Perianal comedones associated with chronic topical fluorinated steroid use

Correspondence Thiothixene d r u g s e n s i t i v i t y To the Editor: Thiothixene is frequently used in the treatment of ,~chizophrenia and was formerly used to treat "anxiety states." This is no longer common practice because of the possibility of tardive dyskinesia. Adverse effects are not uncommon and include akathisia (restlessness), insomnia, and extrapyramidal or pseudo-Parkinson's symptoms. We report here a case of thiothixeneinduced skin lesions. Case report, A 3 l-year-old white woman was seen for an asymptomatic " r a s h " involving her palms. The patient had been treated with major tranquilizers, including phenothiazines, for an anxiety state during the previous 15 years. One month prior to the clinic visit, she had been placed on a regime of thiothixene, 40 rag, and benztropine, 3 nag, daily. The cutaneous lesions developed a few days following the initiation o f the psychotropic drugs. The skin lesions consisted of telangiectatic macules on the palms, most prominent over the hypothenar eminences (Fig. l). The macules were also evident on the palmar side of her fingers. The antinuclear antibody (ANA) test was positive at a titer of 1:80. The pattern of fluorescence was homogeneous. The following tests were normal: sedimentation rate, complete blood cell count, serum electrolytes, liver enzymes, creatine phosphokinase, aldolase, thyroid function tests, and urinalysis. A search for anti-DNA antibodies and the rheumatoid factor gave negative results. Due to the cutaneous eruption, the benztropine was discontinued and the thiothixene decreased to 10 rag/ day. Within 2 weeks the cutaneous lesions resolved and a repeat ANA test was negative. Seven months later, because of an exacerbation of the anxiety state, the thiothixene was increased to 40 nag daily. The palmar lesions recurred within 2 weeks. In addition, telangiectasias were observed in the V area of the chest. The patient's A N A was positive. Thiothixene was discontinued again, and the lesions promptly resolved. Comment. Thiothixene is a thioxanthene derivative. Cutaneous reactions due to this drug are rare. This patient's palmar erythema and telangiectasias appear to be manifestations of drug sensitivity. The skin lesions resolved when the dosage of thiothixene was decreased and exacerbated in response to rechallenge with a

Fig. 1. Erythematous macules on palms.

high dose. ANAs were also associated with the skin lesions.

Lois Y. Matsttoka, M.D. Division o f Dermatology Southern Illinois University School of Medicb~e P. O, Box 3926 Springfield, IL 62708

Perianal eomedones associated with chronic topical f l u o r i n a t e d s t e r o i d u s e

To the Editor: Topical steroid therapy is unquestionably one of the major therapeutic modalities currently employed in the treatment o f skin diseases. However, chronic use of high-potency topical steroids can be associated with a variety of deleterious effects. The following case demonstrates a possible association between the chronic use of a topical fluorinated steroid and a comedonal eruption involving the perianal area. Case report. A 62-year-old white diabetic man was referred to the Cinncinati Veterans Hospital Dermatology Clinic in September, 1980, for evaluation of a nodular perianal skin eruption. For 4 years, the patient Reprint requests to: Dr. Stephen A. Estes, University of Cincinnati Medical Center, Department of Dermatology, 319 Pavilion A, 234 Goodman Ave., Cincinnati, OH 45267.

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Fig. 1. Clinical photograph of the patient's perianal area showing numerous large open comedones extending distally from the anal canal.

Fig. 2. Photomicrograph of a biopsy specimen taken from the patient's perianal region demonstrates a keratin-filled comedo. (Original magnification, x 16.) experienced chronic diarrhea secondary to a spastic colon. Concurrent with his persistent diarrhea, he suffered with recalcitrant pruritus ani. For 3 years, the patient treated his anal area with 0.025% flurandrenolide cream used three to five times daily. A review of the Veterans Hospital Pharmacy records revealed that during the previous 4-month period the patient was dispensed 300 gm of the flurandrenolide cream. The patient was unaware of any skin lesions in his anal region. He had previously been seen in our

clinic in 1972 for a contact dermatitis to hexachlorophene. At that time, the dermatologic examination of the perianal region was normal. Physical examination revealed numerous large, open comedones scattered over the perianal region (Fig. 1). The lesions extended from the proximal margin of the appendage bearing stratified epithelium of the anal canal, distally to encircle the anus. No lesions were noted in the nonoccluded skin surfaces. Keratinous material was expressed from many of the lesions. A

Volume 7 Number 3 September, 1982

biopsy revealed a large keratin-filled comedo (Fig. 2). Additionally, the patient was noted to have an erythematous, scaly eruption involving the groin and the axilla, which under Wood's light examination showed aeoral red fluorescence consistent with the diagnosis of erythrasma. Discussion, Topical steroid therapy is known to be associated with multiple undesirable side effects. Among the side effects which have been previously reported are: striae, cutaneous atrophy, steroid rosacea, perioral dermatitis, acne, adrenal suppression, aggravation of cutaneous infections, ocular hypertension, glaucoma, cataracts, hypertrichosis, hypopigmentation, and allergic contact dermatitis.l-3 This case illustrates an example of a perianal comedonal eruption associated with chronic fluorinated steroid use. Steroid ache lesions and acne vulgaris lesions evolve via different pathophysiologic mechanisms. In ache vulgaris, one of the initial pathologic changes is abnormal keratinization of the follicular epithelium. In steroid ache, the preliminary event is necrosis and ruppare of a segment of the follicular epithelium. This disruption of the follicular wall leads to perifollicular abscess formation. 4 It is the perifollicular abscess, represented clinically as the monomorphic papulopustule, which is generally considered to be the hallmark lesion 0fstemid acne. Comedones, the primary lesion of acne vulgaris, may also be present in steroid acne eruptions. Topical steroids induce comedo formation by rendering the follicular epithelium more responsive to the comed0genic effects of s e b u m ? '~'* Comedo formation occurs over a period of months and may evolve into the dominant lesion in the late stages of steroid acne.* Additionally, many topical steroid vehicles are themselves comedogenic and capable of inducing acneiform lesions? Surprisingly, this patient initially presented without prior evidence of a papulopustular eruption. One explanation for this could be that because of the location, Se patient may have gone through an inflammatory phase without being aware of it. An alternate explanation by Kaidbey and Kligman 4 described how chronic use of potent topical steroids can lead to comedo formation without prior inflammatory lesions. They stated that the steroid suppresses the inflammation associated with the rupture of the follicular wall. Thus, the initial inflammatory phase of the steroid acne eruption may clinically be undetectable. Why was this patient's skin eruption so well lo*KligmanAM, Mills OH Jr: Steroid acne. Dermatology& Allergy 2:27-28, 1979.

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calized? Perhaps the occlusive conditions of the involved areas enhanced the percutaneous absorption o f the fluorinated steroid. This m a y have accentuated the comedogenic effect and explain why contiguous nonoccluded skin was spared. This case of topical steroid-induced acne in the perianal area should alert the clinician to another possible effect of chronic fluorinated steroid usage in this region.

Eric J. Oliet, M.D. Stephen A. Estes, M.D. Department of Delwzatology Universi~ of Cineitmati Medical Center Citwinnati, OH 45267

REFERENCES 1. Bondi EE, Kligman AM: Adverse effects of topical corticosteroids. Prog Dermatol 14: 1-4, 1980. 2. Feiwel M, James VHT, Barnett ES: Effect of potent top[cal steroids on plasma-cortisol levels of infants and children with eczema. Lancet 1:485-487, I969. 3. Sneddon I: Perioral dermatitis. Br J Dermatol 87:430-434, 1972. 4. Kaidbey K, Kligman AM: The pathogenesis of topical steroid acne. J Invest Dermatol 62:31-36, 1974. 5. Mills OH Jr, Kligman AM: Acnegenicity of corticosteroids: Mode of action. Clin Res 22:330, 1974. (Abst.)

Safety of gamma benzene hexachioride To the Editor: The articles by Drs, Rasmussen and Shatter, which appeared on pages 507 and 517 of the November, 1981, issue of the JOURNAL, are certainly timely in view of the controversy that has been brewing over the safety of gamma benzene hexachloride (GBH). Your readers might be interested in knowing that in Canada since 1960 GBH (Kwellada in Canada) has been available from the pharmacist without need for prescription. This ready access to GBH would tend to favor inappropriate use, and this certainly has been my experience. In over eleven years of practice I have seen numerous individuals who have used GBH for extended periods, often on the advice of friends or because of self-conceived ideas about infestation. Both pregnant women and infants have been doused with many treatments, all without any significant ill effect. There have been many cases of irritancy and a rare contact dermatitis. This is not surprising since both Kwellada cream and lotion contain parabens and also fragrance. Even under medical supervision it is difficult to control strictly the rate of application since the patient can readily obtain more GBH and continue treatment on