Dermatologic therapy: December, 1978, through November, 1979

'rneranv Dermatologic therapy: December, 1978, through November, 1979 Ralph J. Coskey, M.D. Detroit, MI

ACNE AND RELATED CONDITIONS

Wilkinson et al' did a 12-year study on perioral dermatitis. During this period, 259 cases were diagnosed. They evaluated numerous etiologic agents and felt that only potent topical corticosteroids could be incriminated. They also stated that tetracyclines were curative in the majority of patients when given over a period of 6 weeks. Thus, they gave 250 mg of tetracycline twice daily for 3 weeks and then once daily for a similar period of time. Forty-three patients with perioral dermatitis were described by Cotterill." In seven of these patients, the eruption was associated with the use of topical hydrocortisone butyrate. Thus, the author felt that this topical steroid could no longer be recommended, unreservedly, for use on the face. Panzer and Panzer' made up a solution of clindamycin hydrochloride 'by dissolving five clindamycin hydrochloride capsules in 2 oz of 50% alcohol. This agent was applied once daily to the face of 100 patients with acne who had been first treated with tetracycline for I to I ~ months. The patient's acne tended to stay under control with this treatment regime. Guin" did a double-blind paired comparison study in twenty-one patients, comparing c1indamycin phosphate with c1indamycin hydrochloride 1% solution, topically, in the treatment of acne. According to Guin, fifteen patients cornFrom the Department of Dermatology, Wayne Slate University, School of Medicine. Presented at a seminar-in-depth at the Annual Meeting of the American Academy of Dermatology, Chicago, IL, December. 1979. Reprint requests to: Dr. Ralph J. Coskey, 23133 Orchard Lake Rd., Suite 201, Farmington. MI 48024.

0190-9622/80/080125+24$02.40/0 © 1980 Am Acad Derrnatol

pieted a 3-month study. Both preparations decreased the number and severity of the lesions. The amount of improvement was identical with both preparations. Stoughton" wrote a review on topical antibiotics for acne vulgaris. He stated that he sent questionnaires to 1,000 dermatologists. Five hundred thirty of them answered the questionnaires. They admitted to treating 7,300 patients with topical clindamycin for acne. Stoughton felt that if you extend these figures to all dermatologists in the country, 300,000 patients were treated in 1978 with topical clindamycin. The dermatologists who responded to the questionnaire also had been using topical erythromycin, but to a lesser extent, and topical tetracycline to a much lesser extent. The dermatologists did feel that clindamycinlincomycin had a slight advantage over the other antibiotics. It was estimated by Stoughton that 500,000 people had been treated with topical clindamycin over a 3-year period of time and not a single case of pseudomembranous colitis was reported. He claimed that less than 10% of topically applied clindamycin is absorbed, and he felt that probably the average patient with acne applied 20 mg of clindamycin to the skin surface and probably does not absorb more than 2 mg per day. However, 200 mg per day is the minimum dose reported to cause pseudomembranous colitis. Stoughton mixes clindamycin by dissolving four 150-mg c1indamycin capsules in 48 ml of 70% isopropyl alcohol, 6 mg of water, and 6 ml of propylene glycol. The ingredients are mixed for 5 to 10 minutes and the supernatant fluid is decanted. The agent is applied twice daily.

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Stoughton also stated that he and his colleagues have been able to show that Corynebacterium acnes may become resistant to both clindamycin and erythromycin when either agent is applied to the skin. Twenty to twenty-five percent of patients who have been treated with these agents for from 2 months to 2 years showed resistant strains. If the organism was resistant to one antibiotic, it also was resistant to the other one. In order to overcome this, Stoughton suggested that patients should be treated with benzoyl peroxide and/or oral or topical tetracycline. In a few instances, he observed patients who were switched to tetracycline for 2 months and then noted that clindamycin-sensitive strains once again became predominant. Feingold et all' applied topical clindamycin and topical erythromycin daily to the shaved backs of Syrian hamsters. A daily dose of O.I mg of clindamycin was lethal to more than half of the hamsters, and when I mg was applied it was lethal to all of the hamsters. The toxin from Clostridium difficile was present in the fecal material of all of these animals. Feingold et al claimed that the lethal dose in hamsters was not dissimilar to that given to humans for acne. However, it is known that Syrian hamsters are very sensitive to clindamycin. When they are given I mg/kg of clindamycin systemically, they develop fatal colitis. Mills and Kligman evaluated topical erythromycin and tretinoin in the treatment of inflammatory acne. They treated four different groups of twenty subjects and found that 2% erythromycin in a hydroalcoholic solution applied twice daily, along with 0.05% tretinoin applied once daily, was more effective than tretinoin or erythromycin alone for the treatment of acne. Belknap" compared 5% benzoyl peroxide gel with 0.05% retinoic acid cream in the treatment of acne vulgaris. More patients treated with benzoyl peroxide had excellent results than those in the· other group. Both medications were effective in decreasing the number of inflammatory and noninflammatory lesions. Mills and Kligman" evaluated various abrasive materials in the treatment of acne. These agents cause peeling and erythema but no decrease in the

Journal of the American Academy of Dermatology

number of comedones. In some cases the acne problem was aggravated. Hurley and Shelley!" treated patients with acne by having them apply aluminum chloride hexahydrate in anhydrous ethanol. They found that 6.25% strength solution was most effective. They had patients apply this to their skin 30 to 60 minutes after washing. They found that thirty-nine of sixth-five patients with acne had an excellent or marked response, while twenty-one patients showed moderate improvement and five patients had a poor or unfavorable response. Half of the patients who were treated were taking antibiotics, but many of them were able to discontinue them during the period of treatment, which lasted from 2 to 32 weeks. Goransson et al!' did a double-blind study of fifty-four patients with acne vulgaris. They evaluated the effect of 6 gm of oral zinc sulfate daily against placebo. The patients were followed for 6 weeks and the acne improved in about one-third with this treatment. The most effective method of evaluating response to therapy was by counting of acne lesions. Cunliffe et al 12 did a double-blind study of forty-eight patients to evaluate an oral zinc sulfate/citrate complex and tetracycline in the treatment of acne vulgaris. They found that after 3 months tetracycline decreased the number of open and closed comedones, papules, pustules, and nodules, while zinc decreased only the pustules. They concluded that tetracycline is superior to zinc complex in moderately severe acne. Weimer et al.!" in twenty-eight patients with acne vulgaris, gave zinc sulfate capsules, 220 mg, corresponding to 50 mg of elemental zinc, three times daily with food. They also gave a placebo to twenty-four patients with the same disease. They counted comedones, papules, pustules, infiltrates, and cysts periodically over a 12-week period. At the end of this period of time, forty patients completed this study. Zinc appeared to be somewhat helpful in decreasing pustules but did not affect the number of comedones, papules, infiltrates, or cysts. Fourteen of the patients who took zinc developed nausea, vomiting, or diarrhea, and six of these patients had to discontinue the drug and withdraw from the study because of side effects.

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Cunliff" ' treated forty -two patients with acne by giving them zinc sulfate, 220 mg three times daily. Thirteen patients had to stop therapy because of side effects . In ten of these patients, severe nausea and vomiting developed, and two of them also developed severe diarrhea. Twelve patients had to stop therapy within the first week of starting treatment. When they retook the zinc, they developed the same side effects. The thirteenth patient had a perforation of a previous asymptomatic gastric ulcer after 4 months of treatment. Of nine patients who could take the zinc sulfate for 4 months, only three patients showed clinical improvement. Thus, Cunliff felt that this therapy should not be used orally in the treatment of acne. Peck et all;; reported on the treatment of fourteen patients with severe, treatment-resistant cystic and conglobate acne with oral 13-ds-retinoic acid. The average dose used WaS 2 mg/kg per day. Thirteen of the patients developed a complete remission, while the other patient had 75% improvement. Therapy was stopped after 4 months, but prolonged remissions occurred, lasting as long as 20 months after discontinuation of therapy. The clinical toxicity was limited to the skin and mucous membranes in most of the treated patients, and it was related to dosage. Peck et al felt that the 13-cis-retinoic acid had a direct inhibitory effect on the sebaceous glands. Palatsi et aP6 treatedtwenty women with resistant acne by having them take tablets containing 2 mg of cyproterone acetate and 0.05 of ethinyl estradiol for 21 of 28 days each month for 6 months. Ten of these patients responded well to therapy, five responded moderately well , three did not improve, and two became worse. Burton and Saihan!? were able to suppress sebum excretion by about 50 % in six patients who were treated with 5 rng prednisone daily and an agent containing 50 fJ-g of ethinyl estradiol, plus I mg norethisterone acetate, for twenty-one consecutive days in each menstrual cycle. These patients improved markedly . with this treatment. Nine males were treated with 5 mg of prednisone daily and also estrogen, but they did not show a similar type of response to treatment. Rose and Birnbaum! " described twenty women

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with acne vulgaris who also had complaints of hirsutism, infertility, and menorrhagia or oligomenorrhea. These women had partial 11- or 21adrenocortical hydroxylase deficiencies. They were then placed on prednisone, 5 mg two times daily or 7.5 mg every day. Six patients with moderate acne improved or became pregnant. Seven of fourteen patients with mild acne improved or became pregnant, and seven did not improve. Conte and Lawrence 19 described their treatment for pseudofolliculitis barbae . They advised the patients not to shave for 4 weeks. During that time, they advised the use of a polyester sponge twice daily. After 4 weeks, they continued the use of a polyester sponge but allowed the patients to shave with electric hair clippers with a 000 head, leaving a millimeter of beard protruding from the skin . A favorable response was seen in ninety-one of ninety-six cases. Hall et al 20 reported three cases of pseudofolliculitis in black American women. Topical retinoic acid appeared to be fairly effective in the treatment of these patients.

ALLERGY Three patients with hereditary angioedema were treated with methandienone, 5 mg twice daily. Three patients were treated with danazol, 200 mg twice daily, and four patients with stanozolol, 5 mg daily. Treatment with these androgenic drugs was continued for a period of 9 to 27 months. In nine patients, the attacks had been controlled completely. With treatment, the Cl esterase inhibitor level rose to normal. 21 An 8-year-old boy with hereditary angioedema was treated with danazol .22 The C 1 esterase inhibitor and C4 levels increased to near normal values after treatment with 400 mg per day and were maintained at 50 % to normal by treating the boy with 200 mg danazol every other day. No attacks of angioedema occurred during II months of treatment. No hormonal imbalance was detected. Commens and Greaves" evaluated the effectiveness of cimetidine for the treatment of chronic idiopathic urticaria. They found that cimetidine , given with chlorpheniramine, was no more effective than chlorpheniramine alone. Matthews et a12~ treated ten patients with symp-

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tomatic dermographism by administering chlorpheniramine and cimetidine . They found the combination of these two drugs produced greater reduction in the wheal-and-flare response from scratching the skin than administering chlorpheniramine alone. Pace '" treated thirty-six patients with chronic urticaria by administering intravenous typhoidparatyphoid vaccine. He claimed that total remission occurred in thirty-five of the patients. The usual first dose of the vaccine is 20 million organisms. COLLAGEN DISEASES AND VASCULITIS

Giannini and Callen-" treated a patient with dermatomyositis, who was steroid-refractory, with a combination of oral methotrexate and prednisone . With the therapy the patient underwent remission. Fauci et aF7 studied seventeen patients with severe necrotizing vasculitis. Sixteen of these patients were treated with cyclophosphamide (2 mg/kg/day), and one of the patients was treated with azathioprine, 2 mg/kg/day . All of the patients had severe disease; sixteen of them had received corticosteroids, which had often caused severe side effects . Three of the patients on the study died, but complete remissions occurred in the fourteen who survived. These patients were placed on alternate-day corticosteroids and cyclophosphamide. In seven"of the patients, the corticosteroids were discontinued. Remissions lasted for a mean duration of approximately 2 months. None of the patients had a recurrence of their disease while being treated with cytotoxic agents. Hazen and Michel'" treated six patients with necrotizing vasculitis by giving them oral colchicine. Four patients with cutaneous vasculitis and normal levels of serum complement and one patient with vasculitis and Behcet 's syndrome clinically improved while receiving the oral colchicine. A patient with cryoglobulinemia, hypocomplementemia , and cutaneous vasculitis did not respond to colchicine therapy . In three patients who were treated, the improvement persisted after withdrawal. Hazen and Michel stated that the colchicine •'inhibits chemotaxis of polymorphonuclear leukocytes, decreases leukocyte motility in

vitro, blocks leukocyte adhesiveness and stabilizes lysosomal membranes." Usual dosage was 0.6 mg two to three times a day. Ayres and Mihan'" described the rationale for using vitamin E in lupus erythematosus . They also described successful response to therapy in some cases with this drug . Sabbour and Osmarr" evaluated chlorambucil, azathioprine, and cyclophosphamide combined with corticosteroids in the treatment of diffuse lupus glomerulonephritis which was proved by biopsy. Patients who were treated with corticosteroids and chlorambucil had an excellent response to therapy. Survival rate was increased and also renal pathology regressed. When azathioprine was added to corticosteroids, the survival rate was not increased . Cyclophosphamide favorably influenced the course of renal glomerulonephritis when added to corticosteroids. However, the fatal side effects nearly balanced the therapeutic effect. Hubbard and Portnoy" treated a pregnant patient with systemic lupus erythematosus with plasmapheresis. The patient had not been able to control her disease with 60 mg of prednisone a day . However, when plasmapheresis was done on five occasions during one week , she showed remarkable improvement. Twelve patients with scleroderma were given a daily dosage of 1.2 mg of colchicine for 6 months. This therapy appeared to be ineffective.F Mclntyre" advised treating Raynaud's phenomenon by having the patients whirl their arms in the direction in which a softball pitcher would move the arm. He had them swing their. arms down and behind their bodies and then upward in front of their bodies at a rate of eighty revolutions per minute . He felt that this maneuver might increase intra-arterial pressure . DERMATITIS

Kaaber et al'" treated eleven patients with chronic dyshidrotic hand dermatitis, who were sensitive to nickel and whose eruption was aggravated by oral challenge with nickel, with disulfiram, 100 mg (Antabuse), two to four times daily for 4 to 10 weeks. Nine of the ten patients flared shortly after they started treatment, but seven 01 the patients cleared during treatment and two im-

Volume 3 Number 2 August, 1980

proved. When the treatment was discontinued, six people flared. During therapy, seven patients developed fatigue, headache, and dizziness, and it was necessary for four patients to stop therapy because of the treatment. Apparently the drug chelated nickel and caused increased excretion of it in the urine. Saarinen et apj followed fifty-four babies who were solely breast-fed for more than 6 months, seventy-seven babies who were breast-fed for 2 to 6 months, and 105 babies who were put on cow's milk formulas for less than 2 months. These babies were followed for the first 3 years of life. The prolonged breast feeding resulted in a lower incidence of severe or obvious atopic disease, especially in babies who had a family history of atopy. Medansky et aP6 evaluated fluocinonide 0.05% in a cream base (FAPG cream: fatty acid propylene glycol) in 105 patients who had not responded to at least 2 weeks of treatment with other corticosteroids. Ninety-three patients could be evaluated, and 71 % of these showed excellent to moderate improvement with fluocinonide. A double-blind study was done comparing fluocinonide 0.05% with other topical steroids in a 3-week study on 240 patients." Fluocinonide emollient (0.05%) cream was compared with either betamethasone valerate 0.1 % cream in the treatment of atopic dermatitis, or fluocinonide cream was compared with triamcinolone acetonide 0.1 % cream in the treatment of psoriasis. In both instances, statistical analysis showed that fluocinonide was more effective. Silverman'" did a paired comparison study of fluocinonide 0.05% cream and halcinonide 0.1 % cream for the treatment of atopic dermatitis. The fluocinonide cream was superior to halcinonide. Sannwald et aP9 treated eleven patients with atopic dermatitis with oral photochemotherapy. Complete clearing in more than 80% was noted . initially in nine of these patients. However, recurrences occurred in most of the patients during maintenance therapy. Hovmark and Ekre " did a controlled study on six patients with atopic dermatitis to see if transfer factor would be helpful. There was no therapeutic effect from this therapy.

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Thirty-two patients with Wiskott-Aldrich syndrome were treated with transfer factor. ~I Benefit was observed in 44% of the patients. The mean age of the patients with improvement was greater than that of the patients who had no benefit. Thirteen of the patients who were given transfer factor are alive, and seventeen are dead. If a patient showed benefit, the median survival was greater than 5 years, but in those patients who did not show clinical benefit it was only 18 months. Thus, transfer factor appeared to be of help in some but not all patients with Wiskott-Aldrich syndrome. Mathias and Maibach f treated a patient who developed contact dermatitis of his feet, secondary to rubber accelerators in his work boots, by having him wear polyvinyl chloride work boots. * Baran:" treated a 55-year-old woman, who had acropustulosis on the finger of her left hand for 25 years, with 0.075% ethylester retinoid solution. There was improvement with this treatment. Then he treated the patient for 3 more weeks with 0.05% ethylester retinoid and the patient developed a complete remission. HAIR

Schmoeckel et al~~ treated thirty-two patients with alopecia areata by topical application of anthralin in concentrations of 0.2% to 0.8%. This agent was applied once daily and usually resulted in dermatitis. Twenty-four of the patients did not have complete hair loss. Eighteen of them had cosmetically good results with this therapy. Eight patients with alopecia totalis were included in the study. Two of them had cosmetically good results: Hair growth usually became visible after 5 to 8 weeks. The hair at first was thin and white but gradually became pigmented. Happle" reported, at the joint meeting of the Society for Investigative Dermatology and the European Society for Dermatology Research, on the effectiveness of squaric acid dibutylester (SADBE) in the treatment of alopecia areata. The patients were sensitized with a 2% solution of this agent, and then after 10 days they were treated with 0.1 % or other concentrations weekly. After 5 *These boots are manufactured by Hampshire Manufacturing Corporation, Factory St., Nashua, NH 03061.

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to 14 months, 87% of fifty-three patients regrew hair on the side that was treated .

GENODERMATOSES Cipollaro and Shaps!" treated Darier's disease with conventional x-rays and grenz rays. Both types of radiation therapy improved the disease , but the conventional x-ray was superior to the grenz ray. However, they did not recommend this as a treatment for Darier's disease except where a temporary effect is required. Zachariae" performed a dermabrasion on five patients with severe Darier 's disease. All of the patients improved. Over 75% of the dermabrasion areas remained free of disease for more than 2'12 years . Gibberd et al 48 treated a patient with severe Refsum 's disease by large -volume plasma exchange and a diet low in phytanic acid as well as high in calories. The ichthyosis improved within 2 weeks and the ataxia was less severe than it had been for years. Also, the patient was able to walk unaided, which he had not been able to do before treatment. Reed et al 49 treated a patient with mal de Meleda with 13-eis-retinoic acid taken by mouth for 16 weeks. There was dramatic improvement . with this therapy . The main side effect that this patient developed was cheilitis.

INFECTIOUS DISEASES Bacterial infections Dore et aJ50 treated a patient with infection due to Mycobacterium kansasii successfully with minocycline hydrochloride. The drug was given in a dosage of 50 mg four times daily for approximately 6 weeks. Contorer and Jones" treated two patients with infections due to Mycobacterium marinum with minocycline. Both of them showed dramatic results with this therapy. Leyden et ap:! described three patients with acne who developed gram-negative folliculitis due to Pseudomonas aeruginosa, In each of these patients, the source of the Pseudomonas was found in ears that were affected with otitis externa . The anterior narcs were not colonized. The otitis externa and also the gram-negative folliculitis were treated with acetic acid compresses and topical

antibiotics. This caused resolution of the problem. Five burn patients with ecthyma gangrenosum were treated with gentamicin sulfate. v' The doses that were given ranged from 15 to 30 mg/kg/day. Four of the five patients were treated successfully. One patient died who had been given smaller doses of the gentamicin. Keeney et al 54 evaluated minocycline and penicillin in the treatment of staphylococcal infections. One hundred fifteen patients were given minocycline and 128 patients were given penicillin V for various types of cutaneous infections. The majority of bacterial isolates were staphylococcal; of these, 82% were sensitive to minocycline and only 20% were sensitive to penicillin V. Cures were achieved in 74% of instances with minocycline and in 54% with penicillin V. Metronidazole was given to thirty patients with tropical phagedinic ulcers. :,;; It tended to be effective in causing the resolution of the ulcers ina period of I to 2 weeks. This indicated to Keeney et al the important role played by fusospirochetes in the cause of tropical ulcers.

Fungal infections Tschen et aP6 evaluated the relative effectivene ss of undecylenic acid ointment, tolnaftate cream, and placebo in the treatment of tinea pedis. Ninety patients were treated . Undecylenic acids and tolnaftate cream were both superior to placebo, but there was no difference in the effectiveness of these two agents. No side effects were noted. Clayton et al 5 i did a double-blind trial study comparing topical haloprogin and miconazole cream against superficial fungus infections of the skin and erythrasma. Both agents were effective against dermatophyte, tinea versicolor, Candida, and erythrasma infections. However, the patients' acceptability was not as good for the haloprogin as it was for the miconazole because of the side effects such as peeling of skin, irritation, burning, and smell. Pazin et aJ58 treated two patients, who had chronic mucocutaneous candidiasis, with topical clotrirnazole . Response to therapy has been good over a period of 20 months. Rockoff'" treated a patient with chronic mucocutaneous candidiasis by giving her intermittent

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oral therapy with clotrimazole. This resulted in a complete and prolonged remission. Lubritz and Spence'" treated a patient with chromoblastomycosis with cryosurgery. This treatment proved to be successful. Tagami et al'" treated a man with a 12- by 9-cm plaque on the buttock due to chromomycosis with local heat therapy using an electric bedwarmer. It had a surface temperature of 46° C. This lesion resolved after 2 months of treatment. Also the histology reverted to normal after 8 weeks of treatment, and the cultures became negative after that period of time. Ditto et al,62 Jacyk.?" and Chermsirivathana'" all treated cases of chromoblastomycosis successfully with 5-f1uorocytosine. Ditto also injected the posttreatment hypertrophic scar with triamcinolone acctonide. Dangy'" treated a patient with sporotrichosis involving the dorsum of the hand and the medial aspect of the upper arm by having him apply two electric heating pads for 3 or 4 hours before bedtime and also while asleep at night. The patient responded after approximately 6 weeks of therapy with this method. Viral infections Pazin et al 6 6 evaluated leukocyte interferon treatment of reactivated herpes simplex infections which occur after operations on the trigeminal root. A double-blind study was done on patients with a history of herpes labialis. These patients were given either interferon or placebo for 5 days beginning on the day of surgery . In eighteen patients treated with placebo, herpes labialis developed in ten and virus was found in the oropharynx in fifteen patients. In nineteen patients treated with interferon only five patients developed lesions, and shedding of virus was found in only nine. Thus, latent herpes simplex infection was reduced when interferon was given before surgery on the trigeminal root. In a double-blind placebo-controlled study, Blough and Giuntoli'" treated thirty-six women who had herpes genitalis with either topical 2-deoxy-o-glucose four times daily or placebo for a 3-week period. In the initial cases, 89% were cured by 2-~eoxY-D-glucose with two recurrences

after 24 months. In the recurrent infections, 90% improved with less frequent recurrences, fewer lesions, and symptoms lasting less time when 2-deoxY-D-glucose was used. In the primary infections the discomfort cleared in 12 to 72 hours of treatment, and 90% of these patients were asymptomatic in 4 days. There was less virus shedding with this agent. Miller'" described a method of treating herpes simplex with subcutaneous injections of small doses of influenza virus vaccine. These injections were administered in most cases by the patients to themselves and appeared to provide marked or complete clearing of pain, burning, tingling, and sensation of fullness in the lesions and also resolution of systemic symptoms. It is necessary to read Miller's article in order to find out his way of preparing dilutions of vaccine that are appropriate . for treatment. McCarty and Jarratt'" evaluated phosphonoacetic acid (PAA) therapy of primary herpes simplex virus infections in guinea pigs. The infected areas were treated with 2% PAA cream or placebo cream. Thi s was applied anywhere from 3 to 84 hours after inoculation . When PAA was applied 3 hours after inoculation, clinical infection did not occur. When applied 84 hours after inoculation, it reduced severity of primary herpes simplex virus infections . Donsky?" evaluated 5% nonoxynol 9 cream in recurrent herpes simplex in twenty patients. The patients applied the cream once every hour during the day as soon as symptoms occurred. Only two patients did not respond to treatment. All of the others tended to improve. Apparently patients have stayed clear for 6 months. Lieb " described two patients with recurrent herpes simplex who tended to improve with lithium treatment, which was being given for psychiatric symptoms. Spruance et al 72 did a double-blind, randomized study on 233 patients with herpes simplex. The drug that they evaluated was 10% adenine arabinoside 5'-rnonophosphate. Nine clinical and four virologic measurements were used to evaluate the drug. There was no statistical improvement in any of the mea surements , and there was no evidence of benefit attributable to the drug. Also, the drug

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132 Coskey

did not affect the rate of recurrence of herpes simplex. Moncada and Rodriguez?" gave levamisole to twenty-two patients with multiple warts in a dosage of 5 mg per kilogram of body weight on three consecutive days every fortnight. Seventeen of these patients were cured in I to 4 months. There were four failures, and one patient improved. Moncada and Rodriguez came to the conclusion that patients with multiple warts have defective cell-mediated immunity as far as E rosette counts are concerned. They found that levarnisole increased the in vitro E rosette formation. Stahl et al H treated 120 patients with virus warts by using methylene blue and a light source which provided ultraviolet A (UVA) to visible light for photodynamic inactivation . Controlled treatment consisted of using an ointment with salicylic acid and creosote. After 8 weeks of treatment, five of sixty-five patients treated with photodynamic inactivation were cured, and eight of fifty-five treated with keratolytic ointment were cured. Stahl et al felt that the treatment was not effective. Lockshinrs treated five patients with facial flat warts by having them apply 5% fluorouracil once or twice daily to their skin. This treatment caused redness and dryness but resulted in resolution of . the warts in four of the five patients . Litt?" described his treatment for subungual and periungual warts and also digital warts. He wraps several layers of l-inch wide Zonas adhesive tape around the wart, has the patient leave it on for 6Yz days and then reapply it again 12 hours later. He has the patient return every 2 weeks , at which time he applies liquefied phenol and nitric acid to the area. He claims that with this method he has had only two failures in the past 2 years. Landegren et aFi did a double-blind study on thirty-eight patients with scabies and treated them with a scabicide containing 0.5% DDT, 2% disulfiram, and 22.5% benzyl benzoate, while forty-two patients were treated with the same emulsion without DDT. The patients were treated with a whole body application which was left on 24 hours. The patients were seen 3 weeks later. Both agents were just as effective, and the authors felt that DDT was not necessary for efficac;:y .

Parasitic infections Jensen et aF s treated , with quassia tincture, 454 patients who had head lice. They found it to be extremely effective. The treatment is to be applied twice at weekly intervals. METABOLIC DISORDERS Giessel et ali!! treated four patients with disseminated granuloma annulare with saturated solution of potassium iodide in a dos age of 500 to 900 mg per day. They noted improvement in the disease with this therapy. Kossard and Winkelrnann'" reported that five of six adults with generalized granuloma annulare responded to low -dose chlorambucil therapy . They advised that if the drug is used, it be used only in patients with persistent widespread, or unusual, generalized granuloma annulare. They also felt that the patients should be followed closely and hematology evaluation be done. A patient with disseminated granuloma annulare was treated with low-dose chlorambucil therapy (2 mg three times a day). After 3Yz months of therapy, the patient was able to discontinue chlorambucil. 81 She remained free of disease in spite of being off the drug. Gilchrest S2 . B:\ found that 80% to 90 % of-thirtyeight patients who had uremic pruritus responded favorably to six to eight exposures of mid -range ultraviolet light (UVB). This treatment was given over a period of 2 to 5 weeks. Patients who were treated more than once a week experienced relief faster than those treated once weekly. Remissions are often long-lasting and may last longer than 2 years. The patient who develops a recurrence of pruritus after one course of phototherapy responds to another course usually as well as patients who have not been treated, and these patients tend to improve more rapidly. The UV photochemotherapy is thought to be due to a systemic effect, rather than a local effect . Harris et al 84 reported on the treatment of eight cases of scleromyxedema with melphalan. They found that low-dose, constant chemotherapy was superior to cyclic therapy. They had excellent results in four patients and a good response in two patients. They found that the mucinous changes and the fibrohistiocytic changes in the skin, as

Volume 3 Number 2 August, 1980

well as the monoclonal protein, could be controlled by local chemotherapy . They did recommend that leukocyte and platelet counts be performed every 3 weeks with the dosa ge of the drug being adjusted accordingly. Jes sen et a1 8;; treated a patient with lichen myxedematosus with oral cyclophosphamide. The patient's condition improved but did not completely resolve. Goerz' " reported on the treatment of porphyria cutanea tarda. He treated seventy-five patients with this disease with chloroquine. After 9.3 plus or minus 3.4 months, outpatients had normal excretions of porphyrins; also, their clinical symptoms disappeared. After a mean period of 21 months, fourteen patients relapsed after being taken off chloroquine. Thomsen et a1 8 ' treated thirty-six patients with erythropoietic protoporphyria for approximately 5 years during the summer with beta carotene or beta carotene plus canthaxanthin in daily doses of 50 to 200 mg. Eighteen patients became free of symptoms, sixteen patients improved, and two ju st had a slight effect. No side effects were noted except for carotenemia. . Beta carotene and canthaxanthin were given in a dosage of 75 to 250 mg a day by mouth to seven patients with erythrohepatic protoporphyria. 88 The symptoms on exposure to sunlight were decreased. Fifteen of eighteen patients with polymorphous light eruptions and three of four patients with discoid lupus erythematosus were also improved with this therapy. Parrish et al 89 compared oral psoralen photochemotherapy and oral beta carotene in twentynine patients with polymorphous light eruption. Complete remission occurred in nine often of those treated with PUVA and six of nineteen treated with beta carotene. Thomsen and Rothenborg?? treated ten patients with pyodermic gangrenosa with clofazimine, 100 mg three times daily. In seven cases the lesions completely healed after 2 to 5 months of therapy, and in three cases the ulcers were healed partially. Side effects of therapy included redness of the skin in seven patients and dryness of the skin in two patients. Hess'" treated pruritus in three patients with

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polycythemia vera and one with myelofibrosis by giving them cimetidine, 300 mg four times daily. Two of the patients with polycythemia vera and the patient with myelofibrosis obtained complete relief of itching while taking the drug. The other patient was improved. Harrison et al 92 treated two patients with cholestatic itching secondary to biliary tract obstruction with cimetidine , 300 mg four times daily. Both patients responded dramatically to this therapy. They then treated six more patients with cholestasis and pruritus, in a double-blind manner with either placebo or cimetidine, and found no difference in either agent. Thus, they claim that the cimetidine was not effective in the treatment of itching associated with cholestasis. Scott and Horton '" treated twelve patients with itching secondary to polycythemia vera with 200 mg daily of cimetidine and did not find the drug helpful. Ridgway et al 9 4 described successful therapy of three of four patients with relapsing polychondritis by giving them approximately 200 mg per day of dapsone. PAPULOSQUAMOUS ERUPTIONS

Six psoriatic patients with lesions on more than 50% of their body surfaces were treated for 3 to 4 months with 35 to 65 gm of a topical fluorinated corticosteroid daily. 95 One patient developed signs of Cushing's syndrome including diabetes mellitus, and another also had a slight cushingoid appearance . The plasma cortisone levels were decreased in five of six patients on the first posttreatment day. There was a decrease in the plasma cortisol response to stimulation with adrenocorticotropic hormone (ACTH) in three patients. In these three patients the topical corticosteroid was discontinued; I month later the laboratory tests were norm al , except for a decreased response to ACTH in one patient. Stawiski et a1 9 6 did two double-blind studies comparing the cyclic nucleotide-altering agent Ro 20-1724 vs vehicle also vs 0.025% triamcinolone acetonide . They found that when these agents were occluded Ro 20-1724 did help the psoriasis, but not as much as occlusion with triamcinolone cream.

134 Caskey

Giacosa et al 9 i described the good response of psoriasis to cimetidine. However, 2 weeks later, in the Dec. 16, 1978 issue oi Lancet, Raffle'" and also McCallum and Grant'" claimed that cimetidine was of no beneficial effect for psoriasis. Rai and Webster'?" reported on a patient who had a duodenal ulcer and psoriasis and was treated with cimetidine. The psoriasis flared each time the cimetidine was given. Finnerty'?' described three cases of psoriasis of the nails that were treated successfully with x-ray therapy. Boer et al 102 reported on the use of U VB with fluorescent sunlamp bulbs for the treatment of psoriasis. Thirteen patients cleared 80% to 100% of their body with this treatment, and maintenance was kept up by exposing them to light every I to 5 weeks. Twenty-eight patients with psoriasis were treated with a home solarium using two high-pressure mercury discharge tubes and three infrared lamps;'?" Twenty of twenty-eight patients healed completely and six improved. Median treatment time was about forty-five treatments. Boer et al felt that this is probably the least expensive effective psoriasis treatment. Le Vine et al'"! evaluated the Goeckerman regimen. They utilized the bilateral comparison technic in thirty patients who were in the hospital with chronic, plaque-like psoriasis. They found that after treating these patients with Westinghouse sunlamp bulbs for 4 weeks, the lesions are markedly improved, but not completely unless the treatment was combined with a tar preparation or lubricating cream. Crude coal tar, 5%, plus ultraviolet radiation did not offer an advantage over lubricating base plus ultraviolet radiation. Various tar preparations were evaluated, but there did not appear to be a difference between any of them in effectiveness. .Frost et al lO :; treated patients with widespread psoriasis by applying a tar gel preparation to their skin, followed in 12 hours by suberythemogenic doses of fluorescent sunlamp ultraviolet radiation. They found this to be aneffective way of treating psoriasis. They also found that ultraviolet radiation by itself and tar gel therapy by itself were

Journal of the American Academy of Dermatology

both effective for psoriasis, but the combination of the two together was most effective. Petrozzi and Barton'?" did a study to evaluate the effectiveness of topical methoxsalen and 1% crude coal tar, along with ultraviolet light in the treatment of psoriasis. Patients with symmetric plaques were treated with 0.1 % methoxsalen in hydrophilic ointment on one side and 1% coal tar in the same ointment base on the other side. These agents were applied 2 hours before ultraviolet light exposure. The patients were then exposed to ultraviolet light in modified cabinets that housed thirty standard fluorescent sunlamp bulbs. Petrozzi and Barton found that fourteen of the sixteen patients cleared completely when treated with methoxsalen and ultraviolet light. Only six patients cleared with tar and ultraviolet light. The number of treatments ranged between ten and twenty-five. Inpatients were treated daily for 5 days, and outpatients were treated three times a week. The amount of light exposure was increased daily. Basler'?" treated twelve patients with psoriasis by giving them 20 mg of 8-methoxypsoralen (8-MOP) 2 hours before sun exposure. The patients then were asked to expose themselves to 15 minutes of midday sunlight on both sides of the body, 2 hours after taking the 8-MOP. They increased the time that they stayed in the sun by 5 minutes each exposure until they reached the maximum of I hour for each side. These patients were treated in the Tucson, AZ, area. Complete remission occurred on all exposed plaques in the twelve patients who were treated. Petrozzi et alIOS treated psoriatic patients by applying either 0.1 % or 1% methoxsalen to the psoriasis and then exposed them 2 hours later to Westinghouse FS40 fluorescent sunlamps in a cabinet containing thirty bulbs. Seventeen of twenty patients resolved completely after an average of eighteen treatments. Blistering, phototoxic reactions, and excessive hyperpigmentation were not encountered. Inpatients were treated five times per week, while outpatients were treated three times weekly on alternate days. Siddiqui and Cormane'?? evaluated the use of oral 8-methoxypsoralen followed by long-wave

Volume 3 Number 2 August. 1980

ultraviolet light (PUVA) in 107 patients. Of these patients, 52.3% cleared completely, 7.5% did not respond, and there was incomplete clearing in 42%. Of those patients who did not initially respond to PUVA therapy, the dosage of 8-MOP was increased from 0.5 mg/kg of body weight to 0.6 mg/kg of body weight. After thirty-five PUVA exposures, 90.9% cleared. Siddiqui and Cormane said that after the course of therapy was over, patients remained in remission for a mean period of 5~ months. During this period of time, the patients used a tar preparation or topical corticosteroids for minor exacerbations. A two-center study was done on 224 patients with chronic plaque psoriasis. 110 They were treated with either dithranol or PUVA therapy. In 91% of the 113 patients treated with PUVA there was satisfactory remission, and in 82% of 111 treated with dithranol there was satisfactory clearing. Clearing took longer for PUVA therapy, 34.4 ± 1.8 days, than with dithranol, 20.4 ± 0.9 days. However, the PUVA treatment took less time and less nursing care than dithranol therapy. In some instances, patients who did not respond to dithranol cleared with PUVA, and also in a few instances patients who did not respond to PUVA cleared with dithranol. Hanke et al ll 1 evaluated the effect of the use of topical betamethasone valerate cream along with PUVA for treatment of psoriasis. Twelve patients with symmetric psoriasis were given PUVA to one side of the body and PUVA plus betamethasone valerate to the other side. Ten of the patients cleared faster on the side that was treated with PUVA and betamethasone than on the side treated only with PUVA. Other patients remained clear of lesions while they were maintained on PUVA alone for 5 months or longer after steroid therapy was discontinued. Thus it appeared that the combination of a topical steroid preparation and PUVA decreased the number of treatments necessary to bring about resolution of psoriasis. Schmoll ei al 112 evaluated ninety patients with psoriasis by treating them either with photochemotherapy (PUVA) or topical corticosteroids under occlusion or a combination of both PUVA and topical corticosteroids under occlusion. They found

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that the occlusion with steroids provided rapid clearing of skin, but there were relapses in 3 weeks in 50% of the patients. PUVA was slower in causing resolution of psoriasis, but 50% of the patients remained free for 10 weeks after clearance. When patients were treated with both corticosteroids under occlusion and PUVA, there was a more rapid normalization of skin than with PUVA alone and also the relapses occurred later than when PUVA alone was used. A clinical cooperative study that included fourteen centers evaluated psoralen and ultraviolet A (PUVA) therapy for psoriasis;'!" Four of sixtyfive patients were treated with a PUVA unit containing forty-eight high-intensity UVA bulbs, and 110 patients were treated with a unit containing sixty-four similar type bulbs. Eight-five percent of those treated with the PUVA-48 box cleared, and 69% treated with the PUVA-64 cleared. No significant laboratory abnormalities were detected, but ophthalmologic examination showed a few abnormal results after PUVA therapy. The shortterm side effects consisted of erythema, nausea, and pruritus. It was felt that the short-term safety of PUVA for psoriasis is confirmed by this study. Seventy-four patients were treated by Hannuksela and Karvonen 114 by bathing them in baths containing trioxsalen, 50 mg per 150 I of water, followed by long-wave ultraviolet light in a UV A box. They claimed that they had good to excellent results in 92% of patients treated initially and 63% during maintenance treatment. It was felt that this treatment was as safe as oral methoxsalen plus UVA in the treatment of psoriasis, but the dose of UV A needed to treat the patients was only one tenth of that needed in systemic PUVA. Dubertret et aJl15 evaluated a new compound, 3-carbethoxypsoralen (3-CPs) in the treatment of ten patients with psoriasis. These patients were treated with local application of 3-CPs plus UV A. They found that the therapeutic activity was the same for this agent as it is for local treatment with 8-MOP plus UVA. However, localized hyperpigmentation did not occur. Honigsmann et al l16 did a study to evaluate 5-methoxypsoralen (5-MOP) in the oral photochemotherapy of psoriasis. The results of their

136 Coskey

study showed that 5-MOP (Bergapten) is as effective or even more effective than 8-MOP in clearing psoriasis. The therapeutic doses of 5-MOP do not cause erythema, and high doses of 5-MOP are not followed by nausea. They felt that 5-MOP PUVA treatment is safer than 8-MOP PUVA therapy . Walter '!? evaluated the use of anthracene plus UVA light in the treatment of psoriasis. The psoriasis tended to improve in four of five patients with this therapy, and complete or almost complete clearing occurred in two of these patients. Perlman et al 118 did a study on photochemotherapy and psoriatic arthritis. They classified patients as either spondylitic or nonspondylitic. Spondylitic patients with psoriasis were difficult to control, and often the course of the skin disease and joint disease tended to vary independently . Patients who had nonspondylitic arthritis and psoriasis, who were treated with PUVA therapy, often showed a response in their skin and in the arthritis to the PUVA treatment. Murray and Warin!'" found that PUVA therapy, with ultraviolet light being given 2 hours after 8-methoxypsoralen, was effective in clearing twelve patients with palmoplantar pustulosis and almost cleared five other patients, while four pa. tients improved. This therapy was more effective than application of topical psoralen followed by long-wave ultraviolet light therapy. Jansen et al l 21) treated nineteen patients with chronic, recurrent palmoplantar pustulosis with either a placebo or the aromatic retinoid Ro 109359 over a 4-month period. Good responses were obtained in six of nine patients on the active medication and two of ten on placebo. . Fredriksson and Pettersson 121 treated eighty patients with the oral retinoid Ro 10-9359. These patients ' had pustulosis palmoplantaris and were given either 75 mg a day of the drug or 200 mg twice weekly. Treatment lasted for 8 weeks. At the end of that time the average reduction of pustules was 80 %. Remission lasted for approximately I month after therapy was stopped. Orfanos et al 122 treated patients with psoriasis on an outpatient basis with the oral retinoid Ro 10-9359 and phototherapy with predominantly UVB light. They achieved good or very good re-

Journal of the Am eric an Academy of Dermatology

suits in nineteen of twenty-three patients with generalized psoriasis. The average number of treatments necessary to achieve this success was 22.9. The mean total therapeutic dose was 73 Jzcrn". A control group of forty patients were treated with radiation therapy only , and good or very good results were achieved in 60% of the patients with twenty-six radiation treatments given. An excellent review on the current status of PUVA therapy can be found in the August, 1979 issue of the JOURNAL. 12:1 A prospective study of 1,373 patients who were treated over 2.1 years with oral 8-MOP photochemotherapy for psoriasis revealed that thirty patients had a total of forty-eight basal cell and squ amous cell carcinomas. This incidence was 2 .63 times that which would be expected. Patients who had been treated previously with ionizing radiation had a risk 3.68 times more than those who did not have x-ray therapy. Patients who had a previous cutaneous carcinoma had a risk 10.22 times more than normal of getting skin cancer. More squamous cell carcinomas occurred than expected, and these often occurred on areas not normally exposed to sun. Stem et aJl 24 felt that new patients with known histories of previous x-ray therapy or of skin cancers should be given PUV A therapy only if they were made aware of the risks of treatment and also had disabling psoriasis that could not be treated by other means. Cox and AbeP25 found dystrophy of epidermal cells in about half of thirty-seven patients who were treated with PUVA therapy for psoriasis. These changes occurred by the end of the clearing phase of treatment and persisted for 1 year after the beginning of treatment. They were not able to say if these changes might be transient, but they were of the opinion that the changes could possibly represent somatic changes that could be dangerous. Bjellerup et al 126 described a case of liver injury that was caused by 8-MOP given during PUVA therapy. This was proved by laboratory tests, but a liver biopsy was not obtained. Dau 12, described a patient who had psoriasis and also myasthenia gravis. The patient had been unresponsive to therapy. However, when the

Volume 3 Number 2 Augu st. 1980

myasthenia gravis was treated with azathioprine and plasmapheresis the lesions disappeared. Over a period of 5 months she was treated with plasmapheresis on fifteen occasions and also immunosuppressive therapy; during that time she had only limited recurrences of the eruption. However, 4 months after the plasmapheresis was discontinued, but immunosuppressive therapy was continued, the psoriasis recurred to its pre-plasmapheresis severity. Price l 28 attempted to desensitize ten patients with psoriasis to mechlorethamine. Attempts to desensitize these patients with small doses of mechlorethamine resulted in contact dermatitis in seven of the ten patients. Thus , Price does not feel that this drug would be of use in the treatment of psoriasis. Handler and Medansky'F" treated nineteen patient s who had psoriasis with topical nitrogen mustard . They claim that eight of nineteen patients had complete or almost complete clearing of their skin. Eleven patients discontinued therapy becau se of side effects or developed tolerance to the medication or did not complete the study . Six patients developed allergy or irritation to the medication after 2 to 15 months. lancu et al l 30 treated , fifteen patients with psoriasis by giving them either aminophylline or dyphylline. These drugs are xanthine derivatives. Treatment was successful in eight patients, and unsuccessful in the other seven. Proctor et aP31 obtained baseline levels of polyamines in the urine of nine patients with psoriasis. After the patients were treated and improved, these levels were again evaluated. They were found to decrease. This suggested to Proctor and associates that topical therapy may reduce epidermal cell proliferation in psoriasis by lowering its polyamine levels. Lichen planus pigmentosus was treated with one or more courses of vitamin A in dosages of 100 ,000 U per day for 15 days followed by a rest period of 15 days . One hundred forty patients were treated with this method. Bhutani et aP32 felt that they were able to show some improvement in some patients with this therapy . Sloberg et al 133 treat ed 23 patients who had severe oral lichen planus with 0.1 % tretinoin in

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an adhesive base. Fifteen control patients were treated with the vehicle only. In the tretinointreated group, 71% of atrophic-erosive lesions improved , but only 29% improved with the vehicle only. The reticulated type of lichen planus improved in 74% of the patients with the tretinoin but in only 15% with the vehicle. Irritation did occur from this agent. Lynch and Saied':" treated three patients with pityriasis lichenoides chronica and one with lymphomatoid papulosis with methotrexate once weekly. All four patients responded successfully to therapy with a minimum number of side effects. PREMALIGNANT AND MALIGNANT CONDITIONS

Price 'P did a comparative study with topical 5-f1uorouracil (5-FU) alone and topical 5-FU with dinitrochlorobenzene (DNCB) in the treatment of actinic keratoses of the upper extremities. Five of ten patients did better with both medications, but complications in the form of contact dermatitis from DNCB developed in five patients. Price felt that it would be better to treat actinic keratoses on the upper limbs for 6 to 8 weeks with 5-FU alone, because of the above complications. Reymann l a G treated eighty-eight patients with a total of ninety-five basal cell carcinomas with 5-FU ointment. A follow-up ex amination 10 to II years later revealed a total of twelve recurrences in fifty-six patients who had ' survived. Reymann found that the recurrence rate was 21.4% and concluded that 5-FU ointment should not be used for the treatment of nodular basal cell carcinomas. Odom and Goette':" treated fourteen patients who had twenty-two keratoacanthomas by injecting these lesions every week with 5-FU. Twentyfive of the treated lesions cleared in an average of 3 weeks after an average of 2.8 injections. No recurrences developed in those lesions that were treated. Hughes' P" treated two patients with verrucous carcinoma of the peni s with liquid nitrogen cryosurgery. In both instances therapy was successful. One percent dilution of cycloheximide in Aquaphor was applied twice daily to superficial basal cell epitheliomas in nine patients. Six of the basal cell epitheliomas cleared with treatment, and this

138

Caskey

was confirmed by re-biopsy of the treated site. Two cases of Bowen's disease were cured by treatment. Also, solar keratoses responded to therapy. \:\9 Helm and Helm!" evaluated bacillus Cal metre-Guerin (BCG) orally in nineteen patients and intradermally in sixteen patients. They treated Stage I and Stage II malignant melanonias. Thirty-two patients were used as controls. The study was done between January, 1972 and December, 1976. The disease-free interval in patients with melanoma after surgery did not differ significantly between either group. Mohs and Blanchard':" reported on the successful treatment of five cases of extramammary Paget's disease with the fixed-tissue chemosurgical technic in one case and fresh-tissue technic in four cases. In each case, they found that the lesion extended histologically several centimeters beyond the clinical lesion. This may explain the high recurrence rate with conventional surgery. Dawber and Wilkinson H2 treated fourteen patients with macular lesions of lentigo maligna with liquid nitrogen by applying 30 seconds' freezing with either a cotton swab or freezing with liquid nitrogen spray. They also treated eight patients with lentigo maligna and associated nodular invasive lesions with liquid nitrogen spray. These patients were treated with two 30-second sprays separated by a thaw interval of 2 minutes. They claim that their fourteen patients with macular lesions were cured, and six of the eight with nodular lesions were cured after one treatment. However, the follow-up time was short, averaging approximately 6 months to 2Yz years. Nazzaro-Porro et all4:l applied a cream containing 15% azelaic acid to three patients with lentigo maligna. The lesions were treated for 90 days. The clinical and histologic results were very good. There was replacement of abnormal melanocytes with normal-appearing cells. This effect was maintained for 2 years. Pitman et al J.l4 reported on the results of treatment of forty-two cases of lentigo maligna and sixteen cases of lentigo maligna melanoma. Twenty-two lesions of lentigo maligna were excised and two of these lesions recurred. Twenty lesions were treated with either x-ray treatment, curettageelectrodeciccation, or cryosurgery, and seven of

Journal of the American Academy of Dermatology

these lesions recurred. Eleven cases of lentigo maligna melanoma were excised. None of these patients had local recurrence, but metastases occurred in one patient. Five of the patients who did have lentigo maligna melanoma had been treated by destructive technics previously. Pitman et al concluded that surgical excision is the best means of therapy. Twenty-one patients with mycosis fungo ides (MF) were treated by the Scandinavian mycosis fungo ides study group. H:J These patients had the plaque stage of the disease. They were treated with whole body application of nitrogen mustard using 20 mg in 40 cc of water per square meter. Complete remission was initially achieved in ten patients and partial remission in nine patients. Molin et al attempted to prevent contact dermatitis by intravenous tolerance induction, as suggested by Van Scott and Kalmanson, in ten patients. However, contact dermatitis developed in two of the ten. Two hundred forty-three patients with MF were treated with either topical application of dilute aqueous solutions of mechlorethamine and/or systemic chemotherapy over a IO-year period. Thirtytwo patients achieved remissions for over 3 years, but Vonderheid et aJl46 were not certain how long these remissions would last. They did state that chemotherapy of MF is as effective as electronbeam therapy in promoting survival. Zackheim et a1 14; reported satisfactory control of twenty-four of thirty-three patients with either plaque-like MF or MF with tumor or ulcers by treating them with topical BCNU. It is found that treatment with BCNU, diluted in alcohol, and applied in doses of 40 to 60 mg on alternate days, until a total dose of 240 mg is used, has been favorable. Roenigk'!" followed ten to twelve patients with MF who were treated with PUVA therapy. Eight of these patients have remained clear while receiving maintenance therapy. Roenigk also reported that an additional thirty-five patients with MF have been treated with success with PUVA. In addition, eight cases of parapsoriasis en plaque have cleared with PUVA. Roenigk stated that PUVA is indicated for the treatment of early eczematous and plaque stages ofMF. It also may be used as an

Volume 3 Number 2 Au gust. 1980

adjunct to x-ray treatment or chemotherapy in the tumor stage of MF. Fischer and Skogh 149 treated three patients with parapsoriasis en plaque, fifteen patients with MF, and one with Sezary's syndrome with trioxsalen baths followed by ultraviolet light. Within 2 to 6 months of therapy, the skin healed completely or almost completely in three patients with parapsoriasis en plaque, seven patients with MF Stage II, and four patients with MF Stage III. Two patients who had MF Stages IV to V showed a fair degree of improvement. One of the patients with the erythrodermic form of MF responded, but not well. The patient with Sezary 's syndrome and a patient with erythrodermic MF developed a severe phototoxic reaction. Lowe et aJl50 treated nine patients with Stage II or Stage III MF with PUVA. They claimed that the patients were adequately controlled clinically in eight of nine cases. The histologic improvement was primarily in the epidermis and the papillary dermis. However, the infiltrate lower in the dermis did not change. When the therapy was stopped in four cases , there was an early relapse, but one patient stayed in remission for 3 months. Bleehen et al 15 1 treated thirty-eight patients with MF with PUVA. Most patients responded to therapy, especially those who were in early stages. Less than half of the patients who had tumors responded, and these lesions frequently recurred. Biopsies did show "that the infiltrate in the epidermis and the dermis cleared with PUVA therapy. They felt that PUVA is an effective therapy for early MF and may be of some use for the treatment of more advanced disease. Warin et aJl52 found that PUVA was highly satisfactory treatment for early MF and may also be helpful when other treatments are used in the treatment of early stages of the disease. Niemi':" treated six patients with MF with PUVA therapy. Two patients who were treated in the plaque stage developed skin tumors that were highly malignant 3 months later. One patient treated in the tumor stage developed spreading of his tumors. Three patients clea red completely or partially with PUVA therapy . Thus, PUVA did not uu the malignant cells in the dermis in the three patients with tumor-like disease.

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Gilchrest's! treated eleven patients with plaquelike MF and four with erythroderma due to MF with psoralen plus long-wave ultraviolet light. All of the patients responded while receiving treatment. Six patients discontinued PUVA, three died within a year, and three developed progression of the disease despite conventional therapy. Nineteen patients with the tumor stage of MF were treated by the Scandinavian MF study group with systemic therapy. Nine of these patients were given bleomycin, 15 mg intramuscularly twice weekly for 7 weeks, and ten patients were given the same dose of bleomycin along with methotrexate, 15 mg intramuscularly per square meter of body ·surface each week for 7 weeks. The bleomycin was considered good in half of the patients, but bleomycin and methotrexate produced a better result. However, remissions were short-lived in the absence of maintenance therapy. The mortality rate was high especially with combination treatment. The authors could not recommend this type of therapy because of side effects from it. 155 Hoppe et aJl56 reported on the use of electronbeam therapy for MF. They reported that it is important to use high initial doses and treat patients in the early stages of the disease. They also discussed the use of total-lymphoid radiation with megavoltage photons, as well as low-dose fractionated total-body radiation and also sequential hemibody radiation. Nisce and Safai!" reported on 115 patients with MF who were treated with electron-beam (totalskin) therapy for 6 to 8 weeks. They were given doses of 400 rads with 3.5-mev electrons. All of the patients developed relief of symptoms and regression of lesions. Remissions lasted 6 to 69 months in eight patients. There were no immediate or late effects on the bone marrow or on the normal skin which was treated with the radiation. Hoppe et aJl58 reported on the treatment of 140 patients with MF with electron-beam therapy. Eighty-four percent of the patients developed an initial remission which was related to the extent of the skin disease. The survival rate was 46% after 10 years . The most important prognostic factor was the extent of skin involvement when first seen . Also, the presence of palpable adenopathy, the patient's age, the ability to receive a complete

140. Caskey

remission initially, the initial dose of electronbeam therapy, and treatment with topical mechlorethamine had influence on the patient's prognosis . Spittle"? reported on the use of total-skin electron-beam therapy for MF and other skin tumors. She claimed that complete clearing can be predicted in patients unless they have very advaneed tumors. The duration of remission is usuaIly 18 months. Spittle is now investigating use of psoralens and ultraviolet light for maintenance after low-dosage electron-beam therapy. Prednimustine is a chlorambucil ester of prednisolone. It was given to five patients with MF in the advanced tumor stage. Partial remission was obtained in only two of the patients. Molin et al 160 did not feel that it was particularly advantageous. Cohen and Bekierkunst''" treated six patients with MF successfully, with intralesional injections of I % mineral oil emulsion of killed BCG and cord factor or topical application of an ointment containing killed BCG and cord factor. According to Cohen and Bekierkunst, cord factor is a glycolipid which is extractable from mycobacteria. The Scandinavian MF study group administered epipodophyIlotoxin (VP-16-213) to nine patients with MF in different stages of the disease. In four patients, cyclophosphamide was added. Epipodophyllotoxin alone or in combination with cyclophosphamide induced remission in all cases, but remission was not maintained. Molin et aJl62 felt that remission would have to be upheld by other agents, possibly added to the active drug. Zachariae et aJl6:1 reported on a patient with the tumor stage of MF who did not respond to conventional treatment with nitrogen mustard, methotrexate, or grenz-ray therapy. The patient was then treated with twelve injections of transfer factor and also x-ray therapy and did respond. Four patients with cutaneous T ceIl lymphoma were treated with intravenous anti thymocyte globulin. Three of the four patients improved.l'" Cohen and Bekierkunst'P treated four patients with Kaposi's sarcoma and one patient with basal cell carcinoma and solar keratoses, successfully, with topical application of an ointment containing killed BCG and "cord factor. " Kim et alIGGtreated two cases of Kaposi's sar-

Journ al of the American Academy of Dermatology

coma with bleomycin . The first patient responded after 240 mg of bleomycin was given over a 13month period. The second patient responded to a course of 105 mg of bleomycin. Soter et a1 16' did a double-blind crossover study to evaluate disodium cromoglycate, given orally, to control gastrointestinal , central nervous system, and cutaneous symptoms of systemic mastocytosis. The study was done on five patients over a period of 8 to 32 months . In fifteen of the eighteen trials, the disodium cromoglycate produced improvement in flushing, whealing, pruritus, diarrhea, abdominal pain, and other symptoms. In the patients in the nineteen trials with placebo, there was no improvement or change in signs or symptoms. Soter et al found that histaminuria and peripheral blood eosinophilia did not appear to be affected by drug therapy. Zachariae- '" reported on two infants with histiocytosis X who were treated successfully with topically applied nitrogen mustard. Cutaneous symptoms disappeared within 2 weeks in one patient, with skin improved in the other. The only side effect from treatment was hyperpigmentation. VESICULOBULLOUS ERUPTIONS

Penneys'?" described how to give gold therapy to patients with pemphigus. Thirteen of eighteen patients had responded favorably to treatment with gold, allowing eventual discontinuation of systemic corticosteroid therapy. He also claimed that follow-up evaluation of seventeen of the original patients he treated indicated that fifteen responded successfully for varying periods of time . He gives aurothioglucose (Solganol) to these patients. Patients with pemphigus are first treated with systemic corticosteroids. Once the disease is under control, the dosage of the corticosteroids is decreased until new blisters appear. If patients are able to be controlled on smaIl doses of corticosteroids, gold is not added. However, if this is not possible gold is added . Patients are treated first with 10 mg intramuscularly of the preparation followed by 25 mg 7 days later. Ifboth of these doses are tolerated, then 50 mg of gold is given weekly. He warned in his article about the possible systemic side effects of gold and how to evaluate them.

Volume 3 Numb er 2 August , 1980

Jacyk'?" treated a patient with pyoderma vegetans of Hallopeau with 100 mg of dapsone once daily. The patient almost completely cleared after 6 weeks on this dosage. The drug was discontinued , and I month later the patient had a mild relapse which was cleared after 2 weeks' therapy with 50 mg of dapsone. Auerbach and Bystryn 171 treated a patient with pemphigus vulgaris by exchange plasmapheresis. · Eight plasmaphereses were performed during a period of 6 weeks. This procedure decreased the number of intracellular antibodies by 50% to 87%. After plasmapheresis, antibodies usually increased again, but this could be decreased by giving cyclophosphamide. After the patient was treated for 6 weeks, symptoms improved and antibody levels were desreased from a titer of 5 , 120 to 160 . Auerbach and Bystryn claimed they could not say that the improvement was due only to plasmapheresis, because the patient was also being treated with low doses of prednisone and cyclophosphamide. O 'Loughlin et ajl72 found that six of seventeen patients with pemphigus who were treated with immunosuppressive agents and/or corticosteroids developed a prolonged remission when off therapy . These patients were treated until their serum and tissue-bound pemphigus antibodies could not be detected. Remissions ranged from 1Y2 to 4 years. However, three of the six patients did relapse after being clear for periods ranging from 19 to 48 months. Seven other patients, whom 0 'Loughlin et al are following, do not have evidence of disease and have pemphigus antibody titers that are 10 or less . The therapy on these patients is being gradually discontinued. 0 'Loughlin et al carne to the conclusion that a large number of patients with pemphigus may develop a prolonged clinical and immunologic remission after being treated successfully. They also felt that once these remissions develop, they may be able to discontinue the therapy . Bohr and Quirk':" treated eight patients with transient acantholytic dermatosis by giving them vitamin A, 50,000 U three times a day for up to 2 weeks. All of their patients improved in less than 2 weeks. They then adjusted the dosage to a maintenance level of 50,000 U daily. This was continued

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for several weeks. Apparently all patients improved in the first 2 weeks of therapy. Livden and Nilsen":' treated a 20-year-old man with acquired epidermolysis bullosa with intramuscular gold sodium thiomalate. A total dose of 1,000 mg was given over a period of 9 months, and this patient showed an almost complete remission. Kingham et al 175 described severe hypoalbuminemia in two patients on long-term dapsone treatment for dermatitis herpetiformis . One patient had been treated for 3 years and the other for I I years before they developed the problem. When the albumin-turnover studies were done, they revealed a great increase in intravascular albumin catabolism and a moderate decrease in synthesis.

MISCELLANEOUS CONDITIONS Limmer'?" treated twenty-one lesions in eleven patients with porokeratosis plantaris discreta with liquid nitrogen. He removed the blister 2 weeks after cryosurgery, and if residual lesions were present, treated them once more . He claimed that he was able to cure 90.5% of the patients with this technic . Mascaro et aP" treated five patients with Behcer's syndrome and one with periadenitis mucosae necrotica recurrens with thalidomide, 100 mg daily. Very good results were noted in the ulcerations involving mucous membranes. Wiener-?" injected sodium chloride intracutaneously as a local anesthetic for superficial skin surgery. He claimed that this had an advantage over the "caines " because there was no burning on injection, the drug was inexpensive, and there was no worry of sensitization. Saline could be used for punch biopsy, some electrocautery tech nics, shaving of lesions, and curettage. He did claim that procedures had to be performed quickly in order for this type of anesthesia to be helpful. Burton et all <9 evaluated a collagen sponge made from bovine tendon in the treatment of six patients with leg ulcers. They found that the sponge enhanced granulation, but the formation of new skin was slower than usual. Olsson and Thyresson 180 were able to heal ischemic ulcers on the toes of a patient by giving the patient intravenous prostaglandin E I .

142 Caskey

Parish and Collinsl'" treated seventeen patients with thirty-four decubitus ulcers with either dextranomer, collagenase, or sugar and egg white. Seven of seven patients treated with dextranomer and two of five treated with collagenase improved at the end of their study , but none of the five responded to sugar and egg white. Apfelberg et aI H ;:! treated 130 patients with port-wine hemangiomas with the argon laser. Seventy-nine of these patients had good or excellent results, thirty-four patients had poor results, and seventeen patients developed scarring. The average number of treatments necessary for these lesions was 7.8. Apfelberg et al also treated capillary/cavernous hemangiomas, with eleven patients receiving excellent to good results, and three patients developing poor results. The average number of treatments in these instances was 4.3. Also, telangiectatic lesions were treated with only one poor result and thirty-two excellent-togood results. Patients with tattoos were also treated. Eight patients received a satisfactory blanching of the tattoos, eleven had subtotal blanching , and three had no change, while six demonstrated hypertrophic scarring with the tattoo resolving. The average number of treatments was 2 .8. Olsen et ap R:l treated a 21-year-old man who had the blue rubber bleb nevus syndrome with a CO 2 laser. It was used to treat 225 lesions. However, it was necessary to do this under general anesthesia. The cosmetic results were excellent. Goldman'>' treated multiple glomangioma tumors in a l3-year-old boy with a ruby laser. This method proved to be effective. Kushner'P treated four patients with hemangiomas involving the -eyelids by injecting them with triamcinolone and betamethasone sodium phosphate. In three of the four cases there was improvement. An excellent review on the use of systemic corticosteroid therapy can be found in an article entitled "Use and Abuse of Systemic Corticosteroid Therapy. "186 Spiegel et al 18i evaluated adrenal function in fourteen patients receiving chemotherapy for cancer. These patients were also given short-term high-dose courses of prednisone. Thirteen of four-

Journal of the American Academy of Derm atology

teen patients had adrenal suppression for at least 24 hours. In most patients , adrenal function returned to normal between the second and fourth days; however, in five patients it was depressed for 7 days. The suppression did not correlate with steroid dosage or duration of therapy. Four of the five patients receiving the 5-day treatment showed evidence of adrenal suppression . Kahn and Rywlint '" described an entity which was given the name "acropustulosis of infancy. " This entity consists of pruritic pustules primarily on extremities of infants. It usually lasts for about 2 years. The two patients he described responded to treatment with sulfones. Apparently no other therapy seems to be effective. Hernandez-Perez 1m treated twenty patients with extensive vitiligo by giving them ACTH gel, 40 mg intramuscularly twice a week for 5 weeks; then after a 5-week rest period, the series was repeated. Six of the twenty patients experienced repigmentat ion at the end of the 15 weeks. However, this pigmentation disappeared when the treatment was stopped. Oleske et a)l90 described a child who was treated with parenteral alimentation for 5 months. This patient developed the syndrome of acrodermatitis enteropathica with a depression in T cells and also abnormal T cell mitogen-induced blast transformation and anergy to skin test antigens. The plasma zinc levels were low in this patient. When the patient was given zinc therapy, the clinical manifestations of acrodermatitis resolved. Also, cell-mediated immune function was restored to normal. Thus, Oleske et al felt that zinc played an important role in cellular responses. Green and Martin'?' described a procedure of dermal grafting for the treatment of Peyronie's disease. In twenty-seven patients , approximately two-thirds were improved by this technic. Epstein192 described a method for treating digital mucous cysts. He taught the patients how to drain the cysts by inserting a 26-gauge needle into them and then squeezing out the cyst contents. Patients did this as often as necessary to prevent the cyst from filling . He reported that twenty-nine of forty digital cysts treated by this method disappeared. Another eleven cysts did not clear, but the patients ignored them because they were asyrnp-

Volume 3 Number 2 August, 1980

tomatic. The cysts had to be needled anywhere from one to more than ten times. Sutherst'P" treated patients with intractable pruritus vulvae by injecting the vulva with 0.1 to 0.2 ml of absolute alcohol placed 5 to 6 mm below the skin surface and at distances of 1 ern. This was done under general anesthesia; only one side of the vulva was treated with this therapy while the other side was treated with sterile water. Follow-up examination 2 months later showed that fourteen of seventeen patients treated with the alcohol were free of itching on the side where the alcohol was given, but not on the side where the water was given. In two patients, symptoms were improved on both sides. Of the fourteen patients who were cured on one side, thirteen were then treated on the other side with alcohol; eight of these have been asymptomatic for 2 years since the second treatment. Wade-'" treated patients with chondrodermatitis nodularis helicis by injecting them with intralesional triamcinolone acetonide (10 mg per cc) with a total of 0.5 cc given per injection. He claimed that he treated patients with this method with very good success. Tkacht'" treated a woman with Fox-Fordyce disease involving theaxillae with a 1: 1 mixture of 0.05% tretinoin cream and 1% hydrocortisone cream applied every other night at bedtime. After 6 weeks of treatment, the condition was completely resolved. At the time of publication of this letter, the patient was applying the above preparation every three nights and remaining free of symptoms. Giacobetti et a)l96treated a 21-year-old woman, who had Fox-Fordyce disease involving the pubic area and axillae, with 0.1 % tretinoin cream. The agent was applied every other night. After 4 weeks of treatment itching became much less. When the therapy was discontinued for 2 weeks, the eruption returned. However, when therapy was restarted itching was controlled. Eleven women with axillary hyperhidrosis were treated with topical application of aluminum chloride hexahydrate 25% in absolute ethanol, which was applied to the axillae and then occluded with plastic foil two nights each week. These women were followed for 24 weeks. Another twelve

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women were treated for up to 12 weeks with the same drug but without plastic occlusion. Both groups of women developed sweat reduction immediately. Thus, effective treatment developed either with or without occlusion."? Farber and South 198 described their nonsurgical method for removing dystrophic nails. They described the treatment of thirty-five patients who used a topical urea preparation under an occlusive dressing. The reader should refer to the article for the exact composition of the preparation used and the exact way that it should be applied. Reed et al 199 did a double-blind, placebocontrolled study to evaluate the effectiveness of neomycin ointment in preventing infection after biopsies. They found that neomycin was no more effective than placebo ointment in preventing infection. Geronemus et aFoo evaluated Neosporin ointment, nitrofurazone (Furacin) ointment, an agent containing povidone-iodine, and also Silvadene and its vehicle to see what effect these agents would have on the rate of re-epithelialization of clean wounds made in white domestic pigs. They found that Neosporin ointment increased the rate of re-epithelialization by 25%, furacin retarded the rate of healing by 24%, the Silvadene increased the rate of healing by 28%, the vehicle of Silvadene increased the rate of re-epithelialization by 21 %, and the povidone-iodine agent did not affect the rate of healing. Cullens?' reported on the successful treatment of reactive perforating collagenosis with 0.1 % tretinoin. This drug reduced the total number of lesions present. Babin and Ceilley/'" treated keloids and hypertrophic scars by freezing them with liquid nitrogen and then injecting them with a fluorinated adrenocorticosteroid. They felt that this was a more effective technic than freezing alone or injections with a corticosteroid alone.

REFERENCES 1. Wilkinson DS, Kirton V, Wilkinson JD: Perioral dermatitis: A 12-year review. Br J Dermatol101:245-257, 1979. 2. Cotterill JA: Perioral dermatitis. Br J Dermatol 101: 259-262, 1979.

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3. Panzer ID, Panzer 11: Topical c1indamycin in acne: A preliminary study. Cutis 24:118-119,1979. 4. Guin ID: Topical clindamycin: A double-blind study comparing clindarnycin phosphate with c1indamycin hydrochloride. Int 1 Dermatol 18:164-166, 1979. 5. Stoughton RB: Topical antibiotics for acne vulgaris. Current usage. Arch Dermatol 115:486-489, 1979. 6. Feingold DS, Chen WC, Chou DL, et al: Induction of colitis in hamsters by topical application of antibiotics. Arch DermatoI115:580-581, 1979. 7. Mills OH, Kligman AM: Treatment of acne vulgaris with topically applied erythromycin and tretinoin. Acta Derm Venereol (Stockh) 58:555-557, 1978. 8. Belknap BS: Treatment of acne with 5 percent benzoyl peroxide gel or 0.05 percent retinoic acid cream. Cutis 23:856-859, 1979. 9. Mills OH, Kligman AM: Evaluation of abrasives in acne therapy. Cutis 23:704-705, 1979. 10. Hurley HI, Shelley WB: Special topical approach to the treatment of acne. Suppression of sweating with aluminum chloride in an anhydrous formulation. Cutis 22:696-703, 1979. I I. Goransson K, Liden S, Odsell L: Oral zinc in acne vulgaris: A clinical and methodological study. Acta Derm Venereol (Stockh) 58:443-448, 1978. 12. Cunliffe WI, Burke B, Dodman B, et al: A doubleblind trial of zinc sulphate/citrate complex and tetracycline in the treatment of acne vulgaris. Br I Dermatol 101:321-325, 1979. 13. Weimar VM, Puhl SC, Smith WH, et al: Zinc sulphate in acne vulgaris. Arch Dermatol114: 1776-I778, 1978. 14. Cunliffe, WI: Unacceptable side-effects of oral zinc sulphate in the treatment of acne vulgaris. Br 1 Dermatol 101:363, 1979. (Letter to the Editor.) 15. Peck GL, Olsen TG, et al: Prolonged remissions of cystic and conglobate acne with 13-cis-retinoic acid. N Engll Med 300:329-333, 1979. 16. Palatsi R, Ylostalo P, Taipale A: Treatment of acne with cyproterone acetate and ethinyl estradio\. Acta Derm Venereol (Stockh) 58:449-454, 1978. 17. Burton Jl., Saihan E: Sebaceous gland suppression in female acne patients by combined glucocorticoidestrogen therapy. Br 1 Dermatol 101:15-16, 1979 (supp\. 17). 18. Rose LI, Birnbaum MD: Therapy of adrenocortical hydroxylase deficiencies in acne vulgaris. Int 1 Dermatol 18:386-389, 1979. 19. Conte MS, Lawrence IE: Pseudofolliculitis barbae. lAMA 241:53-54, 1978. 20. Hall lC, Goetz CS, Bartholome CS, et al: PseudofolIiculitis-revised concepts of diagnosis and treatment. Report of three cases in women. Cutis 23:798-800, '1979. 21. Warin AP, Gatecliff l\t, Greaves MW, et al: The treatment of hereditary angioedema with low dose androgenic drugs. Br 1 Dermatol 101: 18-19,1979 (supp\. 17). 22. Tappeiner G, Hintner H, Glatzl 1, et al: Hereditary angie-oedema: Treatment with danazol. Br 1 Dermatol 100:207-212, 1979. 23. Cornmens CA, Greaves MW: Cimetidine in chronic idiopathic urticaria: A randomized double-blind study. Br 1 Dermatol 99:675-679, 1978.

Journal of the American Academy of Dermatology 24. Matthews CNA, Boss 1M, Warin RP, et al: The effect of HI and H2 histamine antagonists on symptomatic dermographism. Br 1 Dermatol 101:57-61, 1979. 25. Pace WE: Intravenous typhoid vaccine injection found beneficial in chronic urticaria. Dermatology News 12: I, 7, 1979. 26. Giannini M, Callen IP: Treatment of dermatomyositis with methotrexate and prednisone. Arch Dermatol 115:1251-1252, 1979. 27. Fauci AS, Katz P, et al: Cyclophosphamide therapy of severe systemic necrotizing vasculitis. N Engl 1 Med 301:235-238, 1979. 28. Hazen PG, Michel B: Management of necrotizing vasculitis with colchicine. Arch Dermatol 115: I303- I306, 1979. 29. Ayres S, Mihan R: Lupus erythematosus and vitamin E: An effective and nontoxic therapy. Cutis 23:49-54, 1979. 30. Sabbour MS, Osman LM: Comparison of chlorambucil, azathioprine or cyclophosphamide combined with corticosteroids in the treatment of lupus nephritis. Br 1 Dermatol 100: I 13-125, 1979. 31. Hubbard HC, Portnoy B: Systemic lupus erythematosus in pregnancy treated with plasmapheresis. Br J Dermatol 101:87-89, 1979. 32. Frayha RA: Colchicine therapy in scleroderma. Dermatologica 159:78-81, 1979. . 33. McIntyre DR: A maneuver to reverse Raynaud's phenomenon of the fingers. lAMA 240:2760-2761, 1978. 34. Kaaber K, Menne T, Tjell JC, et al: Antabuse treatment of nickel dermatitis. Chelation-a new principle in the treatment of nickel dermatitis. Contact Dermatitis 5:221-228, 1979. 35. Saarinen UM, Kajossari M, Backman A, et al: Prolonged breastfeeding as prophylaxis for atopic disease. Lancet 2: 163-166, 1979. 36. Medansky RS, Handler RM, et al: A trial with f1uocinonide in recalcitrant dermatoses. Int 1 Dermatol 18:83-88, 1979. 37. Fisher M, Kelly AP: Multicenter trial of fiuocinonide in an emollient cream base. Int 1 DermatoI 18:660-664, 1979. 38. Silverman A: Fluocinonide vs. halcinonide in atopic dermatitis. A paired comparison of two potent topical corticosteroids. Cutis23:375-378, 1979. 39. Sannwald C, Ortonne IP, Thivolet 1: La photochirniotherapie orale de I'eczema atopique. Dermatologica 159:71-77, 1979. 40. Hovmark A, Ekre PT: Failure of transfer factor therapy in atopic dermatitis. Acta Derm Venereol (Stockh) 58:497-500, 1978. 41. Spitler LE: Transfer factor therapy in the WiskottAldrich syndrome: Results of a long-term follow-up in 32 patients. Am 1 Med 67:59-66, 1979. 42. Mathias CGT, Maibach HI: Polyvinyl chloride work boots in the management of shoe dermatitis in industrial workers. Contact Dermatitis 5:249-250, 1979. 43. Baran R: Hallopeau's acrodermatitis. Arch Derrnatol 115:815, 1979. (Letter to the Editor.) 44. Schmoeckel C, Weissmann I, Plewig G, et al: Treatment of alopecia areata by anthralin-induced dermatitis. Arch Dermatol 115:1254-1255, 1979.

Volume 3 Number 2 August, 1980 45 . Happle , Prof: Contact allergens regrow hair in alopecia areata, according to report given at SID-ESDR meeting. Dermatology News 12: I, 1979. 46 . Cipollaro VA, Shaps R: The treatment of Darier 's disease. Int J Dermatol 18:580-583, 1979. 47. Zachariae H: Dermabrasion in Darier 's disea se. Acta Derm Venereol (Stockh) 59:184-186, 1979. 48. Gibberd FB , Page NGR , Billimoria JD, et al: Heredopathia atactica polyn euritiform is (Refsum's disease) treated by diet and plasma-exchange . Lancet 1:575 578, 1979. 49. Reed ML, Stanley J, Stengel F, et al: Mal de me!eda treated with 13-cis-retinoic acid. Arch Dermato! 115: 605-608, 1979. 50. Dore N, Collins JP, Mankiewic E: A sporotrichoid-Iike Mycobacterium kansasii infection of the skin treated with minocyeline hydrochloride. Br J Dermatol 101:75-79, 1979. 51. Contorer P, Jones RN: Minocycline therapy of aqua rium granuloma. Case reports and literature review. Cutis 23:864-868, 1979. 52. Leyden n. McGinley KJ, Mills OH: Pseudomonas aeruginosa: Gram-negative folliculitis. Arch Dermatol Il5:1203-1204,1979 . 53. Solem LD, Zaske D, Strate RG: Ecthyma gangrenosum . Arch Surg 114:580-583, 1979. 54 . Keeney RE, Seamans ML, Russo RM, et al: The com parative efficacy of minocycline and penicillin- V in Staphylococcus aureus skin and soft tissue infection s. Cutis 23:711-718, 1979. 55. Yesudian P, Rhamb iah AS: Metron idazole in the treatment of tropical phagedenic ulcers. Int J Dermatol 18:755-757, 1979. 56 . Tschen EH , Becker LE, Ulrich JA, et al: Comparison of over-the-counter agents for tinea pedis. Cutis 23:696697, 1979. 57. Clayton YM, Gange RW , MacDonald DM , et al: A clinical double-blind trial of topical haloprogin and miconazole against superficial fungal infections. Clin Exp Dermatol 4:65-73, 1979. 58. Pazin 01, Nagel JE, Friday GA, et al: Topical clotrirnazole treatment of chronic mucocutaneous candidiasis. J Pediatr 94:322-325, 1979. 59. Rockoff AS: Chronic mucocutaneous candid iasis. Successful treatment with intermitt ent oral doses of clotrimazole . Arch Dermatol 115:322-323, 1979. 60. Lubritz RR, Spence JE: Chromobl astomycosis: Cure by cryosurgery . Int J Derrnatol 17:830-832, 1978. 61. Tagami H, Ohi M, Aoshima T, er al: Topical heat therapy for cutaneous chrornornycosis. Arch Dermatol Il5:740-74I,1979 . 62. Uitto J, Santa-Cruz DJ, Eisen AZ, et al: Chromomycosi s. Successful treatment with 5 fluorocytosine . J Cutan Pathol 6:77-84, 1979. 63. Jacyk WK: Chromomycosis due to Cladosporium carrioni treated with 5-fluorocytosine. A case report from northern Nigeria. Cutis 23:649-650, 1979. 64. Chermsirivathana S, Bunyaratavej K, Pupaibul K: The treatment of chromomycosis with 5-f1uorocystine. Int J Dcrmatol 18:377-379, 1979. 65. Dangy FW: Report thenn~i therapy succes s in treatment of sporotrichosis. Dermatology News 12:8, 1979.

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66. Pazin GJ, Armstrong lA, et al: Prevention of reactivated herpes simplex infection by human leukocyte interferon after operation on the trigeminal root. N Engl J Med 301:225-230, 1979. 67. Blough HA, Giuntoli RL: Successful treatment of human genital herpes infections with 2-deoxy-o-glucose. JAMA 241:2798-2801, 1979. 68. Miller JB: Treatment of active herpes virus infections with influenza virus vaccine. Ann Allergy 42:295-305, 1979. 69. McCarty JR , Jarratt MT: Topical phosphonoacetic acid treatment of cutaneous herpes simplex infections in the guinea pig . J AM ACAD DER~IATOL 1:244 -248, 1979. 70. Donsky HJ: Nonoxynol 9 cream for genital herpes simplex, N Engl J Med 300:371, 1979. (Leiter to the Editor.) 71. Lieb J: Remission of recurrent herpes infection during therapy with lithium. N Engl J Med 301:942, 1979. (Leiter to the Editor .) 72. Spruance SL, Crumpacker CS, Haines H, et al: Ineffectiveness of topical adenine arabinoside 5'-rnonophosphate in the treatment of recurrent herpes simplex labialis. N Engl J Med 300:1180-1184, 1979. 73, Moncada B, Rodriguez ML: Levamisole therapy for multiple warts. Br J Dermatol 101:327-330, 1979. 74. Stahl D, Veien NK, Wulf HC: Photodynamic inactiva tion of virus warts: A controlled clinical trial. Clin Exp DermatoI4:81-85, 1979. 75. Lockshin NA: Flat facial warts treated with fluorouracil. Arch Dermatol 115:929-930, 1979. (Letter to the Editor.) 76. Litt JZ: Don't excise-exorcise. Treatment for subungual and periungual warts. Cutis 22:673-676, 1978. 77. Landegren J, Berglund E, Storgard s K: Treatment of scabies with disulfiram and benzoate emulsion: A controlled study. Acta Derm Venereal (Stockh) 59:274276 , 1979. 78. Jensen 0, Nielsen AO, Bjerregaard P: . Pediculosi s capitis treated with quassia tincture. Acta Derm Venereal (Stockh) 58:557-559, 1978. 79. Giessel M, Graves K, Kalivas J: Treatment of disseminated granuloma annulate with potassium iodide . Arch Dennatol 115:639-640, 1979. (leiter to the Editor.) 80. Kossard S, Winkelmann RK: Low-dose chlorambucil in the treatment of generalized granuloma annulare. Dermatologica 158:443-450, 1979. 8!. Rudolph JI: Disseminated granuloma annul are treated with low-dose chlorambucil. Arch Dermatol 115: 1212-/213, 1979. 82. Gilchrest BA: Ultraviolet phototherapy of uremic pruritus. Int J DennatoI18:741-748, 1979. , 83. Gilchrest BA, Rose JW, Brown RS, et al: Ultraviolet phototherapy of uremic pruritus. Long-term results and possible mechanism of action . Arin Intern Med 91:1721, 1979. 84. Harris RB, Perry HO, et al: Treatment of sclerornyxedema with melphalan. Arch Derrnatol 115:295-299, 1979. 85. Jessen RT, Straight M, Becker LE: Lichen myxedematosus. Treatment with cyclophosphamide. Int J Dermato! 17:833-839, 1978.

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86. Goerz G: Klinik und therapie der porphyria cutanea tarda, Dermatologica 159:393-399, 1979. 87. Thomsen K, Schmidt H, Fischer A: Beta-carotene in erythropoietic protoporphyria: 5 years' experience. Dermatologica 159:82-86, 1979. 88. Haeger-Aronson B, Krook G, Abdulla M: Oral carotenoids for photohypersensitivity in patients with erythrohepatic protoporphyria, polymorphous light eruptions and lupus erythematodes discoides. Int J Dermatol 18:73-82, 1979. 89. Parrish JA, Levine Ml, Morison WL, et al: Comparison of PUV A and beta-carotene in the treatment of polymorphous light eruption. Br 1 Dermatol 100: 187191, 1979. 90. Thomsen K, Rothenborg HW: Clofazimine in the treatment of pyoderma gangrenosum. Arch Derrnatol IIS:851-852, 1979. 91. Hess CE: Cirnetidine for the treatment of pruritus. N Engll Med 300:370, 1979. (Letter to the Editor.) 92. Harrison AR, Littenberg G, et al: Pruritus, cimetidine and polycythemia. N Engl 1 Med 300:433-434, 1979. (Letter to the Editor.) 93. Scott GL, Horton Rl: Pruritus, cimetidine and polycythemia. N Engl J Med 300:434, 1979. (Letter to the Editor.) 94. Ridgway HB, Hansotia PL, Schorr WF: Relapsing polychondritis. Unusual neurological findings and therapeutic efficacy of dapsone. Arch Dermatol 1I5:43-45, 1979. 95. Nilsson JE, Gip LJ: Systemic effects of local treatment with high doses of potent corticosteroids in psoriatics. Acta Derm Venereol (Stockh) 59:245-248, 1979. 96. Stawiski MA, Rusin U, Burns TL, et al: Ro 20-1724: An agent that significantly improves psoriatic lesions in double-blind clinical trials. 1 Invest Dermatol 73:261263, 1979. 97. Giacosa A, Farris A, Cheli R: Cirnetidine and psoriasis. Lancet 2:1211-1212, 1978. (Letter to the Editor.) 98. Raffle El: Cirnetidine and psoriasis. Lancet 2: 1314, 1978. (Letter-to the Editor.) 99. McCallum Dl, Grant PW: Cimetidine and psoriasis. Lancet 2:1314-1315, 1978. (Letter to the Editor.) 100. Rai GS, Webster SGP: Cimetidine and psoriasis. Lancet 1:50, 1979. (Letter to the Editor.) 101. Finnerty EF: Successful treatment of psoriasis of the nails. Cutis 23:43-44, 1979. 102. Boer J, Schothorst AA, Suurmond D: Ultraviolet B phototherapy for psoriasis in sunlight-responsive patients. Lancet 1:773, 1979. (Letter to the Editor.) 103. Larko 0, Swanbeck G: Home solarium treatment of psoriasis. Br J Dermatoll01:13-16, 1979. 104. Le Vine Ml, White HAD, Parrish lA: Components of the Goeckerman regimen. J Invest Dermatol 73: 170173, 1979. 105. Frost P, Horwitz N, Caputo RV, et al: Tar gelphototherapy for psoriasis. Combined therapy with suberythemogenic doses of fluorescent sunlamp ultraviolet radiation. Arch Dermatol 115:840-846, 1979. 106. Petrozzi JW, Barton 10: Comparison of crude coal tar and topical methoxsalen in treatment of psoriasis. Arch Dermatol 115:1061-1063, 1979. 107. Basler RSW: Psoralen and sunlight for psoriasis in the southwest. Cutis 24:386-388, 1979.

Journal of the American Academy of Dermatology 108. Petrozzi lW, Barton 10, Kligman A, et al: Topical methoxsalen administration and sunlamp fluorescent irradiation in psoriasis. Arch Dermatol 115:436-439, 1979. 109. Siddiqui AH, Cormane RH: Initial photochemotherapy of psoriasis with orally administered 8-methoxypsoralen and long-wave ultraviolet light (PUV A). Br 1 Dermatol 100:247-250, 1979. 110. Rogers S, Marks 1, Shuster S, et al: Comparison of photochemotherapy and dithranol in the treatment of chronic plaque psoriasis. Lancet 1:455-458, 1979. III. Hanke CW, Steck WD, Roenigk HH: Combination therapy for psoriasis (psoralens plus long-wave ultraviolet radiation with betamethasone valerate). Arch Dermatol 115:1074-1077, 1979. 112. Schmoll M, Henseler T, Christophers E: Evaluation of PUV A, topical corticosteroids and the combination of both in the treatment of psoriasis. Br J Dermatol 99:693-702, 1978. 113. Photochernotherapy for psoriasis. A clinical cooperative study of PUVA-48 and PUVA-64. Arch Dermatol II5:576-579, 1979. 114. Hannuksela M, Karvonen 1: Trioxsalen bath plus UVA effective and safe in the treatment of psoriasis. Br 1 Dermatol 99:703-713, 1978. 115. Dubertret L, Averbeck D, Zajdela F, et al: Photochemotherapy (PUV A) of psoriasis using 3-carbethoxypsoralen, a non-carcinogenic compound in mice. Br 1 Dermatol 101:379-389, 1979. 116. Honigsmann H, laschke E, Gschanait F, et al: 5-Methoxypsoralen (Bergapten) in photochernotherapy of psoriasis. Br 1 Dermatol 101:369-378, 1979. 117. Walter IF: Psoriasis improved by anthracene with near ultraviolet light. 1 AM ACAD DERMATOL 1:261-264, 1979. 118. Perlman SG, Gerber LH, Roberts RM, et al: Photochernotherapy and psoriatic arthritis. Ann Intern Med 91:717-722, 1979. 119. Murray D, Warin AP: Photochemotherapy for persistent palrnoplantar pustulosis (PPP). Br 1 Dermatol 101:13-14, 1979 (suppl. 17). 120. lansen C, Hollmen A, Pajarre R: Peroral aromatic retinoid treatment of palmoplantar pustulosis: Doubleblind comparison of Ro 10-9359 and placebo. Acta Derm Venereol (Stockh) 59:271-273, 1979. 121. Fredriksson T, Pettersson U: Oral treatment of pustulosis palrno-plantaris with a new retinoid, Ro 109359. Derrnatologica 158:60-64, 1979. 122. Orfanos CE, Steigledger GK, Pullmann H, et al: Oral retinoid and UVB radiation: Anew, alternative treatment for psoriasis on an out-patient basis. Acta Derm Venereol (Stockh) 59:241-244, 1979. 123. Current status of oral PU VA therapy for psoriasis. 1 AM ACAD DERMATOL 1:106-117, 1979. 124. Stern RS, Thibodeau LA, Kleinerman RA, et al: Risk of cutaneous carcinoma in patients with oral methoxsalen photochernotherapy for psoriasis. N Engl 1 Med 300:809-813, 1979. 125. Cox Al, Abel EA: Epidermal dystrophy. Occurrence after psoriasis therapy with psoralen and long-wave ultraviolet light. Arch Dermatol 115:567-570, 1979. 126. Bjellerup M, Bruze M, Hansson A, et al: Liver injury following administration of 8-methoxypsoralen during

Volume 3 Number 2 August, 1980 PUVA therapy . Acta Derm Venereol (Stockh) 59: 371-372, 1979. 127. Dau PC: Resolution of psoriasis during plasmapheresis therapy. Arch Dermatol115:1171, 1979. (Letter to the Editor .) 128. Price NM: Topical mechlorethamine for psoriasis. An attempt to avoid the development of sensit ization by the use of a topical tolerogenic schedule. Int J Derrnatol 18:390-392, 1979. [29. Handler RM, Medansky RS: Treatment of psoria sis with topical nitrogen mustard . Int J Derrnatol 18:758761, 1979. . 130. lancu L, Shneur A, Cohen H: Trials with xanthine derivatives in systemic treatment of psoriasis. Dermatologica 159:55-61 , 1979. 13\. Proctor MS, Wilkinson DI, Orenberg EK , ct al: Lowered cutaneous and urinary levels of polyamines with clinical improvement in treated psoriasis . Arch Derrnatol 115:945-949, 1979. [32. Bhutani LK , George M, Bhate SM: Vitamin A in the treatment of lichen planus pigrnentosu s. Br J Dermatol 100:473-477, 1979. 133. Sloberg K, Hersle K, Mobacken H, et al: Topical tretinoin therapy and oral lichen planus . Arch Dermatol 115:716-718, [979 . [34. Lynch PJ, Saied NK: Methotrexate treatment of pityriasis Iichenoides and lymphomatoid papulosis. Cutis 23:634-636, [979. 135. Price NM: Actinic keratoses treated with a combination of topical 5-fluorouracil and dinitrochlorobenzene . Dermatologica 158:279-286, 1979. 136. Reymann F: Treatment of basal cell carcinoma of the skin with 5-lluorouracil ointment. A 10-year follow-up study . Derrnatologica 158:368-372, 1979. 137. Odom RB , Goette DK: Treatment of keratoacanthomas with intralesional fluorouracil. Arch Dermatol 114: [779 -1783, 1978. 138. Hughes PSH: Cryosurgery of verrucou s carcinoma of the penis (Buschke-Lowcnstein tumor) . Cutis 24:43-45 , 1979. ' 139. DuVivier A: The treatment of cutaneous malignancies with topically applied cycloheximide. Br J Derrnatol 101:167-169, 1979. 140. Helm F, Helm J: Introduct ion to tumor immunotherapy. Int J Dermatol 18:205-210, 1979. 141. Mohs FE, Blanchard L: Microscopic ally controlled surgery for extrarnamrnary Paget 's disease. Arch Dermatol 115:706-708, 1979. 142. Dawber RPR, Wilkinson JD: Melanotic freckle of Hutchinson: Treatment of macular and nodular phases with cryotherapy. Br J Dermatol 101:47-49, 1979. 143. Nazzaro-Porro M, Passi S, Balus L, et al: Effect of dicarboxylic acids on lentigo malign a. J Invest Dermatol 72:296-305, 1979. 144. Pitman GH, Kopf AW, Bart RS, et al: Treatment of lentigo maligne and lentigo malign a melanoma. J Derrnatol Surg Oncol 5:727-737, 1979. [45. Molin L, Thomsen K, Volden G, et al: Mycosis fungoides plaque stage treated with topical nitrogen muslard with and without attempts to tolerance induction: Report from the Scandinavian mycosi s fungoides study group. Acta Derm Venereol (Stockh) 59:64-68, 1979. 146. Vonderheid EC , Van Scott EJ, Wallner PE, et al: A

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Kaposi's sarcoma, basal cell carcinoma and solar kerntosis with ointment of BCG and cord factor. Dermatologica 158:117-125, 1979. Kim R, Guerrero RC, Ho R: Treatment of Kaposi's sarcoma with bleomycin. Cutis 23:73-76, 1979. Soter NA, Austen KF, Wasserman S[: Oral disodium cromoglycate in the treatment of systemic mastocytosis . N Engl J Mcd 301:465-469, [979 . Zachariae H: Histiocytosis X in two infants treated with topical nitrogen mustard. Br J Dermatol 100:433-438, 1979. Penneys NS: Gold therapy: Dermatologic uses and toxicities . J AM ACAD DER~IATOL 1:315-320, 1979. Jaeyk WK: Treatment of pyoderma vegetans of Hallopeau with dapsone. Arch Dermatol 115: 1035-1036, [979. (Letter to the Editor.) Auerbach R, Bystryn JC: Plasmapheresis and immunosuppressive therapy. Effect of levels of intercellular antibodies in pemphigus vulgaris, Arch Dermatol 115:728-730, 1979. o 'Loughlin S, Goldman GC, Provost TT: Fnte ofpemphigus antibody following successful therapy. Preliminary evaluation of pemphigus antibody, determinations to regulate therapy, Arch Derrnatol 114:1769-1772, 1978. Bohr JB, Quirk CJ: Treatment of transient acantholytic dermatitis. Arch DermatoI115:1033-1034, 1979. (Letter to the Editor.) Livden JK, Nilsen R: Acquired epidermolysis bullosa treated with a gold compound. Acta Derm Vcnereol (Stockh) 59:378-379, 1979 . Kingham JGC, Swain P, Swarbrick ET, et al: Dapsone and severe hypoalbuminaerni a. Lancet 2:662-664, . 1979 . Limmer BL: Cryosurgery of porokeratosis plantaris discrete. Arch Dermatol 115:582-583, 1979. Mascaro JM, Lecha M, Torras H: Thalidomide in the treatment of recurrent, necrotic, and giant mucocutaneous aphthae and aphthosis. Arch Dermatol 115:636637, 1979. (Letter to the Editor.) Wiener SG: Injectable sodium chloride as a local anesthetic for skin surgery. Cutis 23:342-343, 1979. Burton JL, Etherington DJ, Peachey RDG: Collagen sponge for leg ulcers. Br J Dermatol 99:681-685, 1978. Olsson AG, Thyresson N: Healing of ischemic ulcers by intravenous prostaglandin E 1 in a woman with thromboangiitis obliterans. Acta Derm Venereol (Stockh) 58: 467-472, 1978. Parish LC, Collins E: pecubitus ulcers: A comparative study. Cutis 23: 106-110, 1979 . Apfelberg DB, Maser MR, Lash H: Extended clinical use of the argon laser for cutaneous lesions. Arch Derrnatol 115:719-721, 1979. Olsen TG, Milroy SK, Goldman L, et al: Laser surgery for blue rubber bleb nevus. Arch Dermatol 115:781782, 1979.

Journal of the American Academy of Dermatology

184. Goldman L: Laser treatment of multiple progressive glomangiomas. Arch Dermatol 114: 1853-1854, 1978. (Letter to the Editor.) 185. Kushner BJ: Local steroid therapy in adnexal hemangioma. J Dermatol Surg Oncol 5:775, 1979 . 186. Storrs FJ: Use and abuse of systemic corticosteroid therapy. J AM ACAD DER~IATOL 1:95 -105, 1979. 187 . Spiegel FJ , Oliff AI, Bruton J, et al : Adrenal suppression after short-term corticosteroid therapy. Lancet 1:630-633, 1979. 188. Kahn G, Rywlin AM : Acropustulosis of infancy. Arch Dermatol 115:831-833, 1979. 189. Hernandez-Perez, E: Vitiligo treated with ACTH. Int J Dermatol 18:578-579, 1979. 190. Oleske JM, Westphal ML, Shore S, et al: Zinc therapy of depressed cellular immunity in acrodermatitis entcropathica. Am J Dis Child 133:915-918, 1979. 191. Green R Jr, Martin DC: Treatment of Peyronie 's disease by dermal grafting. Plast Rcconstr Surg 64:208213, 1979. 192. Epstein E: A simple technique for managing digital mucous cysts. Arch Dermatol 115:1315-1316, 1979. 193. Sutherst JR: Treatment of pruritus vulvae by multiple intradermal infections of alcohol. A double-blind study . Br J Obstet Gynaecol 86:371-373, 1979. 194 . Wade TR: Chondrodermatitis nodularis chronica helicis. A review with emphasis on steroid therapy. Cutis 24:406-409, 1979. 195 . Tkach JR: Tretinoin treatment of Fox-Fordyce disease. Arch Dermatol 115: 1285, 1979 . (Letter to the Editor.) 196 . Giacobetti E, Caro WA, Roenigk HH: Fox-Fordyce disease . Arch Dermatol 115: 1365-1366, 1979 . 197. Brandrup F, Larsen PO: Axillary hyperhidrosis: Local treatment with aluminum chloride hexahydrate 25% in absolute ethanol. Acta Derm Venereol (Stockh) 58: 461-465, 1978 . 198 . Farber EM, South DA: Urea ointment in the nonsurgical avulsion of nail dystrophies. Cutis 22:689-692, 1978. 199 . Reed JC, Panzer JD, Panzer JJ: The noneffective ness of neomycin ointment when used prophylactically following skin electrodesiccation and curettage. Cutis 23: 823-827, 1979. 200 . Geronemus RG, Mertz PM, Eaglstein WH: Wound healing. The effects of topical antimicrobial agents. Arch DermatoII15:1311-[314, 1979 . 201. Cullen SI: Successful treatment of reactive perforating collagenosis with tretinoin, Cutis 23:187-193, 1979. 202. Babin RW, Ceilley RI: The combined use of cryosurgcry and intralesional injections of suspensions of fluorinated adrenocorticosteroids for reducing keloids and hypertrophic scars. J Dermatol Surg Oncol 5:54-57, 1979.