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Successful treatment of geographic tongue with tacrolimus 0.1% ointment
P574
P576
SUCCESSFUL TREATMENT OF GEOGRAPHIC TONGUE WITH TACROLIMUS 0.1% OINTMENT Shane Silver, MD, Department of Dermatology, Health Science Center, Winnipeg, MB, Canada
SWEET’S SYNDROME FOLLOWING ORAL TERBINAFINE THERAPY: A CASE REPORT Avinash Belgi, MD, Maria Konstantopoulou, Andrew Macfarlane, MBChB, Department of Dermatology, Bangor, Wales
Geographic tongue is a common, benign clinical condition of unknown etiology with the histology very similar to psoriasis. It is usually asymptomatic, although some patients may experience significant burning sensation or sensitivity with active disease.
Sweet’s syndrome is usually idiopathic but it may be caused by drugs. We report a case associated with terbinafine treatment. Three weeks after starting oral terbinafine for onychomycosis, a 66-year-old white woman presented with acutely painful, erythematous plaques and papulopustular lesions on the photoexposed areas of her arms, legs, and chest, with malaise and intermittent fever up to 398C. There was no significant past medical history, and her only other medication was longstanding celecoxib for osteoarthritis. Laboratory studies revealed a marked neutrophilia (15.7 3 109/L), moderate rise in inflammatory markers (erythrocyte sedimentation rate 48 mm/hr, C-reactive protein 120 mg/L), significantly raised transaminases (aspartate aminotransferase 115 IU/L, alanine aminotransferase 174 IU/L), and alkaline phosphatase. Renal function, chest radiograph, blood cultures, and infection and hepatitis screen were normal or negative. Skin biopsy showed pronounced dermal oedema and a marked dermal neutrophilic infiltrate centred on blood vessels, without frank vasculitis. Druginduced Sweet’s syndrome was diagnosed. She required hospitalisation for 17 days and prednisolone 60 mg/day for 10 days before tapering. Transaminases normalised from day 9. Her skin slowly settled but she still had residual blanchable erythematous lesions on review on day 39. Terbinafine is an allylamine fungicidal agent widely used for the treatment of dermatophyte infections including onychomycosis. Adverse effects may occur in 11% of patients, with skin reactions in 2.7%. Serious skin reactions include toxic epidermal necrolysis, Stevens-Johnson syndrome, subacute cutaneous lupus erythematosus, acute generalised exanthematous pustulosis, and psoriasis. Sweet’s syndrome has been reported in association with celecoxib, trimethoprimsulphamethoxazole, oestrogens, tetracyclines, diazepam, diclofenac, carbamazepine and others, and especially with GCSF. (Our patient had been on celecoxib for several months with no previous problems.) The raised transaminases may have been caused by direct drug toxicity rather than mediated via the Sweet’s syndrome. It has been postulated that terbinafine-associated skin eruptions may last longer than average because of its slow elimination from the skin after the last dose. There has been an increase in reports of drug-induced Sweet’s syndrome in recent years and a careful drug history should be obtained in all cases. We report the first case of Sweet’s syndrome in association with terbinafine.
Topical tacrolimus is a steroid-free immunomodulator approved for the treatment of atopic dermatitis, but has been used off-label for many dermatologic conditions. It has been efficacious in patients with inverse and facial psoriasis due to decreased skin thickness and occlusion. Its use in some mucosal diseases is well documented. This is a unique case report of a 68-year-old woman with symptomatic biopsye proven geographic tongue, which was successfully treated with the application of tacrolimus 0.1 % ointment twice daily. Both burning sensation and objective signs of disease would clear completely within 1 week of application. The patient continues to use tacrolimus 0.1% ointment intermittently for symptomatic relief. This case illustrates that tacrolimus ointment can be used successfully in the treatment of symptomatic geographic tongue. Nothing to disclose.
Nothing to disclose.
P575 SURVEY OF ANTIBIOTIC PRESCRIPTION USE FOR INFLAMED EPIDERMAL INCLUSION CYSTS Tasneem Poonawalla, PhmD, University of Texas Medical Branch at Galveston, Dickinson, TX, United States; Dayna Diven, MD, University of Texas Medical Branch at Galveston, Galveston, TX, United States Background: Symptomatic epidermal inclusion cysts (EICs) are variously referred to as ‘‘inflamed’’ or ‘‘infected’’ in the literature. The lack of consensus hinges on the mechanism for the inflammation and suppuration of EICs, which is still not fully understood. Recent studies have suggested that bacterial infection is perhaps a less likely cause for the inflammation, and alternative mechanisms have been presented. The extent of antibiotic treatment of EICs is uncertain, and is of potential concern because of patient financial burden and bacterial resistance. Methods: The extent of antibiotic prescription was assessed by conducting a survey of practicing general practitioners and dermatologists using a standard case study and photo of a representative patient. Each physician that agreed to participate in the study was shown the picture of the EIC, narrated the clinical scenario, and then asked to complete questions on a data collection form about diagnosis and treatment. The responses were used to evaluate the rate of antibiotic treatment for both the general practitioners and the dermatologists, and to estimate the financial impact of any antibiotic prescriptions. Results: One hundred twenty-five general practitioners and 52 dermatologists were surveyed. Ninety-four percent of the general practitioners and 100% of the dermatologists used the term cyst for diagnosis. Sixty-seven percent of the general practitioners used the term infected, while 69% of the dermatologists used the term inflamed or ruptured. Seventy-five percent of the general practitioners used the term sebaceous, while 84.6% of dermatologists used the term epidermal and inclusion. All of the physicians agreed that the lesion needed to be treated, and 70% of the physicians agreed upon incision and drainage. Eighty-four percent of the general practitioners and 94% of the dermatologists wanted to use antibiotics.
P577 SYSTEMIC EXPOSURE TO LIDOCAINE AND TETRACAINE IS LOW AFTER APPLICATION OF A LIDOCAINE 7% AND TETRACAINE 7% PEEL IN ADULTS Lazarre Ogden, MD, University of Utah Health Science Center, Salt Lake City, UT, United States Objective: The lidocaine 7% and tetracaine 7% (LT) peel is a self-occlusive topical local anesthesic that has been studied for a variety of dermatologic procedures. The LT peel applies as a cream and, when exposed to air, dries and forms a flexible membrane that can be easily peeled off. Reported here are the pharmacokinetics and safety of the LT peel after a single administration in adult volunteers. Methods: This was a randomized, factorial design study to evaluate the pharmacokinetic profile of the LT peel after a single application in adult volunteers (N = 36; mean age 26.6 years). The LT peel was applied to the anterior surface of the left or right thigh of volunteers for 30, 60, or 90 minutes over a 50-, 100-, or 200-cm2 area. Plasma samples were collected at 0, 30, 60, 90, 120, 150, 180, 210, 300, and 420 minutes after the initial application of the LT peel. Samples were analyzed for lidocaine and tetracaine via a validated gas chromatographic method.
Conclusion: This study shows that despite the differences between general practitioners and dermatologists in the diagnosis of inflamed EICs, there are no major differences in treatment. We also see that the majority of all physicians use antibiotics to treat these lesions, which increases the cost and exposure to the patient as well as a risk for increasing antimicrobial resistance. A prospective study would be helpful to see if antibiotics are necessary.
Results: The concentrations of lidocaine and tetracaine at all time points were below the limit of quantitation for the assay: 100 ng/mL and 5 ng/mL, respectively. Because of the lack of concentrations above the limit of quantitation, it was not possible to determine pharmacokinetic parameters other than Cmax \ 100 ng/mL for lidocaine and Cmax \ 5 ng/mL for tetracaine. The LT peel was well tolerated. Conclusion: These pharmacokinetic data showing no detectable levels of lidocaine and tetracaine suggest that the LT peel can be applied to relatively large surface areas with limited systemic exposure.
Nothing to disclose.
100 percent supported by ZARS company
P60
J AM ACAD DERMATOL
MARCH 2005
P576
SUCCESSFUL TREATMENT OF GEOGRAPHIC TONGUE WITH TACROLIMUS 0.1% OINTMENT Shane Silver, MD, Department of Dermatology, Health Science Center, Winnipeg, MB, Canada
SWEET’S SYNDROME FOLLOWING ORAL TERBINAFINE THERAPY: A CASE REPORT Avinash Belgi, MD, Maria Konstantopoulou, Andrew Macfarlane, MBChB, Department of Dermatology, Bangor, Wales
Geographic tongue is a common, benign clinical condition of unknown etiology with the histology very similar to psoriasis. It is usually asymptomatic, although some patients may experience significant burning sensation or sensitivity with active disease.
Sweet’s syndrome is usually idiopathic but it may be caused by drugs. We report a case associated with terbinafine treatment. Three weeks after starting oral terbinafine for onychomycosis, a 66-year-old white woman presented with acutely painful, erythematous plaques and papulopustular lesions on the photoexposed areas of her arms, legs, and chest, with malaise and intermittent fever up to 398C. There was no significant past medical history, and her only other medication was longstanding celecoxib for osteoarthritis. Laboratory studies revealed a marked neutrophilia (15.7 3 109/L), moderate rise in inflammatory markers (erythrocyte sedimentation rate 48 mm/hr, C-reactive protein 120 mg/L), significantly raised transaminases (aspartate aminotransferase 115 IU/L, alanine aminotransferase 174 IU/L), and alkaline phosphatase. Renal function, chest radiograph, blood cultures, and infection and hepatitis screen were normal or negative. Skin biopsy showed pronounced dermal oedema and a marked dermal neutrophilic infiltrate centred on blood vessels, without frank vasculitis. Druginduced Sweet’s syndrome was diagnosed. She required hospitalisation for 17 days and prednisolone 60 mg/day for 10 days before tapering. Transaminases normalised from day 9. Her skin slowly settled but she still had residual blanchable erythematous lesions on review on day 39. Terbinafine is an allylamine fungicidal agent widely used for the treatment of dermatophyte infections including onychomycosis. Adverse effects may occur in 11% of patients, with skin reactions in 2.7%. Serious skin reactions include toxic epidermal necrolysis, Stevens-Johnson syndrome, subacute cutaneous lupus erythematosus, acute generalised exanthematous pustulosis, and psoriasis. Sweet’s syndrome has been reported in association with celecoxib, trimethoprimsulphamethoxazole, oestrogens, tetracyclines, diazepam, diclofenac, carbamazepine and others, and especially with GCSF. (Our patient had been on celecoxib for several months with no previous problems.) The raised transaminases may have been caused by direct drug toxicity rather than mediated via the Sweet’s syndrome. It has been postulated that terbinafine-associated skin eruptions may last longer than average because of its slow elimination from the skin after the last dose. There has been an increase in reports of drug-induced Sweet’s syndrome in recent years and a careful drug history should be obtained in all cases. We report the first case of Sweet’s syndrome in association with terbinafine.
Topical tacrolimus is a steroid-free immunomodulator approved for the treatment of atopic dermatitis, but has been used off-label for many dermatologic conditions. It has been efficacious in patients with inverse and facial psoriasis due to decreased skin thickness and occlusion. Its use in some mucosal diseases is well documented. This is a unique case report of a 68-year-old woman with symptomatic biopsye proven geographic tongue, which was successfully treated with the application of tacrolimus 0.1 % ointment twice daily. Both burning sensation and objective signs of disease would clear completely within 1 week of application. The patient continues to use tacrolimus 0.1% ointment intermittently for symptomatic relief. This case illustrates that tacrolimus ointment can be used successfully in the treatment of symptomatic geographic tongue. Nothing to disclose.
Nothing to disclose.
P575 SURVEY OF ANTIBIOTIC PRESCRIPTION USE FOR INFLAMED EPIDERMAL INCLUSION CYSTS Tasneem Poonawalla, PhmD, University of Texas Medical Branch at Galveston, Dickinson, TX, United States; Dayna Diven, MD, University of Texas Medical Branch at Galveston, Galveston, TX, United States Background: Symptomatic epidermal inclusion cysts (EICs) are variously referred to as ‘‘inflamed’’ or ‘‘infected’’ in the literature. The lack of consensus hinges on the mechanism for the inflammation and suppuration of EICs, which is still not fully understood. Recent studies have suggested that bacterial infection is perhaps a less likely cause for the inflammation, and alternative mechanisms have been presented. The extent of antibiotic treatment of EICs is uncertain, and is of potential concern because of patient financial burden and bacterial resistance. Methods: The extent of antibiotic prescription was assessed by conducting a survey of practicing general practitioners and dermatologists using a standard case study and photo of a representative patient. Each physician that agreed to participate in the study was shown the picture of the EIC, narrated the clinical scenario, and then asked to complete questions on a data collection form about diagnosis and treatment. The responses were used to evaluate the rate of antibiotic treatment for both the general practitioners and the dermatologists, and to estimate the financial impact of any antibiotic prescriptions. Results: One hundred twenty-five general practitioners and 52 dermatologists were surveyed. Ninety-four percent of the general practitioners and 100% of the dermatologists used the term cyst for diagnosis. Sixty-seven percent of the general practitioners used the term infected, while 69% of the dermatologists used the term inflamed or ruptured. Seventy-five percent of the general practitioners used the term sebaceous, while 84.6% of dermatologists used the term epidermal and inclusion. All of the physicians agreed that the lesion needed to be treated, and 70% of the physicians agreed upon incision and drainage. Eighty-four percent of the general practitioners and 94% of the dermatologists wanted to use antibiotics.
P577 SYSTEMIC EXPOSURE TO LIDOCAINE AND TETRACAINE IS LOW AFTER APPLICATION OF A LIDOCAINE 7% AND TETRACAINE 7% PEEL IN ADULTS Lazarre Ogden, MD, University of Utah Health Science Center, Salt Lake City, UT, United States Objective: The lidocaine 7% and tetracaine 7% (LT) peel is a self-occlusive topical local anesthesic that has been studied for a variety of dermatologic procedures. The LT peel applies as a cream and, when exposed to air, dries and forms a flexible membrane that can be easily peeled off. Reported here are the pharmacokinetics and safety of the LT peel after a single administration in adult volunteers. Methods: This was a randomized, factorial design study to evaluate the pharmacokinetic profile of the LT peel after a single application in adult volunteers (N = 36; mean age 26.6 years). The LT peel was applied to the anterior surface of the left or right thigh of volunteers for 30, 60, or 90 minutes over a 50-, 100-, or 200-cm2 area. Plasma samples were collected at 0, 30, 60, 90, 120, 150, 180, 210, 300, and 420 minutes after the initial application of the LT peel. Samples were analyzed for lidocaine and tetracaine via a validated gas chromatographic method.
Conclusion: This study shows that despite the differences between general practitioners and dermatologists in the diagnosis of inflamed EICs, there are no major differences in treatment. We also see that the majority of all physicians use antibiotics to treat these lesions, which increases the cost and exposure to the patient as well as a risk for increasing antimicrobial resistance. A prospective study would be helpful to see if antibiotics are necessary.
Results: The concentrations of lidocaine and tetracaine at all time points were below the limit of quantitation for the assay: 100 ng/mL and 5 ng/mL, respectively. Because of the lack of concentrations above the limit of quantitation, it was not possible to determine pharmacokinetic parameters other than Cmax \ 100 ng/mL for lidocaine and Cmax \ 5 ng/mL for tetracaine. The LT peel was well tolerated. Conclusion: These pharmacokinetic data showing no detectable levels of lidocaine and tetracaine suggest that the LT peel can be applied to relatively large surface areas with limited systemic exposure.
Nothing to disclose.
100 percent supported by ZARS company
P60
J AM ACAD DERMATOL
MARCH 2005