A randomized comparison of 4 weeks of terbinafine vs. 8 weeks of griseofulvin for the treatment of tinea capitis

BACKGROUND

Tinea capitis is a common childhood infection that has recently become more frequent in urban areas in Europe and the U.S.A. The current licensed treatment in children is griseofulvin 10 mg kg(-1) daily, which is usually given for 6--8 weeks.

OBJECTIVES

To compare this treatment with a 4-week course of oral terbinafine.

METHODS

Terbinafine was given at the following doses: in children weighing < 20 kg, 62.5 mg daily; 20--40 kg, 125 mg daily; > 40 kg, 250 mg daily. Two hundred and ten children aged 2--16 years, with mycologically confirmed tinea capitis, were randomized to 4 weeks treatment with terbinafine or 8 weeks with griseofulvin, and followed for a total of 24 weeks to determine the difference between treatments with respect to short- and long-term efficacy and tolerability.

RESULTS

One hundred and forty-seven patients were evaluable (terbinafine 77, griseofulvin 70). Although the 4-week course of terbinafine resulted in a trend to more rapid clearance of tinea capitis, there were no statistically significant differences between the two drugs in terms of overall outcome or tolerability, apart from in a subgroup of patients with Trichophyton infections, and weighing > 20 kg, who responded better to terbinafine than to griseofulvin at 4 weeks. By contrast, there was a better response to griseofulvin than to terbinafine in patients with Microsporum audouinii infections.

CONCLUSIONS

Overall, the study showed that 4 weeks of treatment with oral terbinafine has similar efficacy to 8 weeks of treatment with griseofulvin for the management of tinea capitis in children.

Guidelines for the management of tinea capitis. British Association of Dermatologists

These guidelines for the management of tinea capitis have been prepared for dermatologists on behalf of the British Association of Dermatologists. They present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation.

A study of the spectrum of skin disease occurring in a black population in south-east London

We recorded the diagnosis made in 461 black patients (187 children and 274 adults) attending a dermatology clinic between January and March 1996. In the childhood population, atopic eczema and tinea capitis were the most frequent dermatoses, comprising 63% of diagnoses recorded. In the adult population, acne and acne keloidalis nuchae were seen most frequently. Other conditions observed commonly were eczema, psoriasis, keloid scarring, pityriasis versicolor and postinflammatory changes. Our study demonstrates a wide spectrum of skin disease and includes disorders more common in black skin, disorders unique to black skin, those which present a greater cosmetic disability, and normal findings which have been mistaken for pathological disease.

Recalcitrant viral warts treated by diphencyprone immunotherapy

Recalcitrant viral warts are a troublesome therapeutic problem. Immunotherapy with the universal allergic contact sensitizer diphencyprone (DCP) has been used successfully in such cases. We have reviewed our experience of the use of DCP in the treatment of resistant hand and foot warts during an 8-year period. Sixty patients were sensitized to DCP during this time; the median duration of warts was 3 years. Twelve patients defaulted from treatment. Of the remaining 48 individuals, 42 (88%) cleared of all warts. The median number of treatments to clear was five (range one to 22) and the median time to clear was 5 months (range 0.5-14). Adverse effects occurred in 27 of 48 patients (56%), most commonly painful local blistering (n = 11), blistering at the sensitization site (n = 9), pompholyx-like reactions (n = 7) and eczematous eruptions (n = 4). Three of those who defaulted did so due to side-effects, one became pregnant and eight dropped out for unknown reasons. Three of the 48 patients who cleared or had at least six treatments also discontinued DCP therapy due to side-effects, but most tolerated treatment well. Twenty-five patients were followed up for periods of 1 month to 8 years (median 2 years) and none had a recurrence. DCP immunotherapy is an effective option for the treatment of recalcitrant viral warts but patients must be motivated to attend for sequential applications and must be warned about potential uncomfortable side-effects.

Analysis of Chinese herbal creams prescribed for dermatological conditions

OBJECTIVE

To determine whether Chinese herbal creams used for the treatment of dermatological conditions contain steroids.

DESIGN

11 herbal creams obtained from patients attending general and pediatric dermatology outpatient clinics were analyzed with high resolution gas chromatography and mass spectrometry.

SETTING

Departments of dermatology and clinical biochemistry. ;

MAIN OUTCOME MEASURE

Presence of steroid.

RESULTS

Eight creams contained dexamethasone at a mean concentration of 456 mug/g (range 64 to 1500 mug/g). All were applied to areas of sensitive skin such as face and flexures.

CONCLUSION

Greater regulation needs to be imposed on Chinese herbalists to prevent illegal and inappropriate prescribing of potent steroids.

Analysis of Chinese herbal creams prescribed for dermatological conditions

OBJECTIVE

To determine whether Chinese herbal creams used for the treatment of dermatological conditions contain steroids.

DESIGN

11 herbal creams obtained from patients attending general and paediatric dermatology outpatient clinics were analysed with high resolution gas chromatography and mass spectrometry.

SETTING

Departments of dermatology and clinical biochemistry.

MAIN OUTCOME MEASURE

Presence of steroid.

RESULTS

Eight creams contained dexamethasone at a mean concentration of 456 micrograms/g (range 64 to 1500 micrograms/g). All were applied to areas of sensitive skin such as face and flexures.

CONCLUSION

Greater regulation needs to be imposed on Chinese herbalists to prevent illegal and inappropriate prescribing of potent steroids.

Resolution of xanthomas in Alagille syndrome after liver transplantation

Alagille syndrome (arteriohepatic dysplasia) is a genetic disorder with autosomal dominant transmission which has been localized to chromosome 20p. Cutaneous manifestations include jaundice, pruritus, and widespread xanthomata. We report a child with severe Alagille syndrome in whom orthotopic liver transplantation caused rapid resolution of disfiguring xanthomas.

Cutaneous Rosai-Dorfman disease

We report a patient with purely cutaneous Rosai-Dorfman disease (RDD) who presented with a solitary, asymptomatic plaque on the back of her left thigh, with characteristic, large histiocytoid cells exhibiting emperipolesis histologically. Cutaneous lesions occur in 27% of patients with lymph node involvement in RDD however purely cutaneous disease has only been reported on 18 previous occasions. The aetiology is unknown, although it is though to be a reactive disorder rather than neoplastic, possibly an immunological response to an infectious agent.

Serum S-100 protein: a potentially useful prognostic marker in cutaneous melanoma

S-100, an acidic calcium-binding protein, is present within cells of neuroendocrine origin. Its value in the immunohistochemical diagnosis of tumours of melanocytic origin is well established. More recently, a potential role has been proposed for the serum concentration of this protein as a marker of metastatic melanoma disease activity. In the present study, the concentration of serum S-100 protein was measured in 97 patients with histologically proven malignant melanoma who were attending a dermatology and/or oncology department for the follow-up of their disease. Serum S-100 was also measured in 48 control subjects without malignant melanoma. The clinical stage of the patients was classified according to the criteria of the American Joint Committee on Cancer into stages I-IV. The median (range) serum S-100 protein concentration was significantly higher in stage I (0.11 (0.1-0.21) microgram/L, P < 0.001), stage II (0.11 (0.05-0.22) microgram/L, P < 0.001), stage III (0.24 (0.07-0.41) microgram/L, P < 0.0001) and stage IV (0.39 (0.06-15.0) microgram/L, P < 0.0001) compared with the control group (0.1 (0.05-0.15) microgram/L). At a threshold value of 0.2 microgram/L, the sensitivity and specificity for detection of advanced disease were 82% and 91%, respectively. Thus serum S-100 protein may be a valuable prognostic marker for malignant melanoma and for monitoring therapy. Serum S-100 protein concentration was also compared with the Breslow thickness of the tumours. There was a significant correlation between these variables (n = 72, rs = 0.32, P < 0.01). Combining a serum S-100 threshold value of > 0.22 microgram/L and a Breslow thickness of > 4 mm improved the sensitivity and specificity for the presence of secondary spread to 91% and 95%, respectively. Therefore, a combination of both baseline serum S-100 protein and Breslow thickness may provide a better indication of the prognosis at diagnosis.

Isoforms of transferrin in psoriasis patients abusing alcohol

The different isoforms of transferrin have been quantified by isoelectric focusing in the sera of psoriasis patients with and without a history of abusing alcohol. In both male and female psoriasis subjects abusing alcohol, there were significant increases in the 2-sialylated forms by comparison to the control subjects. Psoriasis patients who had no evidence of alcohol abuse had similar profile for the isoforms of transferrin to that of the controls. Other groups of patients with alcohol-induced tissue damage, i.e. liver, brain or muscle, used as positive controls, similarly showed significant increases in the 2-sialylated forms, by comparison to controls. These results substantiate the current use of carbohydrate-deficient transferrin as a sensitive marker of alcohol abuse, particularly in subjects not drinking in excess of 60 g of ethanol/day but showing alcohol-related psoriasis.

Psychiatric illness in patients referred to a dermatology-psychiatry clinic

There is a recognized psychiatric morbidity among those who attend dermatology clinics. We aimed to determine the pattern of psychological and social problems among patients referred to a liaison psychiatrist within a dermatology clinic. Notes from 149 patients were reviewed and more detailed assessments performed in a subgroup of 32 consecutive referrals. All but 5% merited a psychiatric diagnosis. Of these, depressive illness accounted for 44% and anxiety disorders, 35%. Less common general psychiatric disorders included social phobia, somatization disorder, alcohol dependence syndrome, obsessive-convulsive disorder, posttraumatic stress disorder, anorexia nervosa, and schizophrenia. Classical disorders such as dermatitis artefacta and delusional hypochondriasis were uncommon. Commonly, patients presented with longstanding psychological problems in the context of ongoing social difficulties rather than following discrete precipitants. Psychiatric intervention resulted in clinical improvement in most of those followed up. Of the dermatological categories 1) exacerbation of preexisting chronic skin disease; 2) symptoms out of proportion to the skin lesion; 3) dermatological nondisease; 4) scratching without physical signs, the commonest were dermatological nondisease and exacerbation of chronic skin disease. Anxiety was common in those from all dermatological categories. Patients with dermatological nondisease had the highest prevalence of depression. Skin patients with significant psychopathology may go untreated unless referred to a psychiatrist. The presence of dermatological nondisease or symptoms out of proportion to the skin disease should particularly alert the physician to the possibility of underlying psychological problems.

Cutaneous manifestations of non-HIV immunosuppression

Advances in organ transplantation and chemotherapeutic techniques have led to an increased interest in both the early and long-term complications of immunosuppression. This article reviews many of the cutaneous complications and highlights the importance of regular skin surveillance in these patients.

Increase in non-melanoma skin cancer--the King's College Hospital experience (1970-92)

A retrospective study of the number of patients with non-melanoma skin cancer treated over a 22-year period at King's College Hospital was carried out. There was a threefold rise in the number of patients with basal cell carcinoma and a 10-fold rise in the number of patients with squamous cell carcinoma from 1970 to 1992. This study demonstrates a marked increase in the number of patients with non-melanoma skin cancers presenting to the Department of Dermatology and reflects a national trend which underlines the need for skin cancer services to be prepared for a growing workload in this area.

Urticaria pigmentosa--response to topical steroids

A case of adult-onset urticaria pigmentosa is presented, in which the eruption cleared following the application of potent topical corticosteroids. Remission could be maintained by intermittent topical treatment. Topical steroids would appear to provide a simple, cheap and effective alternative to standard therapies.