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Topical 5% imiquimod treatment for refractory cutaneous warts1
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P163
THE YEAR AT PARKLAND HOSPITAL (2004) Whitney A High, MD, UTSW Medical Center, Dallas, TX, United States, Carrie Kovarik, MD, UTSW Medical Center, Dallas, TX, United States Parkland Memorial Hospital (PMH) is the primary indigent care hospital for Dallas County, Texas, USA. This poster is the twelfth in a consecutive series of annual clinicopathological presentations of extraordinary patients seen throughout the year at PMH. Cases to be discussed herein include: cutaneous disseminated tuberculosis in a previously undiagnosed HIV-positive man, a newborn girl with Conradi-Hunermann disease, a middle-aged man with metastatic melanoma presenting with melanouria, a Mexican national with a seizure disorder presenting with Koenen tumors and undiagnosed tuberous sclerosis, a young girl immigrating from Afghanistan with cutaneous leishmaniasis, and a middle-aged woman with Hailey-Hailey disease.
EVIDENCE-BASED RECOMMENDATIONS FOR RECOGNITION AND DIAGNOSIS OF PRIMARY FOCAL HYPERHIDROSIS John C Hornberger, MD, MS, Acumen, LLC; Stanford University, Burlingame, CA, United States, Hans Naver, MD, Uppsala University Hospital, Uppsala, Syria, Lewis P Stolman, MD, University of Medicine and Dentistry of New Jersey, New Jersey, NJ, Kevin Grimes, MD, Acumen, LLC, Burlingame, CA, United States Background: Approximately 1% of the US population suffers from hyperhidrosis that impairs daily activities (Strutton, 2003). However, there is limited summary information in the medical literature on the recognition and diagnosis hyperhidrosis, and particularly primary focal hyperhidrosis. Such information, especially from an evidence-based perspective, would be valuable for physicians and other health care professionals. Methods: A multi-specialty working group of 26 internationally recognized experts reviewed the clinical evidence and developed recommendations on recognition and evaluation of hyperhidrosis. The working group employed an evidence-based approach, performing a comprehensive literature search of English language articles between 1966 and 2002. The working group met for 2 days to appraise evidence reports. Recommendations were drafted and discussed, followed by a vote of the working group. Results: 1,240 publications were identified. Among 15 controlled trials, 1 study was randomized by patient and 14 studies were randomized by anatomical side of treatment administration. There were 60 observational studies or case series. No clinical guideline had been published on this subject. This working group defined the condition and drafted 4 recommendations on recognition of (n ⫽ 1) and evaluation (n ⫽ 3) of a patient presenting with hyperhidrosis. When performing a medical evaluation, the review of systems should include questions regarding problematic excessive sweating. The history should include questions about the pattern of sweating, age of onset, impact on daily activities/quality of life, family history, and a review of systems to exclude secondary causes. The physical examination should focus on visible evidence of excessive sweating in the characteristic locations and on signs suggesting a secondary cause of hyperhidrosis. Laboratory tests are not needed if the presentation is characteristic of primary focal hyperhidrosis, such as bilateral and relatively symmetric involving focal axillae, palms, soles, or face, typical age of onset, no evidence of secondary causes by history and physical examination. Tests quantifying sweat production are not practically nor routinely performed in clinical practice. Conclusion: A multi-specialty, international working group achieved consensus on a large number of clinical recommendations, the dissemination of which should assist physicians to provide, and their patients to obtain, more appropriate referral and care.
The authors have no conflicts of interest to disclose.
P162 PLASMA CELL BALANITIS SUCCESSFULLY TREATED WITH TACROLIMUS 0.1% OINTMENT Gerardo A Moreno-Arias, MD, Centro Medico Teknon/Espitau Vall d’Aran, Barcelona, Spain, Alejandro Camps-Fresneda, MD, PhD, Hospital General de Catalunya, Sant Cugat del Valle`s (Barcelona), Spain, Josep Palou-Almerich, MD, Hospital Clı´nic i Provincial de Barcelona, Barcelona, Spain, Carles Llaberia, MD, Laboratori d’Histopatologia i Citologia, Barcelona, Spain Plasma cell balanitis or balanitis of Zoon (BZ) was originally described by Zoon in 19721. BZ is a frequent diagnosis in mature men and lesions are generally localized on the glans but may involve the prepuce2. Etiology remains unknown, however Weyers et al have suggested that BZ is a non-specific inflammatory reactive pattern that may occur as an isolated finding or complicate other skin diseases (i.e. lichen plannus, contact dermatitis, psoriasis) of the glans penis or prepuce in uncircumcised aged men. Moreover, BZ may result from irritation or mild trauma affecting keratinized skin in a moist environment3. The clinical picture is characterized by a sharply demarcated, shinny, erythematous or red-brown, asymptomatic plaque affecting the glans penis and prepuce. Differential diagnosis should be done with lichen planus, erytroplasia of Queyrat, squamous cell carcinoma, contact dermatitis, and psoriasis3. Treatment alternatives include topical steroids4, fusidic acid5, tannic acid6, laser7,8, and circumcision9. Tacrolimus was the first non-steroidal topical immunomodulator developed for treatment of atopic dermatitis10. Efficacy/safety profile, lack of rebound effect and absence of tachyphylaxis are some of the tacrolimus attractive properties that prompted dermatologists to prescribe it in the treatment of other skin conditions11. The aim of this poster is to present our experience with tacrolimus 0.1% ointment in the treatment of two patients with balanitis of Zoon refractive to other topical treatments. References 1. Zoon JJ. Balanoposthite chronique circonscrite be´nigne `a plasmocytes. Dermatologica 1972;105:1-7. 2. Braun-Falco O, Plewig G, Wolff HH, Burgdorf WH. Dermatology. Springler: Berlin, 2002. Second edition. 3. Weyers W, Ende Y, Schalla W, Diaz-Cascajo C. Balanitis of zoon: a clinicopathologic study of 45 cases. Am J Dermatopathol 2002;24:459-67. 4. Tang A, David N, Horton LW. Plasma cell balanitis of Zoon: response to Trimovate cream. Int J STD AIDS 2001;12:75-8. 5. Petersen CS, Thomsen K. Fusidic acid cream in the treatment of plasma cell balanitis. J Am Acad Dermatol 1992;27:633-4. 6. Altmeyer P. Therapielexicon. Dermatologie und Allergologie. Springer:Berlin, 1997. 7. Baldwin HE, Geronemus RG. The treatment of Zoon’s balanitis with the carbon dioxide laser. J Dermatol Surg Oncol 1989;15:491-4. 8. Aynaud O, Casanova JM, Tranbaloc P. CO2 laser for therapeutic circumcision in adults. Eur Urol 1995;28:74-6. 9. Kumar B, Sharma R, Rajagopalan M, Radotra BD. Plasma cell balanitis: clinical and histopathological features--response to circumcision. Genitourin Med 1995;71:32-4. 10. Worm M. Novel therapies for atopic eczema. Curr Opin Investig Drugs. 2002;3:1596603. 11. Sugerman JH, Fleisher AB, Feldman SR. Off-label prescribing in the treatment of dermatologic diseases. J Am Acad Dermatol 2002;47:217-22.
TOPICAL 5% IMIQUIMOD TREATMENT FOR REFRACTORY CUTANEOUS WARTS Conal M Perrett, MB, ChB, Centre for Cutaneous Research, London, England, Catherine Harwood, MBBS, PhD, Centre for Cutaneous Research, London, England, Victoria Brown, MBBCh, Centre for Cutaneous Research, London, England, Charlotte Proby, MBBS, Centre for Cutaneous Research, London, England Extensive viral warts are a cause of significant morbidity, particularly in individuals unable to mount an adequate Th1 cell mediated immune response to human papillomavirus. Imiquimod belongs to a new class of immune response modifiers which are potent inducers of antiviral cytokine activity, principally interferon alpha. Imiquimod cream has shown significant efficacy compared with placebo in double-blind controlled studies of genital warts, but similar efficacy in cutaneous warts is not yet established. In this study, we assess the response of refractory cutaneous warts to imiquimod cream. Twelve patients with viral warts (palmoplantar warts, n ⫽ 10; and/or plane warts, n ⫽ 5) persisting for ⬎18 months which had failed to respond to a minimum of ⬎3 months of keratolytics and 4 cycles of cryotherapy were recruited (renal transplant recipients, n ⫽ 10; Hodgkins disease, n ⫽ 1; T-cell immunodeficiency, n ⫽ 1). Imiquimod was applied in a right versus left comparison, initially 3 times a week for 8 weeks, then daily for 8 weeks, then daily with occlusion for 8 weeks, depending on response. Complete clearance occured in one patient and ⬎75% clearance in a second. Although warts persisted in the remaining 10 patients, 4 experienced variable symptomatic improvement. Local skin reactions were infrequent, but transient rises in creatinine were observed in 3 transplant recipients (11.7-29% above baseline) of whom 2 were successfully rechallenged, without further problem. In conclusion, we provide preliminary evidence that topical imiquimod may benefit a subgroup of patients with refractory cutaneous warts. Treatment failures may partly reflect reduced penetration of the drug resulting from greater keratinisation of cutaneous warts, despite use of occlusion; trials of combined treatment with keratolytics and/or cryotherapy are now justified. Finally, until further data is available, we suggest that renal function should be closely monitored in renal transplant recipients receiving topical imiquimod.
The authors declare neither significant financial interest nor other relationship with the manufacturer of tacrolimus 0.1% ointment.
Disclosure not available at press time. 3M Health Care provided £500 and the topical 5% Imiquimod for this study.
MARCH 2004
Conflicts of Interest: (1) Each author received honoraria for attending and participating in the consensus statement development process. (2) With the exception of the Chair and Co-Chair of this committee, committee members are employed or derive income from the practice of medicine involving consultation or use of procedures to manage patients with hyperhidrosis. (3) Dr. Hornberger is Clinical Professor of Medicine at Stanford University School of Medicine, and derives no clinical income. 100 percent sponsored by Allergan, Inc.
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J AM ACAD DERMATOL
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P163
THE YEAR AT PARKLAND HOSPITAL (2004) Whitney A High, MD, UTSW Medical Center, Dallas, TX, United States, Carrie Kovarik, MD, UTSW Medical Center, Dallas, TX, United States Parkland Memorial Hospital (PMH) is the primary indigent care hospital for Dallas County, Texas, USA. This poster is the twelfth in a consecutive series of annual clinicopathological presentations of extraordinary patients seen throughout the year at PMH. Cases to be discussed herein include: cutaneous disseminated tuberculosis in a previously undiagnosed HIV-positive man, a newborn girl with Conradi-Hunermann disease, a middle-aged man with metastatic melanoma presenting with melanouria, a Mexican national with a seizure disorder presenting with Koenen tumors and undiagnosed tuberous sclerosis, a young girl immigrating from Afghanistan with cutaneous leishmaniasis, and a middle-aged woman with Hailey-Hailey disease.
EVIDENCE-BASED RECOMMENDATIONS FOR RECOGNITION AND DIAGNOSIS OF PRIMARY FOCAL HYPERHIDROSIS John C Hornberger, MD, MS, Acumen, LLC; Stanford University, Burlingame, CA, United States, Hans Naver, MD, Uppsala University Hospital, Uppsala, Syria, Lewis P Stolman, MD, University of Medicine and Dentistry of New Jersey, New Jersey, NJ, Kevin Grimes, MD, Acumen, LLC, Burlingame, CA, United States Background: Approximately 1% of the US population suffers from hyperhidrosis that impairs daily activities (Strutton, 2003). However, there is limited summary information in the medical literature on the recognition and diagnosis hyperhidrosis, and particularly primary focal hyperhidrosis. Such information, especially from an evidence-based perspective, would be valuable for physicians and other health care professionals. Methods: A multi-specialty working group of 26 internationally recognized experts reviewed the clinical evidence and developed recommendations on recognition and evaluation of hyperhidrosis. The working group employed an evidence-based approach, performing a comprehensive literature search of English language articles between 1966 and 2002. The working group met for 2 days to appraise evidence reports. Recommendations were drafted and discussed, followed by a vote of the working group. Results: 1,240 publications were identified. Among 15 controlled trials, 1 study was randomized by patient and 14 studies were randomized by anatomical side of treatment administration. There were 60 observational studies or case series. No clinical guideline had been published on this subject. This working group defined the condition and drafted 4 recommendations on recognition of (n ⫽ 1) and evaluation (n ⫽ 3) of a patient presenting with hyperhidrosis. When performing a medical evaluation, the review of systems should include questions regarding problematic excessive sweating. The history should include questions about the pattern of sweating, age of onset, impact on daily activities/quality of life, family history, and a review of systems to exclude secondary causes. The physical examination should focus on visible evidence of excessive sweating in the characteristic locations and on signs suggesting a secondary cause of hyperhidrosis. Laboratory tests are not needed if the presentation is characteristic of primary focal hyperhidrosis, such as bilateral and relatively symmetric involving focal axillae, palms, soles, or face, typical age of onset, no evidence of secondary causes by history and physical examination. Tests quantifying sweat production are not practically nor routinely performed in clinical practice. Conclusion: A multi-specialty, international working group achieved consensus on a large number of clinical recommendations, the dissemination of which should assist physicians to provide, and their patients to obtain, more appropriate referral and care.
The authors have no conflicts of interest to disclose.
P162 PLASMA CELL BALANITIS SUCCESSFULLY TREATED WITH TACROLIMUS 0.1% OINTMENT Gerardo A Moreno-Arias, MD, Centro Medico Teknon/Espitau Vall d’Aran, Barcelona, Spain, Alejandro Camps-Fresneda, MD, PhD, Hospital General de Catalunya, Sant Cugat del Valle`s (Barcelona), Spain, Josep Palou-Almerich, MD, Hospital Clı´nic i Provincial de Barcelona, Barcelona, Spain, Carles Llaberia, MD, Laboratori d’Histopatologia i Citologia, Barcelona, Spain Plasma cell balanitis or balanitis of Zoon (BZ) was originally described by Zoon in 19721. BZ is a frequent diagnosis in mature men and lesions are generally localized on the glans but may involve the prepuce2. Etiology remains unknown, however Weyers et al have suggested that BZ is a non-specific inflammatory reactive pattern that may occur as an isolated finding or complicate other skin diseases (i.e. lichen plannus, contact dermatitis, psoriasis) of the glans penis or prepuce in uncircumcised aged men. Moreover, BZ may result from irritation or mild trauma affecting keratinized skin in a moist environment3. The clinical picture is characterized by a sharply demarcated, shinny, erythematous or red-brown, asymptomatic plaque affecting the glans penis and prepuce. Differential diagnosis should be done with lichen planus, erytroplasia of Queyrat, squamous cell carcinoma, contact dermatitis, and psoriasis3. Treatment alternatives include topical steroids4, fusidic acid5, tannic acid6, laser7,8, and circumcision9. Tacrolimus was the first non-steroidal topical immunomodulator developed for treatment of atopic dermatitis10. Efficacy/safety profile, lack of rebound effect and absence of tachyphylaxis are some of the tacrolimus attractive properties that prompted dermatologists to prescribe it in the treatment of other skin conditions11. The aim of this poster is to present our experience with tacrolimus 0.1% ointment in the treatment of two patients with balanitis of Zoon refractive to other topical treatments. References 1. Zoon JJ. Balanoposthite chronique circonscrite be´nigne `a plasmocytes. Dermatologica 1972;105:1-7. 2. Braun-Falco O, Plewig G, Wolff HH, Burgdorf WH. Dermatology. Springler: Berlin, 2002. Second edition. 3. Weyers W, Ende Y, Schalla W, Diaz-Cascajo C. Balanitis of zoon: a clinicopathologic study of 45 cases. Am J Dermatopathol 2002;24:459-67. 4. Tang A, David N, Horton LW. Plasma cell balanitis of Zoon: response to Trimovate cream. Int J STD AIDS 2001;12:75-8. 5. Petersen CS, Thomsen K. Fusidic acid cream in the treatment of plasma cell balanitis. J Am Acad Dermatol 1992;27:633-4. 6. Altmeyer P. Therapielexicon. Dermatologie und Allergologie. Springer:Berlin, 1997. 7. Baldwin HE, Geronemus RG. The treatment of Zoon’s balanitis with the carbon dioxide laser. J Dermatol Surg Oncol 1989;15:491-4. 8. Aynaud O, Casanova JM, Tranbaloc P. CO2 laser for therapeutic circumcision in adults. Eur Urol 1995;28:74-6. 9. Kumar B, Sharma R, Rajagopalan M, Radotra BD. Plasma cell balanitis: clinical and histopathological features--response to circumcision. Genitourin Med 1995;71:32-4. 10. Worm M. Novel therapies for atopic eczema. Curr Opin Investig Drugs. 2002;3:1596603. 11. Sugerman JH, Fleisher AB, Feldman SR. Off-label prescribing in the treatment of dermatologic diseases. J Am Acad Dermatol 2002;47:217-22.
TOPICAL 5% IMIQUIMOD TREATMENT FOR REFRACTORY CUTANEOUS WARTS Conal M Perrett, MB, ChB, Centre for Cutaneous Research, London, England, Catherine Harwood, MBBS, PhD, Centre for Cutaneous Research, London, England, Victoria Brown, MBBCh, Centre for Cutaneous Research, London, England, Charlotte Proby, MBBS, Centre for Cutaneous Research, London, England Extensive viral warts are a cause of significant morbidity, particularly in individuals unable to mount an adequate Th1 cell mediated immune response to human papillomavirus. Imiquimod belongs to a new class of immune response modifiers which are potent inducers of antiviral cytokine activity, principally interferon alpha. Imiquimod cream has shown significant efficacy compared with placebo in double-blind controlled studies of genital warts, but similar efficacy in cutaneous warts is not yet established. In this study, we assess the response of refractory cutaneous warts to imiquimod cream. Twelve patients with viral warts (palmoplantar warts, n ⫽ 10; and/or plane warts, n ⫽ 5) persisting for ⬎18 months which had failed to respond to a minimum of ⬎3 months of keratolytics and 4 cycles of cryotherapy were recruited (renal transplant recipients, n ⫽ 10; Hodgkins disease, n ⫽ 1; T-cell immunodeficiency, n ⫽ 1). Imiquimod was applied in a right versus left comparison, initially 3 times a week for 8 weeks, then daily for 8 weeks, then daily with occlusion for 8 weeks, depending on response. Complete clearance occured in one patient and ⬎75% clearance in a second. Although warts persisted in the remaining 10 patients, 4 experienced variable symptomatic improvement. Local skin reactions were infrequent, but transient rises in creatinine were observed in 3 transplant recipients (11.7-29% above baseline) of whom 2 were successfully rechallenged, without further problem. In conclusion, we provide preliminary evidence that topical imiquimod may benefit a subgroup of patients with refractory cutaneous warts. Treatment failures may partly reflect reduced penetration of the drug resulting from greater keratinisation of cutaneous warts, despite use of occlusion; trials of combined treatment with keratolytics and/or cryotherapy are now justified. Finally, until further data is available, we suggest that renal function should be closely monitored in renal transplant recipients receiving topical imiquimod.
The authors declare neither significant financial interest nor other relationship with the manufacturer of tacrolimus 0.1% ointment.
Disclosure not available at press time. 3M Health Care provided £500 and the topical 5% Imiquimod for this study.
MARCH 2004
Conflicts of Interest: (1) Each author received honoraria for attending and participating in the consensus statement development process. (2) With the exception of the Chair and Co-Chair of this committee, committee members are employed or derive income from the practice of medicine involving consultation or use of procedures to manage patients with hyperhidrosis. (3) Dr. Hornberger is Clinical Professor of Medicine at Stanford University School of Medicine, and derives no clinical income. 100 percent sponsored by Allergan, Inc.
P164
J AM ACAD DERMATOL
P41