Wayne State University School of Medicine. Reprint requests: Ralph J, Caskey, MD, 23133 Orchard Lake Rd., Farmington, MI 48336.
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episodes of rectal bleeding, related to hemorrhoids, and in the fourth patient a flare of Crohn's disease developed. This article indicates that oral isotretinoin may be used in severe cystic acne in patients with inflammatory bowel disease, who do not tolerate oral antibiotic therapy. 5 ALLERGY
Three patients with solar urticaria were successfully treated with astemizole, 10 mg/day. This dosage increased the minimal urticarial dose elaborated by phototesting to visible light from 2 to 12 times. 6 Twenty-two patients with chronic idiopathic urticaria were treated in a double-blind cross-over study with nifedipine, 10 mg four times daily, or chlorpheniramine, 4 mg four times daily. Partial or total control of itching and hives was noted in 39% of patients receiving nifedipine and 28% of patients receiving chlorpheniramine. Nifedipine was not found to be superior to chlorpheniramine in controlling chronic urticaria. 7 Terfenadine, 60 mg twice daily, was compared with c1emastine, 2 mg twice daily, for their antipruritic effect in atopic dermatitis. These drugs were not more effective than a placebo. These findings support the view that histamine is probably not of importance in the pathogenesis of itch in atopic dermatitis. s COLLAGEN DISEASES AND VASCULITIS
Ten patients with discoid lupus erythematosus or subacute cutaneous lupus erythematosus (SCLE) were treated with interferon alfa-2a. After 4 to 8 weeks marked improvement was noted in the skin lesions of six patients treated with lower doses. Two patients with SCLE received high doses for 12 weeks with complete clearing and one had marked improvement. When treatment was discontinued, relapses occurred. 9 271
Journal of the American Academy of Dermatology
272 Caskey
Eleven patients with severe extensive localized scleroderma were treated with D-penicillamine. Improvement was noted within 3 to 6 months with cessation of active cutaneous lesions in seven patients, skin softening in five, and more normal growth ofthe affected limb in two of three children. In addition, improvement in stiffness and contractures of joints was noted. Dosage was as low as 2 to 5 mg/kg/day given for 15 to 53 months. Nephrotic syndrome occurred in one patient and reversible proteinuria in three other patients,lO Eight patients with refractory cutaneous vasculitis were treated by intermittent plasma exchange. All but one improved. ll Two monoclonal antibodies, Campath-IH and rat CD4, were used to treat a patient with intractable systemic vasculitis. Treatment was well tolerated and the patient remained well a year after therapy. 12 MUCOSAL ERUPTIONS
In a controlled trial, azathioprine (2.5 mg/kg of body weight/day) was given to 25 Turkish men with Beh~t's syndrome without eye disease and 48 with eye disease. 13 All patients also had corticosteroid treatment available to them. Six patients withdrew from the study because ofsevere eye disease but they were receiving placebo. Azathioprine was found to be superior to placebo in prevention of new eye disease in the first group of patients and in the second group in the 14 patients who had disease in only one eye. There were fewer episodes of hypopyon and uveitis in the two patients with eye disease who took azathioprine. In the group who took azathioprine oral-genital ulcers and arthritis occurred less frequently. A double-blind trial was done in 16 patients with symptomatic oral lichen planus. I4 The patients swished and spit out 5 ml of cyclosporine, 100 mg/ ml, three times daily. After 8 weeks cyclosporine produced marked improvement from treatment whereas those who used the vehicle had little change or minimal improvement. When the placebo group switched to cyclosporine, they also improved. The authors did not note side effects and in most cases the blood cyclosporine levels were low or not detectable. Fifty-one patients with venous lakes of the lips were treated with the argon laser. ls Ninety percent obtained excellent results and only one patient had recurrent lesions after 18 months. In another study 43 patients with actinic cheilitis were treated with the carbon dioxide laser. 16 After
follow-up of at least 10 months, 26 patients thought that the lip was cosmetically improved and 40 believed that the function of the lip was improved. DERMATITIS
Clobetasol propionate 0.05% cream was evaluated in the treatment of experimentally induced Rhus dermatitis. 17 It decreased vesiculation at the treated sites and was most effective when applied 12 hours after exposure to Rhus extract. Ten of 12 patients with vesicular hand eczema were given a high nickel diet for 4 days.I8 Hand eczema was aggravated in 10 patients by the eleventh day. The authors suggested that nickel-allergic patients with severe vesicular hand eczema should be given a low nickel diet. Thirty-eight patients with atopic dermatitis were treated with UVB on one side of the body and a combination of UVA and UVB to the other side of the body three times weekly for 8 weeks. 19 Improvement was noted on both sides of the patients' bodies but there were statistically significant differences in favor of the combined UVA and UVB therapy. Thirty patients with mild to moderate atopic dermatitis were treated on one side of the body with a purified coal tar cream and the other side with hydrocortisone 1% cream for 4 weeks. 2o Both treatments were equally effective in reducing symptoms and there was no difference in the patients' preference for treatment. A double-blind, placebo-controlled, cross-over study was done to assess the effect ofpapaverine, 100 mg, four times daily on the severity of pruritus in atopic dermatitis. 21 It was not found to be effective after 4 weeks of therapy. Thirteen patients with severe atopic dermatitis were treated for up to 31 months with oral cyclosporine. 22 Ten patients had a good response, one had a moderate response, and two a slight response. In two of the patients cYclosporine was withdrawn because of increasing plasma creatinine levels. BACfERIAL INFECTIONS
Seventy-two adults with erythema migrans were treated with either amoxicillin, 500 mg, in combination with probenecid, 500 mg, three times a day or doxycycline, 100 mg, twice a day for 21 days.23 Both regimens were equally effective. The authors stated that this regimen should not be used for patients with active central nervous system infection
Volume 25 Number 2, Part I August 1991
becuase the efficacy of oral therapy has not been proved. A randomized study compared mupirocin 2% ointment with oral erythromycin ethylsuccinate in the treatment of impetigo. 24 Mupirocin ointment was as safe and effective as oral erythromycin ethylsuccinate. Mupirocin ointment was used also in the treatment ofsecondarily infected dermatoses in a doubleblind, randomized, vehicle-controlled study.25 It was found to be safe and effective especially for infections caused by Staphylococcus aureus. Forty-seven patients with epidermolysis bullosa were treated with topical mupirocin ointment. 26 In five of these patients cultures from nonhealing wounds revealed S. aureus resistant to mupirocin. A total of 8220 cultures were obtained from inpatients and outpatients in England between 1987 and 1989.27 Of these 7137 grew S. aureus, of which only 0.3% were resistant to mupirocin. Three percent of coagulase-negative staphylococcal isolates were resistant. Sixteen patients with recurring staphylococcal furunculosis had a low serum iron concentration, although they were not anemic. 28 The furunculosis resolved after 3 to 4 weeks of treatment with iron supplements in all but one of the patients. Twenty-four patients with severe interdigital toe web infections not caused by dermatophytes were treated with topical econazole nitrate or its vehicle.29 Ofthese, 88% had a good to excellent response to the active agent. Aerobic flora decreased in 93% in the actively treated group. This study demonstrated that econazole has antibacterial activity and is an effective agent for the treatment of interdigital bacterial infections not complicated by dermatophyte colonization. FUNGUS INFECfIONS An open study was done to evaluate 2% ketoconazoIe cream in the treatment of tinea corporis and tinea cruris. 3o After 30 days, 32 of 35 patients were clinically cleared. Seventy patients with tinea cruris or tinea corporis were treated with naftifine 1% cream or its vehicle once daily for 4 weeks. 3! At the end of 4 weeks, 86% were mycologically cured with naftifine whereas 30% were mycologically cured with the vehicle. In another study 210 patients with tinea pedis were treated with naftifine cream once or twice daily or clotrimazole cream twice daily for 4 weeks. 32
Dermatologic therapy: 1990 273 When seen 2 weeks after therapy was stopped, 81 % of the patients in the naftiiine group and 58% of those in the clotrimazole group had been treated successfully. In two separate studies patients with tinea cruris were treated with topical terbinafine 1%cream twice daily.33, 34 Mter 2 weeks, in both studies, terbinafine was more effective than placebo in 78% of the patients. In two other studies 1% terbinafine cream was used to treat chronic tinea pedis. 35 ,36 Terbinafine was effective clinically and mycologically in 78% of the patients treated for 4 weeks. 35 Oral terbinafine, 125 mg twice daily, was given for the treatment of chronic moccasin-type tinea pedis. Mycologic cure and near to complete clearing of signs and symptoms were obtained in 59% of the patients. 36 In another double-blind study oral terbinafine was compared with ketoconazole in the treatment of patients with dermatophyte infections. 37 Both groups responded equally well after a maximum of 6 weeks. Eleven patients with onychomycosis of the fingernails were treated with terbinafine, 125 mg twice daily, for 6 months or until the infection cleared. 38 At the end of the treatment period all patients were clinically and mycologically normal. The only side effect noted was mild gastric discomfort in one patient. Eighty patients with onychomycosis of the toenails and 23 with fingernail onychomycosis were treated with terbinafine, 250 mg daily.39 The fingernails were treated for 6 months and the toenails for 12 months. Of 89 patients who completed the study, 95% with a fingernail infection and 82% with a toenail infection were cured. The mean time for mycologic cure was 13.4 weeks for fingernail infection and 28 weeks for toenail infections. Gastrointestinal symptoms were the most common cause for patients to withdraw from the study. Terbinafine, 125 mg twice daily, was compared with griseofulvin, 250 mg twice daily, in patients with moccasin-type tinea pedis. 4o After 6 weeks of therapy mycologic and clinical cure or mycologic cure with minimal signs of infection was noted in 12 of 16 patients receiving terbinafine but only 3 of 12 patients treated with griseofulvin. Six to IS months after completion of the study, 94% of terbina:finetreated patients remained clear. Of the patients treated with griseofulvin, 30% remained cured; toenails improved in only 14%. Ninety-four patients with dermatophytosis and 16 with tinea versicolor were treated with itracona-
274 Coskey zole, 100 mg, for 15 to 30 days.41 All patients responded to therapy. In another study oral itraconazole was evaluated in onychomycosis. 42 It was more effective than griseofulvin. With a dosage of 100 mg per day fingernail infections were cured in 9 of 11 patients. Mter 6 to 8 months of treatment, toenail infections were cured in one patient and markedly improved in 14 of 25 patients. PARASITIC INFECfIONS
In three separate studies permethrin 5% cream was found to be extremely effective in the treatment of scabies in adults and children. 43.45 It was more effective than crotamiton 10% cream and slightly more effective than lindane lotion. In addition, it was found to cure cases of scabies resistant to lindane. Permethrin cream has a lower potential for neurologic toxicity and may be preferable to lindane for the treatment of scabies, particularly in young children. In two separate studies albendazole was found to be effective in the treatment of cutaneous larva migrans. 46,47 In onestudy eight patients weretreated with either 400 mg twice a day or 400 mg once daily for 3 days46 and in the other study they were treated with 400 mg daily for 3 days.47 VIRUS INFECTIONS
Thirty-two adults with varicella were treated with acyclovir, 4 gm daily, for 5 days.48 Those treated within 24 to 48 hours ofonset had a milder case than those treated later or not at all. In another study acyclovir was used to treat varicella in otherwise healthy children. 49 Fever was reduced sooner in the patients given acyclovir, they had fewer skin lesions, and they healed sooner. However, acyclovir did not change the rate of complications in this group. In an open study, continuous oral therapy with either ibuprofen or indomethacin reduced the incidence and frequency of recurrent herpes simplex in 9 of 16 patients.50 In another study topical interferon-a was evaluated in recurrent genital herpes simplex. 51 Topical human leukocyte interferon-a, either 104 or 106 IV/ gm in a 1% nonoxynol 9 base, was evaluated. The agents were applied either during the prodromal stage or during the first stage of recurrence. The higher dose ofinteferon-a was more effective than the lower dose with respect to duration of viral shedding as well as reducing time to the end of symptoms. However, there was no difference be-
Journal of the American Academy of Dermatology
tween placebo and the interferon groups in the time to crust formation and healing. A study was done to evaluate the prophylactic effect of oral acyclovir on primary herpes simplex infections in a day-care nursery.52 Twenty-three children treated with prophylactic acyclovir did not have herpetic gingivostomatitis whereas in the second group the disease developed in 18 of 22 not given prophylactic treatment. Podophyllotoxin 0.5% solution was compared with podophyllotoxin 0.5% cream and podophyllin 25% solution in the treatment of condyloma acuminatum. 53 The podophyllotoxins were applied by the patients three consecutive days per week, whereas the podophyllin was applied once weekly by the physician. Therapy ranged from 1 to 6 weeks. Podophyllotoxin was more effective (56% to 79%) than podophyllin (38%). In another study topical idoxuridine, 0.25% or 0.5% twice daily, was evaluated in the treatment of genital warts ofless than 3 months' duration.54 Treatment was not continued longer than 28 days. Three months after the start of treatment the cure rate was 60% with idoxuridine 0.5% cream and 32% with idoxuridine 0.25% cream. Two patients with the acquired immunodeficiency syndrome (AIDS) developed severe ulcerative proctitis caused by herpes simplex virus type 2 resistant to acyclovir.55 However, when high-dose, continuous-infusion acyclovir, 1.5 to 2.0 mg/kg/hr, was given in 6 weeks the eruption resolved. In another study 92 pregnant women with recurrent genital herpes received either acyclovir, 200 mg four times daily, starting 1 week before expected term and 46 women were not treated.56 Acyclovir was given for an average of 10 days. Treated women did not develop a symptomatic recurrence during the treatment period and did not excrete virus at the time of labor. Twelve nontreated women had symptomatic recurrences within 10 days before or at the time of delivery and nine had a cesarean section because of herpes. None of the 92 infants had neonatal herpes. Seven patients who tested positive for the human immunodeficiency virus (HIV) with red blood cell aplasia also had high concentrations of B19 parvovirus in their serum. 57 Six of these patients were treated with intravenous immunoglobulin. In all cases they developed a rapid reduction in the serum virus concentration and full recovery of erythropoiesis.
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Thirty-one men with androgenetic alopecia completed 4V2 to 5 years of treatment with topical 2% and 3% topical minoxidil. 58 Hair growth peaked at 1 year with a slow decline in regrowth over subsequent years. At the end of the treatment time maintenance of nonvellus hairs persisted beyond that seen at baseline. Five percent minoxidil plus 0.5% anthralin was used to treat severe treatment-resistant alopecia areata. 59 Irritant dermatitis developed in all patients. A cosmetic response was seen in 5 of 45 patients who completed the six months study. This was maintained in four of the patients for as long as 84 weeks. Polymyalgia was noted in four healthy men who had used topical minoxidil for 2 to 14 months. 6o The symptoms resolved after 2 to 4 weeks and recurred in two patients who started therapy again. When it was discontinued again the symptoms resolved. Hypertrichosis in remote parts of the body as well as rare cases of nerve or cardiovascular toxicity have also been reported. Topical cyclosporine was evaluated in male pattern alopecia in a double-blind study.61 Hair growth was observed in two of the eight patients who completed the study. Oral cyclosporine was evaluated in alopecia areatao Six patients were treated with 6 mg/kg/day for 12 weeks. 62 Cosmetically acceptable terminal hair regrowth occurred in three of six patients. However, hair loss occurred in all of the patients within 3 months of discontinuation of cyclosporine. METABOLIC DISEASES
A patient with porphyria cutanea tarda on longterm hemodialysis was treated with recombinant human erythropoietin, which mobilizes excess iron stores. 63 Transfusions were not necessary to treat the anemia produced by end-stage renal disease. In addition, small-volume phlebotomies (120 to 180 ml) were performed with a total of 900 ml of blood removed. The clinical course of this patient was improved and plasma porphyrin levels were markedly reduced. In another study two patients with chronic renal impairment complicated by anemia who also had porphyria cutanea tarda were treated with chloroquine, 50 mg twice a week. 64 Both patients improved and the uroporphyrin levels were reduced. Two children with erythropoietic protoporphyria,
Dermatologic therapy: 1990 275
who were only moderately responsive to beta carotene and sunscreens, were also treated with pyridoxine with a dramatic reduction in sun sensitivity.65 A 55-year-old man with lichen myxedematosus of the urticarial plaque and nodular type was treated with chloroquine and had significant clinical improvement. 66 PAPULOSQUAMOUS ERUPTIONS
A randomized, double-blind, paired trial compared c1obetasol propionate ointment and diflorasone diacetate ointment in moderate to severe psoriasis. 67 Clobetasol propionate was significantly more effective in alleviating erythema, scaling, and skin thickening on days 8 and 15. Ten patients with psoriasis were treated with topical capsaicin four times daily.68 Seven patients had marked improvement in itching, scaling, and erythema. An 8-week, double-blind trial of sulfasalazine for the treatment of moderate to severe psoriasis was undertaken. 69 Seven of 17 had marked improvement and seven had moderate improvement. Only one patient who received placebo had moderate improvement. The authors believe this drug may be useful in psoriasis patients in whom methotrexate, etretinate, or PUVA is not indicated but whose disease is too widespread to justify topical corticosteroids. Acitretin in combination with UVB was found to be more effective than UVB alone. 7o Acitretin also decreases the effective accumulative UV dose necessary to treat psoriasis. A supplement in the British Journal ofDermatology summarizes the efficacy of cyclosporine in psoriasis and its side effects.71 •78 A supplement in this JOURNAL also discusses the usage ofcylosporine in dermatology.79.90 Forty-three patients with plaquelike psoriasis had half the body treated with UVB plus an emollient whereas the other side was treated with UVB alone. 91 The half treated with the emollient improved faster. In 40 patients with relapsing plaque-type psoriasis, the effectiveness of cyclosporine plus PUVA was compared with that of etretinate plus PUVA. 92 PUVA in combination with etretinate was more effective. Of 892 men who had been exposed to long-term PUVA therapy, 14 had 30 genital tumors. 93 The
276 Coskey authors recommend genital protection for men when they are treated with PUVA or other types of UV light. Two patients with AIDS and psoriasis were treated with zidovudine. 94 Lesions in one of the patients cleared after 2 weeks and in the other patient after 4 weeks of therapy. Severe extensive lichen planus treated with cyclosporine, 3 mg/kg/day, in seven of eight patients cleared after 10 days to 3 weeks of treatment,95 In another studytwo patients with severe chronic lichen planus had complete clearing after 8 weeks of cyclosporine, 6 mg/kg/day.96 Patients with seborrheic dermatitis of the scalp and culture positive for Pityrosporum ovale were treated in a double-blind, placebo-controlled study with ketoconazole shampoo or placebo twice weekly for 4 weeks. 97 Sixteen of 18 patients treated with ketoconazole became free of lesions or improved compared with 8 of 18 in the placebo group.97 In another study both ketoconazole shampoo and selenium sulfide shampoo were found to be effective in the treatment of dandruff. Ketoconazole reduced greasiness. 98 It was also found that 2% ketoconazole shampoo used once weekly prevented recurrence of dandruff. Eighteen patients with pityriasis rubra pilaris were treated with either isotretinoin, etretinate, or both. 99 Sixty percent of patients treated with isotretinoin achieved sustained resolution. Four patients treated with etretinate had complete clearing; another improved substantially. A patient with lichen nitidus was treated with astemizole, 10 mg/day, for 14 days and the lesions resolved. 100
NEOPLASMS A patient with xeroderma pigmentosum was treated with etretinate, 25 mg daily, for 22 months. WI During this period tumor development was completely suppressed. Seventy-three children with port-wine stains were treated with a flashlamp-pumped pulsed dye laser. 102 Thirty-three had more than 75% lightening after an average of 2.5 treatments, 31 patients had 50% to 74% lightening after an average of 1.7 treatments, and 26% to 49% lightening occurred after two treatments in another 7% of patients. Two patients with metastatic basal cell carcinoma responded to cisplatin chemotherapy.103
Journal of the American Academy of Dermatology
Ten of twelve solitary keratoacanthomas regressed completely after short-term, low-dose, oral isotretinoin therapy.l04 In another study two patients with multiple keratoacanthomas were treated with oral retinoids. 105 Retinoid therapy resulted in regression of larger, more typical lesions but smaller follicular keratoacanthomas were not affected. Sixty-five basal cell carcinomas were treated with intralesional sustained-release interferon alia-2b, 10 million IU per injection. 106 At study week 16, 80% of the evaluable tumors treated with three injections and 52% treated with one injection were cured histologically. In another study nine intralesional injections of two different doses of interferon-')' were evaluated in 29 patients with basal cell carcinoma. 107 One group of 15 patients received interferon-')', 0.01 mg, intralesionally three times a week for 3 weeks and in another group 14 patients received 0.05 mg intralesionally. Twelve weeks after therapy, excision of biopsy specimens revealed no tumor in four of seven patients treated with the higher dose, although only 1 of 15 patients treated with low dose interferon was cured. In another study 172 patients were given interferon alfa-2b or placebo for basal cell carcinoma three times weekly for 3 days for a cumulative dosage of 13.5 million IU l08 Sixteen to 20 weeks later 86% of interferon-treated patients were cured. Ten patients with basal cell carcinoma were treated with sublesional injections of interferon alfa-2b three times a week for 3 weeks (1.5 X 106 units per injection).109 Six treated lesions cleared completely. Fourteen patients with advanced squamous cell carcinoma of the skin or lip were treated with one to four cycles of cisplatin, 5-fluorouracil, and bleomycin. IIO Objective responses were seen in 11 of 13 evaluable patients, of whom four had a completeremission and seven had a partial remission. Sixty-nine patients with mycosis fungoides in the plaque stage were treated with either photochemotherapy (PUVA) or a combination of oral retinoids and PUVA (REPUVA).lll The response rate of PUVA and REPUVA was equal, with complete remission in 73% and 72%, respectively. However, there were fewer PUVA sessions and a lower UVA dosage was obtained when REPUVA was used. One hundred forty-three patients with cutaneous T cell lymphoma were treated with topical carmustine. A complete response was obtained in 86% of
Volume 25 Number 2, Part 1 August 1991
patients treated with less than 10% involvement of plaques, in 40% of those with extensive plaques, and in 21% of those with erythroderma. 112 The 5-year overall survival rate was 77%; the median survival time was 9.4 years. Photopheresis was used to treat eight patients with cutaneous T cell lymphoma. I13 Four of five patients with erythrodermic disease had either complete or partial clinical remission with photopheresis alone; one patient with extensive plaque disease had a partial remission of 7 months. Two patients with tumor stage disease were treated. One had no evidence ofdisease at 10 months. The second patient had a partial remission of 5 months with local radiation therapy and monthly photopheresis. Sixty patients with disseminated and progressive AIDS-related Kaposi's sarcoma were treated with bleomycin.114 Thirty were treated with intramuscular bleomycin and 30 with slow intravenous infusion. The mean duration of therapy was 5 months. A partial response was observed in 29 patients and the disease was stabilized in 18 patients. Low-dose recombinant interferon alfa-2b was used to treat two patients with Kaposi's sarcoma who did not have AIDS.1 15 Clinical improvement was obtained after a few months in both cases. In another study 43 patients with Kaposi's sarcoma associated with AIDS were treated with interferon-a (4.5,9, or 18 million U jday) and zidovudine, 100 to 200 mg orally every 4 hours. 116 Of 37 patients who were able to be examined, 17 showed complete or partial tumor regression.
VESICULOBULLOUS ERUPTIONS Carbon dioxide laser vaporization of localized, recalcitrant intertriginous plaques was performed in two patients with Hailey·Hailey disease and two with Darier's disease. 117 Only one patient had a recurrence in one treatment site. Two patients with severe pemphigus vulgaris were treated with cyclosporine for 12 and 30 months. I IS A good clinical response was obtained in both cases with no major side effects. The patients have remained free of disease for more than 20 months after stopping cyclosporine. Twenty-six patients with bullous pemphigoid were treated with a combination of chlorambucil and a systemic corticosteroid I 19; 23 completed treatment. The corticosteroid requirement during therapy was reduced by 50% compared with that reported for
Dermato!oglc therapy: 1990
277
corticosteroid and azathioprine and the mean total duration of treatment was 5 months. Thirty percent of patients had mild transient thrombocytopenia. A patient with acquired epidermolysis bullosa whose disease was refractory to prednisolone, corticotropin, sulfasalazine, and phenytoin was treated with cyclosporine, 6 mg/kgjday.120 The prednisolone could be reduced to 15 mg a day and the blistering decreased dramatically. Twenty patients with striae distensae were treated with topical tretinoin 0.1 % cream. 121 Of the 16 patients who completed the study 15 had significant improvement. A double-blind study evaluated oral pentoxifylline in the treatment of venous ulcers. 122 Complete healing in 23 of 38 patients treated with the active drug and 12 of 42 treated with placebo. A 58-year-old black man with sickle cell leg ulcers of43 years' duration was treated with pentoxifylline, 400 mg three times a day, for 8 months and the ulcer healed. 123 Patients with brittle fingernails and onychoschizia were treated with biotin, 2.5 mgjday.124 Splitting of the nails was decreased and in some of the patients thickness of the nail increased. A patient with 20-nail dystrophy was treated with topical PUVA therapy.125 After 7 months excellent improvement was noted. Twenty-six patients with idiopathic guttate hypome1anosis were treated with liquid nitrogen. 126 The lesions became repigmented in 6 to 8 weeks. A 30-year-old Japanese woman with eosinophilic pustular folliculitis was treated with indomethacin, 25 to 250 mg daily, and went into remission. 127 REFERENCES 1. Schachner L, Eaglstein W, Kittles C, et al. Topical eryth-
2.
3. 4. 5. 6. 7.
romycin and zinc therapy for acne. JAM ACAD DERMA1990;22:253-60. Schachner L, Pestana A, Kittles C. A clinical trial comparing the safety and efficacy of a topical erythromycinzinc formulation with a topical c1indamycin formulation. JAM ACAD DERMATOL 1990;22:489-95. Buckley D, Rogers S, Daly P. Isotretinoin therapy for acne vulgaris: results in Irish population. Ir Moo J 1990;83:2-5. Chivot M, Midoun H. Isotretinoin and acne: study of relapses. Dermatologica 1990;180:240-3. Godfrey KM, James MP. Treatment of severe acne with isotretinoin in patients with inflammatory bowel disease. Br J Dermatol 1990;123:653-5. Monfreco1a G, Nappa P, Pini D. Solar urticaria in the visible spectrum successfully treated with astemizole. Dermatologica 1990;180:154-6. Liu HN, Pan LM, Hwang SC, et al. Nifedipine for the TOL
278 Caskey treatment of chronic urticaria: a double-blind cross-over study. J Dennatol Treat 1990;1:187-9. 8. Wahlgren CF, Hagennark 0, Bergstrom R. The antipruritic effect of a sedative and a non-sedative antihistamine in atopic dennatitis. Br J DermatoI1990;122:545-51. 9. Thivolet J, Nicolas JF, Kanitakis J, et a1. Recombinant interferon alpha2A is effective in the treatment of discoid and subacute cutaneous lupus erythematosus. Br J Dermatol 1990;122:405-9. 10. Falanga V, Medsger TA. D-Penicillamine in the treatment of localized sclerodenna. Arch Dermatol 1990;126:60912. 11. Turner AN, Whittaker S, Banks I, et al. Plasma exchange in refractory cutaneous vasculitis. Br J Dermatol 1990; 122:411-5. 12. Mathieson PW, Cobbold SP, Hale G, et a1. Monoclonalantibody therapy in systemic vasculitis. N Engl J Med 1990;323:250-4. 13. Yazigi H, Pazarli H, Barnes CG, et al. A controlled trial of azathioprine in Behs:et's syndrome. N Engl J Med 1990;322:281-5. 14. Eisen D, Ellis CN, Duell EA, et al. Effect of topical cyclosporine rinse on oral lichen planus: a double-blind analysis. N Engl J Med 1990;323:290-4. 15. NeumannRA, Knobler RM. Venous lakes (Bean-Walsh) of the lips: treatment experience with the argon laser and IS months follow up. Clin Exp DermatoI1990;15:1l5-8. 16. Zelickson BD, Roenigk RK. Actinic cheilitis: treatment with the carbon dioxide laser. Cancer 1990;65:1307-11. 17. Vernon HJ, Olsen EA. A controlled trial of clobetaso1 propionate ointment 0.05% in the treatment of experimentally induced Rhus dermatitis. J AM ACAD DERMA. TOL 1990;23:829-32. 18. Nielsen GD, Jepsen LV, Horogensen PJ, et al. Nickelsensitive patients with vesicular hand eczema: oral challenge with a diet naturally high in nickel. Br J Dermatol 1990;122:299-308. 19. JekIer J, Larka O. Combined UVA-UVB versus DVB phototherapy for atopic dermatitis: a paired-comparison study. J AM ACAD DERMATOL 1990;22:49-53. 20. Munkvad M. A comparative trial of clinitar versus hydrocortisone cream in the treatment of atopic eczema. Br J DermatoI1989;121:763-6. 21. Berth Jones J, Graham-Brown RAC. Failure of papaverine to reduce pruritus in atopic dermatitis: a double-blind, placebo-controlled cross-over study. Br J Dermatol 1990;123:553-7. 22. Ross JS, Camp RDR. Cyclosporin A in atopic dermatitis. Br J DermatoI1990;122(supp136):41-5. 23. Dattwyler RJ, Volkman DJ, Conaty SM, et al. Amoxicillin plus probenecid versus doxycycline for treatment of erythema migrans borreliosis. Lancet 1990;336:1404-6. 24. McLinn S. A bacteriologically controlled, randomized study comparing the efficacy of 2% mupirocin ointment (Bactroban) with oral erythromycin in the treatment of patients with impetigo. J AM ACAD DERMATOL 1990; 22:883-5. 25. Breneman DL. Use of mupirocin ointment in the treatment of secondarily infected dermatoses. J AM ACAD DERMATOL 1990;22:886-92. 26. Moy JA, Caldwell-Brown D, Lin AN, et a1. Mupirocinresistant Staphylococcus aureus after long-term treat· ment of patients with epidermolysis bullosa. J AM ACAD DERMATOL 1990;22:893-5. 27. Cookson BD, Lacey RW, Noble WC, et aJ. Mupirocin-
Journal of the American Academy of Dermatology resistant Staphylococcus aureus [Letter]. Lancet 1990; 335: 1095-6. 28. Weijmer MC, Neering H, Welton C. Preliminary report: furunculosis and hypoferraemia. Lancet 1990;336:464-6. 29. Kates SG, Myung KB, McGinley KJ, et al. The antibacterial efficacy of econozole nitrate in interdigital toe web infections. J AM ACAD DERMATOL 1990;22:583-6. 30. Wong KS, Tham SN. An open clinical study of 2% ketoconazole cream for treating superficial dermatomycoses. J Dermatol Treat 1990;1:207-8. 31. Jordon RE, Rapini RP, Rex IH, et a1. Once-daily naftifine cream I % in the treatment of tinea cruris and tinea corporis. Int J Dermatol 1990;29:441-2. 32. Smith EB, Wiss K, Hanifin JM, et al. Comparison ofonceand twice-daily naftiline cream regimens with twice-daily c1otrimazole in the treatment of tinea pedis. J AM ACAD DERMATOL 1990;22:116-7. 33. Greer DL, Jolly HW Jr. Treatment of tinea cruris with topical terbinafine. J AM ACAD DERMATOL 1990;23: 800-4. 34. Millikan LE. Efficacy and tolerability of topical terbinaline in the treatment of tinea cruris. J AM ACAD DERMATOL 1990;23:795-9. 35. Savin RC. Treatment ofchronic tinea pedis (athlete's foot type) with topical terbinafine. J AM ACAD DERMATOL 1990;23:786-9. 36. Savin RC, Zaias N. Treatment of chronic moccasin-type tinea pedis with terbinafine: a double.blind, placebo-controlled trial. JAM ACAD DERMATOL 1990;2:804-7. 37. DeWit RFE. A randomized double-blind multicentre comparative study of Lamisil (terbinafine) versus ketoconazole in tinea corporis. J Dermatol Treat 1990;1 (suppl 2):41-2. 38. Zaias N. Management of onychomycosis with oral terbinafine. J AM ACAD DERMATOL 1990;23:810-2. 39. Goodfield MJD. Clinical results with terbinafine in onychomycosis. J Dermatol Treat 1990;1 (suppl 2):55-7. 40. Savin RC. Oral terbinafine versus griseofulvin in the treatment of moccasin-type tinea pedis. J AM ACAD DERMATOL 1990;23:807-9. 41. Roseeuw D, Willemsen M, Kint RT, et a1. Itraconazole in the treatment of superficial mycoses: a double-blind study vs. placebo. Clin Exp Dermatol 1990;15:101-4. 42. Walsoe IDA, Strangerup M, Svejgaard E. Itraconazole in onychomycosis. Acta Derm Venereol (Stockh) 1990;70: 137-40. 43. Schultz MW, Gomez M, Hansen RC, et al. Comparative study of 5% permethrin cream and 1% lindane lotion for the treatment of scabies. Arch Dermatol 1990;126:16770. 44. Yonkosky D, Ladia L, Gackenheimer L, et al. Scabies in nursing homes: an eradication program with permethrin 5% cream. JAM ACAD DERMATOL 1990;23:1133-6. 45. Taplin D, Meinking TL, Chen JA, et al. Comparison of crotamiton 10% cream (Eurax) and permethrin 5% cream (Elimite) for the treatment of scabies in children. Pediatr Dermatol 1990;7:67-73. 46. Jones SK, Reynolds NJ, Oliwiecki S, et al. Oral albendazole for the treatment of cutaneous larva migrans. Br J Dermatol 1990;122:99-101. 47. Orihuela AR, Torres Jr. Single dose of albendazole in the treatment of cutaneous larva migrans [Letter]. Arch DermatolI990;126:39S-9. 48. Feder H. Treatment of adult chickenpox with oral acyclovir. Arch Intern Med 1990;150:2061-5.
Volume 25 Number 2, Part I August 1991 49. Balfour HH, Kelly JM, Suarez CS, et al. Acyclovir treatment of varicella in otherwise healthy children. J Pediatr 1990;116:633-9. 50. Wachsman M, Aurelian L, Burnett JW. The prophylactic use of cyclooxygenase inhibitors in recurrent herpes simplex infections. Br J Dermatol 1990;123:375-80. 51. Shupack J, Stiller M, Knobler E, et al. Topical alpha-interferon in recurrent genital herpes simplex infection: a double-blind, placebo-controlled clinical trial. Dermatologica 1990; 181: 134-8. . 52. Kuzushima K, Kimura H, Shibata M, et al. Prophylactic oral acyclovir in outbreaks of primary hcrpes simplex virus 1 infection [Letter). Lancet 1990;335:1043. 53. Mazurkiewicz W, Jahlonska S. Clinical efficacy of condyline (0.5% podophyllin) in the treatment of external condylomata acuminata. J Dermatol Treat 1990;1:123-5. 54. Happonen HP, Lassus A, Santalahi J, et al. Topical idoxuridine for treatment of genital warts in males: a doubleblind comparative study of 0.25% and 0.5% cream. Genitourin Med 1990;66:254-6. 55. Engel JP, Englund JA, Fletcher CV. Treatment of resistant herpes simplex virus with continuous-infusion acyclovir. JAMA 1990;263:1662-4. 56. Pedersen BS. Acyclovir in late pregnancy to prevent neonatal herpes simplex [Letter]. Lancet 1990;336:756. 57. Frickhofen N, Abkowitz JL, Safford M, et al. Persistent B19 parvovirus infection in patients infected with human immunodeficiency virus type 1 (HIV-I); a treatable cause of anemia in AIDS. Ann Intern Med 1990;113:926-33. 58. Olsen EA, Weiner MS, Amara lA, et al. Five-year follow-up of men with androgenetic alopecia treated with topical minoxidil [Letter]. 1 AM ACAD DERMATOl 1990; 22:643-6. 59. Fiedler ve, Wendrow A, Szpunar Gl, et al. Treatmentresistant alopecia areata. Response to combination therapy with minoxidil plus anthralin. Arch Dermatol 1990; 126:756-9. 60. Colamarino R, Dubost JJ, Sauvezie B. Polymyalgia and minoxidil. Ann Intern Med 1990;113:256-7. 61. Gilhar A, Pillar T, Etzioni A. Topical cyclosporine in male pattcrn alopecia. J AM ACAD DERMATOL 1990;22:251-3. 62. Gupta AK, Ellis CN, Cooper KD, et al. Oral cyclosporine for the treatment of alopecia areata. 1 AM ACAD DERMA· TOlI990;22:242-50. 63. Anderson KE, Goeger DE, Carson RW, et al. Erythropoietin for the treatment of porphyria cutanea tarda in a patient on long-term hemodialysis. Med Intell 1990; 322:315-7. 64. Wright AL, McColl KEL, Hunter lAA, et al. Treatment of porphyria cutanea tarda in renal failure with ultra-Iowdose chloroquine. J Dermatol Treat 1990;1:159-61. 65. Ross lB, Moss MA. Relief of the photosensitivity of erythropoietic protoporphyria by pyridoxine. 1 AM ACAD DERMATOL 1990;22:340-2. 66. Cernea SS, Rivitti EA. Successful treatment of mucinosis with chloroquine. J Dermatol Treat 1990;1:163-5. 67. Jegasothy BV. Clobetasol propionate ointment 0.05% versus diflorasone diacetate ointment 0.05% in moderate to severe psoriasis. Int 1 Dermatol 1990;29:729-30. 6S. Kurkcuoglu N, Alaybeyi F. Topical capsaicin for psoriasis [Letter]. Br J Dermatol 1990;123:549-50. 69. Gupta A, Ellis CN, Siegel MT, et al. Sulfasalazine improves psoriasis: a double-blind analysis. Arch Dermatol 1990;126:487-93. 70. Ruzicka T, Sommerburg C, Braun-Falco 0, et aJ. Effi-
Dermatologic therapy: 1990 279 ciency of acitretin in combination with UY-B in the treatment of severe psoriasis. Arch Dermatol 1990;126: 482-6. 71. Fradin MS, Ellis CN, Voorhees JJ. Efficacy ofcyclosporin A in psoriasis: a summary ofthe United States experience. Br J Dermatal I990; I22(suppl 36):21-5. 72. Meinardi MM, DeRie MA, Bos JD. Oral cyclosporin A in the treatment of psoriasiS: an overview of studies performed in The Netherlands. Br J Dermatol 1990; 122(suppl 36):27-31. 73. Timonen P, Friend D, Abeywickrama K, et al. Efficacy of low dose cyclosporin A in psoriasis: results of dose-finding studies. Br J DermatoI1990;122:(suppl 36):33-9. 74. Powles AY, Baker BS, Valdimarsson H, et al. Br J Dermatol 1990;122(suppl 36);13-9. 75. Halioua B, Saurat JH. Risk:benefit ratio in the treatment of psoriasis with systemic retinoids. Br J Dermatol 1990; 122(suppI36):135-50. 76. Mason J. Renal side-effects of cyclosporin A. Br 1 DermatolI990;122:(supp136):71-7. 77. Feutren G, Abeywickrama K, Friend D, et al. Renal function and blood pressure in psoriatic patients treated with cyclosporin A. Br J Dermatoll990;122(suppI36):5769. 7S. Krupp P, Monka C. Side-effect profile of cyclosporin Ain patients treated for psoriasis. Br J Dermatol 1990; 122(suppI36):47-56. 79. Griffiths CEM. Systemic and local administration of cyc1osporine in the treatment of psoriasis. 1 AM ACAD DERMATOL 1990;23:1242-7. SO. Ho YC, Lui H, McLean DI. Cyclosporine in nonpsoriatic dermatoses. 1 AM ACAD DERMATOL 1990;23:1248-59. 81. Eisen D, Ellis CN. Topical cyclosporine far oral mucosal disorders. 1 AM ACAD DERMATOL 1990;23:1259-64. 82. Fradin MS, Ellis CN, Voorhees J1. Management ofpatients and side effects during cyclosporine therapy for cutaneous disorders. J AM ACAD DERMATOL 1990;23:126575. 83. Mockli G, Kabra PM, KurtzTW. Laboratory monitoring of cyclasporine levels: guidelines for the dermatologist. J AM ACAD DERMATOL 1990;23:1275-9. 84. Bennett WM. Renal effects of cyclosporine. 1 AM ACAD DERMATOlI990;23:1280-7. 85. Messana JM, Rocher LL, Ellis CN, et al. Effects of cyclosporine on renal function in psoriasis patients. 1 AM ACAD DERMATOL 1990;23:1288-93. 86. Valdimarsson H. Immunity during cyclosporine therapy. J AM ACAD DERMATOL 1990;23:1294-300. 87. Watkins PB. The role of cytochromes P-450 in cyclosporine metabolism. J AM ACAD DERMATOL 1990;23:130111. 88. Baadsgaard 0, Fisher Gl, Voorhees JJ, et al. Interactions of epidermal celIs and T cells in inflammatory skin diseases. 1 AM ACAD DERMATOL 1990;23:1312-7. 89. Cooper KD, Yoorhees JJ, Fisher Gl, et al. Effects of cyc1osporine on immunologic mechanisms in psoriasis. 1 AM ACAD DERMATOL 1990;23:1318-28. 90. Fairley lA. Intracellular targets of cyclosporine. J AM ACAD DERMATOL 1990;23:1329-34. 91. Berne B, Blom I, Spangberg S. Enhanced response of psoriasis to UYB therapy after pretreatment with a lubricating base. A single-blind controlled study. Acta Derm Venereol (Stockh) 1990;70:474·7. 92. Petzelbauer P, Honigsmann H, Langer K, et aL Cyclosporin A in combination with photochemotherapy
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Journal of the American Academy of Dermatology 111. Thomsen K, Hammar H, Molin L, et al. Retinoids plus PUVA (REPUVA) and PUVA in mycosis fungoides plaque stage. A report from the Scandinavian Mycosis Fungoides Group. Acta Derm Venereol (Stockh) 1989; 89:536-8. 112. Zackheim HS, Epstein EH Jr, Crain WR. Topical carmustine (BCNU) for cutaneous T cell lymphoma: a IS-year experience in 143 patients. JAM ACAD DERMATOL 1990;22:802-10. 113. Armus·S, Keyes B, Cahill C, et al. Photopheresis for the treatment of cutaneous T cell lymphoma. J AM ACAD DERMATOL 1990;23:898-902. 114. Lassoued K, Clauvel JP, Katlama C, et al. Treatment of the acquired immune deficiency syndrome-related Kaposi's sarcoma with bleomycin as a single agent. Cancer 1990;66:1869-72. 115. Monti M, Barbareschi M, Angius A, et al. Responsiveness of classical Kaposi's sarcoma to recombinant interferon alpha 2b treatment. J Dermatol Treat 1990;1:209-10. 116. Krown SE, Gold JWM, Niedzwiecki D, et al. Interferona with zidovudine: safety, tolerance, and clinical and virologic effects in patients with Kaposi's sarcoma associated with the acquired immunodeficiency syndrome (AIDS). Ann Intern Med 1990;112:812-21. 117. McElroy JA, Mehregan DA, Roenigk RK. Carbon dioxide laser vaporization ofrecalcitrant symptomatic plaques ofHailey-Hailey disease and Darier's disease. JAM ACAD DERMATOL 1990;23:893-7. 118. Alijotas J, Pedragosa R, Bosch J, et al. Prolonged remission after cyclosporine therapy in pemphigus vulgaris: report of two young siblings. J AM ACAD DERMATOL 1990;23:701-3. 119. Milligan A, Hutchinson PE. The use of chlorambucil in the treatment of bullous pemphigoid. J AM ACAD DER. MATOL 1990;22:796-801. 120. Layton AM, Cunliffe WJ. Clearing of epidermolysis bullosa acquisita with cyclosporine [Letter]. J AM ACAD DERMATOL 1990;22:535. 121. Elson ML. Treatment of striae distensae with topical tretinoin. J Dermatol Surg Oneol 1990;16:267-70. 122. Colgan MP, Dormandy JA, Jones PW, et aL Oxpentifylline treatment of venous ulcers of the leg. Br Med J 1990;300:972-5. 123. Frost ML, Treadwell P. Treatment of sickle cell leg ulcers with pentoxifylline. Int J DermatolI990;29:375. 124. Colombo VE, Gerber F, Bronhofer M, et al. Treatment of brittle fingernails a.nd onychoschizia with biotin: scanning electron microscopy. J AM ACAD DERMATOL 1990; 23:1127-32. 125. Sorensen LH, Cramers M, Kragballe K. Twenty-nail dystrophy treated with topical PUVA. Acta Derm Venereol (Stockh) 1990;70:510-1. 126. Ploysangam T, Dee-Ananlap S, Suvanprakorn P. Treatment of idiopathic guttate hypomelanosis with liquid nitrogen: light and electon microscopic studies. J AM ACAD DERMATOL 1990;23:681-4. 127. Kato H. Eosinophilic pustular folliculitis treated with indomethacin [Letter]. Dermatologica 1989; 179:217-23.