Effect of sulphapyridine, 5-aminosalicylic acid, and placebo in patients with idiopathic proctitis: a study to determine the active therapeutic moiety of sulphasalazine

Suppositories of sulphapyridine, 5-aminosalicylic acid, and placebo were used in 45 patients with idiopathic proctitis to determine the active part of sulphasalazine. Each patient used one of the suppositories twice daily for four weeks in a double-blind controlled trial. Complete clinical remission with normal rectal mucosa on sigmoidoscopy occurred in 60% of patients given 5-aminosalicylic acid, but in only 13% and 27% of those given sulphapyridine and placebo respectively. Twelve patients were included twice. In eight of these patients 5-aminosalicylic acid was given one time and sulphapyridine (two patients) or placebo (six patients) another time. Clinical remission occurred in each patient with 5-aminosalicylic acid, but in only one patient during other therapy. The results suggest that 5-aminosalicylic acid is the active therapeutic moiety of sulphasalazine.

[Intestinal lymphagiectasis. Use of immunoregulators]

The authors present a patient with intestinal lymphangiectasis discussing the pathophysiology, diagnosis and immunologic treatment instituted which was with mebendazole, sulfazalosopyridine and oral calcium. Immunoglobulins and T and B leukocytes showed increase together with clinical improvement in the diarrheal picture.

[Short term prognosis of ulcerative colitis (author's transl)]

The authors analyse the short-term prognosis of ulcerative colitis from a series of 65 patients followed during ten years and treated with the same attitude. The results are compared to those of the most important published, from which they differ just a little. The medical treatment is effective in 84,6% of cases. The mortality of first attack is 6,1%. Only 1,4% of patients in our series are colectomised. It seems that the short-term prognosis has been slightly better during the last few years perhaps because of improvement in management and appearance of corticosteroids and/or salazosulfapyridine. The factors of bad prognosis in a first attack are its severity, its extension to the whole colon, its beginning after 60 years.

A case of cicatricial pemphigoid or cicatricial linear IgA bullous dermatosis

A case has been described with clinical features of cicatricial pemphigoid, but immunofluorescent (IF) biopsy findings are suggestive of linear IgA bullous dermatosis (LABD), i.e., the presence of IgA deposits with a linear pattern at the basement membrane zone. The patient failed to respond to sulfones and gave a limited response to corticosteroid. These findings suggest that therapy of the type found to be effective in cutaneous forms of LABD, i.e., combinations of low doses of sulfones and corticosteroids, may be indicated in such cases.

Sulfones and sulfonamides in dermatology today

Although dapsone and sulfapyridine have been used for years in dermatology, there has not always been a clear understanding of how these agents work. Recent investigation, however, has shed new light on thes agents which now allows a more rational approach to their use. This review is an attempt to familiarize the clinician with how these agents work, in what disease states they are effective, how to administer them, what adverse effects may occur, and how to monitor the patient to detect these adverse effects.

[Long-term therapy in ulcerative colitis and Crohn's disease]

The remission period of patients with ulcerative colitis was extended by long term treatment with 2-3 g sulphasalazine daily. Proctocolectomy should be performed if no remission can be obtained on continued medical therapy. Moreover, in these cases the operation is suggested to avoid the unwanted side effects of the drugs and the increased risk of cancer.

Bullous disease of childhood

Bullous disease of childhood (BDC) is a persistent or recurrent blistering skin disease characterized by large, tense bullae in a generalized distribution, but with a predilection for the scalp, trunk, pubis, and inner thighs. It usually begins in the first decade of life and spontaneously remits after several months to three years of activity. Sulfapyridine or dapsone therapy usually controls the disease. Administration of corticosteroids for systemic effects should be avoided.

Polymorphic pemphigoid

We describe 20 patients with a chronic polymorphic eruption; they shared clinical, histopathological, and therapeutic features of both dermatitis herpetiformis and bullous pemphigoid (BP). In 14 of these 20 cases, direct and indirect immunofluorescence studies corresponded to BP. The remaining six patients showed IgA deposits in a linear pattern at the basement membrane zone, and two of these six showed IgA pemphigoid antibodies in their sera as well. No significant clinical and histological differences were detected in the patients, in connection with the immunological findings. Furthermore, one patient's condition, which was studied by repeated immunofluorescence examinations, changed from a linear IgA pattern and a negative indirect test to a linear IgG pattern and a positive reaction for IgG pemphigoid antibodies. We concluded that these cases constitute a polymorphic variant of BP.

[Crohn's disease--Indication for surgery (author's transl)]

60 to 90% of patients with Crohn's disease have to undergo surgery due to complications; one half of these patients do suffer a relapse. Comments are given as to the rate of recurrence and the factors which may influence it (age, localisation and duration of the disease, timing and technique to surgery). The absolute and relative indications for surgery as well as preoperative preparation are discussed in detail. Optimal therapy of Crohn's disease is only possible in close cooperation between gastroenterologist and surgeon.

Bullous pemphigoid responding to sulfapyridine and the sulfones

Since 1968, a total of 84 patients with bullous pemphigoid have been seen at the Mayo Clinic. Of these, 41 were given a trial of sulfapyridine or dapsone, and six showed a significant response. In five patients, the condition was controlled completely. All responsive patients showed indirect and direct immunofluorescent tests indistinguishable from typical bullous pemphigoid. The patients, however, were somewhat younger (mean 54 years) than others having pemphigoid; and in two patients, biopsy specimens showed a reversal of the usual eosinophilic predominance over neutrophils. Three of the six patients were also diabetic.

[Surgical and medical treatment of Crohn's disease (author's transl)]

Regional enteritis does present therapeutical problems because of the unpredictable course of this disease. 162 patients were operated upon in the Surgical Department of the University of Mainz Medical School between 1964 and 1976. Medical and surgical treatment of these patients has been rather different due to the heterogenity of the patient group. Curative therapy of regional enteritis does not exist. Medical treatment is aimed at converting the active form of the disease into an inactive, 'burnt out' form. One therapeutic regimen widely used is the combination of salazosulfapyridin and corticosteroids, another regimen is the combination of azathioprine and prednisolone. Surgery is indicated when complications arise and after medical treatment has failed. The optimal approach is resection of the afflicted part of the intestine. Even after surgery prognosis is doubtful and depends upon the activity of the disease in each individual case.

Chronic bullous dermatosis of childhood

The clinical features, laboratory studies, and therapeutic responses of two boys with chronic bullous dermatosis of childhood are described. Direct immunofluorescent preparations of sections from a lesion, skin adjacent to a lesion, and uninvolved skin demonstrated linear deposition of IgA at the dermoepidermal junction in all three biopsy specimens from one patient. Similar preparations from the second child were negative for staining. No circulating antibodies to skin components were detected in either child by means of multiple substrates. Neither child had clinical manifestations nor laboratory findings suggestive of an associated gastrointestinal lesion; therefore, small bowel biopsies were not performed. Immunologic studies failed to demonstrate any of the abnormalities frequently described in dermatitis herpetiformis. Both boys responded dramatically to sulfapyridine therapy.

Bullous and cicatricial pemphigoid. Clinical, histopathologic, and immunopathologic correlations

A study of the records, biopsies, and immunopathologic data from 84 patients with bullous pemphigoid and 60 patients with cicatricial pemphigoid revealed that patients with bullous pemphigoid and negative or perhaps very low titer of circulating antibasement-membrane antibodies may constitute a distinct subgroup of patients with bullous pemphigoid. This group contained more women than men, had increased mucous membrane involvement, and had higher incidences of hypothyroidism, positive antinuclear antibody tests, and malignancy than did the other patients with bullous pemphigoid. Six of 41 patients with bullous pemphigoid who were given sulfapyridine or dapsone responded to these drugs, and these 6 constitute another group of patients necessitating further study. In nine patients, localized pemphigoid was found. The lesions were of two types: those occurring in sun-exposed areas and those occurring pretibially. Three of 57 patients with cicatricial pemphigoid had circulating antibasement-membrane antibodies. The clinical extent of disease in cicatricial pemphigoid was less extensive in our series than that previously seen at our institution. This was probably due to the earlier and more accurate diagnosis afforded by immunopathologic studies and to wider appreciation of the disease among nondermatologists.

Dapsone-induced motor polyneuropathy. A complication of prolonged treatment of subcorneal pustular dermatosis

A motor polyneuropathy developed in a woman with subcorneal pustular dermatosis of 16 years' duration, who had received at least 300 gm of dapsone over a five-year period and 80 gm during the four-month period of progression of her neurologic symptoms. Although the patient believed her muscle power had returned to normal four months after the drug was stopped, a slight peripheral neuropathy remained. Electrodiagnostic and clinical features during the period of greatest weakness and the subsequent 16 months were consistent with a polyneuropathy of the axonal type. The neurotoxicity of dapsone appears to be dose-dependent, but the mechanism by which it occurs is unknown.

[Ulcerative colitis and pregnancy. Surgical treatment of acute complications (author's transl)]

Ulcerative colitis occurs chiefly in women in the reproductive age group. The disease tends to exacerbate in affected patients with florid colitis at time of conception. Toxic complications and severe haemorrhage are indications for surgical intervention at the earliest possible time. Treatment of choice consists of multiple enterostomies. Two female patients could be saved with this method. Proctocolectomies were always unsuccessful.

Clinical response of dermatitis herpetiformis skin lesions to a gluten-free diet

Patients with dermatitis herpetiformis have been studied prospectively for 2 years to assess the effect of a gluten-free diet (GFD) on control of the skin lesions. Daily requirements for oral medication with sulphapyridine or dapsone were reduced by GFD treatment and if complete clinical remission of the skin disease occurred, it was maintained while the diet was strictly observed. However, complete remission did not occur significantly more often in GFD-treated patients than in patients taking a normal diet. Many of the latter group exhibited variation in their drug dose requirements during the period of study. GFD treatment seems desirable for the majority of patients with dermatitis herpetiformis, not only to correct the intestinal abnormality but also to minimize the dose of drugs necessary to control the skin lesions.

[Results of surgical treatment of Crohn's enterocolitis granulomatosa (author's transl)]

The possibilities of surgical treatment are outlined with reference to 45 patients with Crohn's enterocolitis granulomatosa. In 82% of the cases a large part of the colon is affected in addition to the terminal ileum, so that resections of the large intestine are necessary as a rule. In our patients the relapse rate after 3 years was 36%. An improvement in the late results can apparently be achieved if the resection is performed to correspond with the extent of the inflammatory changes demonstrated by a preoperative mesentericography. Postoperative immunosuppressive treatment over a long period may well contribute to the prevention of recurrences.