Cloxacillin versus Pristinamycin for Superficial Pyodermas: A Randomized, Open-Label, Non-Inferiority Study

BACKGROUND

Superficial pyodermas may require systemic antibiotics. In a previous open-label trial, oxacillin and pristinamycin achieved similar cure rates, but its design was not truly that of a non-inferiority study.

OBJECTIVES

To assess the efficacy and safety of oral cloxacillin versus pristinamycin (both 2 g/day) to treat superficial pyodermas.

METHODS

Multicentre, parallel-group, open-label, randomized non-inferiority trial.

RESULTS

French general practitioners in private practice included 334 out-patients (mean age: 42 years). At the follow-up (day 14), the cure rates (primary efficacy end point) for the intent-to-treat populations were 80.7% (138/171) for cloxacillin and 82.8% (135/163) for pristinamycin. The observed difference between cure rates was -2.1%, with the lower limit of the two-sided 95% confidence interval higher than the non-inferiority threshold of -15%. The per-protocol analysis yielded similar results. Therapy was discontinued for 10 patients (cloxacillin: 1, pristinamycin: 9; p = 0.01).

CONCLUSION

Cloxacillin could be an alternative to pristinamycin in out-patients with superficial pyodermas.

Syndrome PHACE (S) d’expression incomplète

INTRODUCTION

Hemangiomas are the most common benign tumors in childhood. In rare cases, they can be associated with dysmorphic malformations. The acronym, the PHACE (S) syndrome, was recently described by Frieden et al. in 1996 as a large facial or cervical Hemangioma, associated with one or more of the following systemic abnormalities including:Posterior fossa malformation, Arterial abnormalities, Coarctation of the aorta and/or cardiac defects, Eye abnormalities and Sternal clefts.

CASE REPORT

A 2 year-old girl presented with a large left hemifacial hemangioma. The rest of the clinical examination was normal. Initially, simple clinical surveillance was scheduled. The outcome was good with almost complete regression of the hemangioma by the age of 8. However, there were remains to the left of the upper lip and plastic surgery was scheduled. Pre-operative conventional arteriography revealed the complete, asymptomatic, absence of the ipsilateral internal carotid artery. Cerebral MRI and cardiac ultrasonography were normal. In the absence of somatic manifestations, regular clinical surveillance was decided on.

DISCUSSION

Large facial or cervical hemagiomas can be associated with one or more systemic abnormalities described by the PHACE (S) acronym. Its prevalence is unknown, but is shows marked female preponderance. Among the systemic abnormalities, neurological and cardiac malformations predominate. Hence the PHACE (S) syndrome must be recognized. Moreover, in patients presenting with large facial or cervical hemangioma, the following examinations should be performed: neurological examination and cerebral MRI to rule out abnormality of the posterior fossa, completed by a sequence of angio-MRI in the search for cerebral artery malformations; cardiovascular exploration, completed by echocardiography in the case of doubt and examination of the eyes and sternum. Lastly, the enhanced risk of laryngeal sub-glottis hemangioma should be kept in mind.

Ex vivo cutaneous absorption assessmentof a stabilized ascorbic acid formulation using a microdialysis system

BACKGROUND

Reactive oxygen species generated by ultraviolet light result in photocarcinogenic and photoaging changes in the skin. Antioxidants protect the skin from these insults.

OBJECTIVE

The aim of this study was to determine the ex vivo ascorbic acid penetration and its degradation in the skin after its topical application from an 8% new formulation.

METHOD

Ascorbic acid was applied to human skin fragments. Ascorbic acid and its metabolites were collected by microdialysis and assessed by gas chromatography mass spectrometry.

RESULTS

After topical application of the new formulation, the ascorbic acid level achieved was 8.5% higher than [corrected] times the normal tissue value. This high ascorbic acid dermal concentration remained constant if a topical application was made every 8 h. No degradation of ascorbic acid was detected.

CONCLUSION

Ascorbic acid penetrates rapidly after its topical application. The persistent reservoir of ascorbic acid provides an important and attractive photoprotection strategy.

Evaluation of a novel 308-nm monochromatic excimer light delivery system in dermatology: a pilot study in different chronic localized dermatoses

BACKGROUND

Recently, units have been developed that are capable of delivering large fluences of narrowband ultraviolet (UV) B selectively to cutaneous lesions within a reasonable time.

OBJECTIVES

To analyse the efficacy of a novel nonlaser 308-nm monochromatic excimer light (MEL) delivery system in various dermatoses usually treated by narrowband UVB phototherapy.

METHODS

Fifty-four patients with chronic and resistant localized dermatoses were enrolled in a prospective study: 17 with palmoplantar pustular psoriasis, seven with plaque-type psoriasis, four with nail psoriasis, eight with chronic atopic dermatitis of the hands, 10 with chronic nonatopic dermatitis of the hands and eight with alopecia areata. The 308-nm xenon chloride MEL delivery system (Excilite; DEKA, Florence, Italy) was used to produce an average incident dose rate of 50 mW cm(-2) at a tube-to-skin distance of 15 cm and with a maximum irradiating area of 512 cm2. The initial dose was based on multiples of a predetermined minimal erythema dose (MED), and subsequent doses were based on the response to treatment. Treatments were scheduled weekly for a maximum of 10 weeks. Clinical responses were evaluated using photographic documentation and (except for alopecia areata) clinical score.

RESULTS

The MED ranged from 250 to 350 mJ cm(-2) (mean +/- SD 318.2 +/- 28.4). MEL at 308 nm was the most effective for palmoplantar pustular psoriasis with a mean improvement of 79% after a mean of 5.3 treatments and a mean dose of 11.8 MED per treatment. Plaque-type psoriasis was significantly less sensitive to treatment and nail psoriasis demonstrated no benefit from treatment. Chronic palmar atopic dermatitis was cleared in two patients and the mean improvement was 54% as compared with 46% in patients with chronic nonatopic dermatitis of the hands. Four complete regrowths among the eight patients with alopecia were observed after a mean of 5.1 treatments. The percentages of improvement had significantly decreased at the 6-month visit, and only four patients (24%) with palmoplantar pustular psoriasis still demonstrated a significant improvement. Common side-effects included intense erythema and, more rarely, blisters, but these were well tolerated.

CONCLUSIONS

Our preliminary results confirm the efficacy of this novel 308-nm MEL delivery system, which appears to be effective and safe for palmoplantar pustular psoriasis. To a lesser extent, plaque-type psoriasis, chronic atopic and nonatopic dermatitis of the hands and alopecia may also benefit from this treatment.

Comparing the contractile properties of human fibroblasts in leg ulcers with normal fibroblasts

OBJECTIVE

The tissue contraction phenomenon associated with wound healing is of prime importance for wound closure. Contractile properties of human fibroblasts from chronic venous leg ulcers were compared with those of normal fibroblasts using in vitro models.

METHOD

Biopsies were taken from the uninvolved skin of the thigh, the epithelialised ulcer edge and the non-epithelialised ulcer centre in four patients (average age: 78 years). Fibroblasts were obtained by an explant technique and expanded in vitro in Dulbecco's Modified Eagle's Medium supplemented with 10% foetal calf serum and used for the assays at their fourth passage. Intracellular alpha-smooth muscle actin expression (alphaSM-actin) was studied by immunofluorescence labelling of cells cultured in monolayer. Contractile properties were evaluated using three-dimensional collagen lattices.

RESULTS

Fibroblasts from the ulcer centre were the richest cells in actin filaments. Both populations of venous ulcer fibroblasts contracted more rapidly and to a greater extent than normal fibroblasts. The peak contractile forces developed by fibroblasts from the ulcer centre and the ulcer edge were 30% and 18% greater than normal fibroblasts respectively.

CONCLUSION

Some functions of fibroblasts, in particular the generation of contractile forces and the formation of cytoplasmic actin filaments, seem not to be affected in chronic venous ulcers.

DECLARATION OF INTEREST

This study was supported by the Fondation Coloplast pour la Qualite de la Vie of France.

[Pruritus sine materia: a prospective study of 95 patients]

PURPOSE

To describe the nature and the frequency of systemic diseases responsible for the pruritus sine materia. Value of this sign as a marker of malignancy.

METHODS

Prospective study undertaken over five years (1996-2001).

INCLUSION CRITERIA

generalized aspect of the pruritus and absence of specific primitive cutaneous lesions of an itching dermatosis. Parameters taken from the data of the anamnesis and the physical examination. Standard biologic and morphologic investigations were done.

RESULTS

Ninety-five patients included (54 men, 41 women) of 55.5 years average age +/-18.1. In 24 patients, traditional hospitalisation with one average duration of eight days stay +/-3.15 was necessary. In 38 cases (40%), a systemic cause was found. The main conditions were: toxocariasis (8 cases), hematologic diseases (7 cases), chronic renal failure (6 cases), hypothyroidism (5 cases) and iron deficiency (5 cases). A neoplasm was found in eight cases (8,42%): seven hematologic malignancy (3 myeloma, 2 Hodgkin's diseases, 2 myeloproliferative syndromes) and one solid cancer (pulmonary adenocarcinoma).

CONCLUSION

A systemic aetiology was observed in 38 cases (40%). The toxocariasis an underestimated disease comes at the first place. The pruritus sine materia can hide an hematologic malignancy.

Pseudo-acrodermatite entéropathique par carence alimentaire en isoleucine chez un nourrisson atteint de leucinose

INTRODUCTION

Leucinosis (maple syrup urine disease) is a metabolic disorder caused by an enzymatic deficiency involved in the degradative pathways of the three branched-chain amino acids. We report an observation of acrodermatitis enteropathica-like syndrome induced by essential amino acid deficiency in a child with leucinosis.

CASE REPORT

A child with leucinosis was referred to our hospital for exfoliative dermatitis of the perioral and anogenital regions associated with diarrhea and pancytopenia. The diagnosis of iatrogenic acrodermatitis enteropathica-like syndrome was confirmed after screening showing isoleucine deficiency. Rapid response was observed after adequate isoleucine supplementation.

DISCUSSION

The acrodermatitis enteropathica-like eruption in our patient was due to an iatrogenic amino acid nutritional imbalance. Our observation underlines the risk of using a branched-chain amino acid-free formula without adequate supplementation of deficient amino acids. In addition, dietary insufficiency of isoleucine, associated with the treatment of organic aciduria should be added to the causes of acrodermatitis enteropathica-like syndrome.

[Ecthyma gangrenosum caused by Pseudomonas stutzeri with bacteraemia and systemic vascularitis]

INTRODUCTION

Ecthyma gangrenosum is a cutaneous manifestation of Pseudomonas infections. This condition may be associated with bacteraemia but can also occur in the absence of bacteraemia.

EXEGESIS

The authors report the case of a 66-year-old woman presented with necrotic ulcerations on the face associated with fever, arthralgia, myalgia, fatigue and neutropenia. Blood cultures and skin cultures were positive for Pseudomonas stutzeri. Her condition improved under appropriate antibiotic therapy. However, the patient further developed clinical and biological symptoms of systemic vasculitis and mixed cryoglubulinemia. Complete healing was finally obtained after a course of corticosteroids.

CONCLUSION

Ecthyma gangrenosum should be suspected in people who have typical clinical presentation. This disease could sometimes be associated with systemic vasculitis.

Comparison of different wound dressings on cultured human fibroblasts and collagen lattices

OBJECTIVE

We compared the effects on cultured human fibroblasts of a new non-adhesive wound dressing, Urgotul, with five other wound dressings. Urgotul is a hydrocolloid dressing; the comparator dressings included impregnated gauze and modern wound dressings.

METHOD

Cultures in monolayer were used to study the morphology and growth of fibroblasts. The Bell model of cultured dermis equivalents was used to investigate myofibroblast differentiation. These cultures were labelled a-SM actin and F-actin.

RESULTS

Two of the tested dressings induced cytotoxic effects. They were found to inhibit cell growth (greater than 60%) and to disturb cell shape and cytoskeletal differentiation. Urgotul and the remaining three dressings showed no effect on proliferation. However, some of them modified fibroblast morphology and affected F-actin distribution.

CONCLUSION

Depending on their nature and components, wound dressings may respect or affect fibroblast behaviour in vitro (proliferation, morphology and a-SM actin and F-actin distribution). The significance of these in vitro observed findings require further investigations.

N-Acetyltransferase 2 Acetylation Polymorphism: Prevalence of Slow Acetylators Does Not Differ between Atopic Dermatitis Patients and Healthy Subjects

The genetic polymorphism of human N-acetyltransferase 2 (NAT2) divides the human population into groups with rapid, intermediate and slow acetylator status. Slow acetylator status has been considered a predisposing factor for allergic diseases, lupus erythematosus, toxic epidermal necrolysis or Stevens-Johnson syndrome. The aim of this study was to investigate whether Caucasian patients suffering from atopic dermatitis differed from healthy individuals with regard to the genotype and phenotype of NAT2. Twenty unrelated healthy Caucasian volunteers (9 females and 11 males, aged from 22 to 59 years) and twenty unrelated Caucasian patients suffering from atopic dermatitis (9 females and 11 males, aged between 20 and 54 years) participated in this study. For each one, the NAT2 genotype was determined by polymerase chain reaction with DNA extracted from peripheral blood, using specific primers for the wild-type allele (wt) and the 3 most frequent mutated alleles of NAT2 (C481-->T, G590-->A and G857-->A). The NAT2 phenotype was evaluated with dapsone as a test substrate using high-pressure liquid chromatography. Statistical analysis was performed using the chi(2) test. Phenotype and genotype were distributed as follows: (1) of the healthy subjects, 60% were rapid acetylators (RA) and 40% were slow acetylators (SA); 10% of the RA and 15% of the SA were homozygous, 50% of the RA and 25% of the SA were heterozygous; (2) of the patients, 55% were RA, 40% were SA and 5% were intermediate acetylators (IA); 10% of the RA and 10% of the SA were homozygous, 45% of the RA and 35% of the SA were heterozygous. No significant statistical difference was found between the two groups for genotypes (p = 0.75) or phenotypes (p = 0.60). The phenotyping and genotyping results of healthy subjects were comparable to those found in previous studies. The absence of a significant statistical difference between healthy subjects and atopic dermatitis patients is in contrast to the results of previous studies. Some authors considered that allergic patients are mostly SAs. This could be explained by the fact that we only considered patients suffering from atopic dermatitis whereas, in other studies, patients suffered from different (one or several associated) allergic diseases. NAT2 polymorphism does not differ between patients suffering from atopic dermatitis and healthy subjects. The importance attributed to the SA status, which was previously considered a predisposing factor for allergic diseases such as atopic dermatitis, should be reviewed.

Leucémie myélomonocytaire juvénile, xanthomes et neurofibromatose de type 1

The triple association of leukemia, xanthogranulomas, and type 1 neurofibromatosis was first described in 1958. Most leukemias were juvenile myelomonocytic leukemias (JMML), usually called juvenile chronic myelogenous leukemia. We describe a 22-month-old female child with neurofibromatosis 1, xanthomagranulomas, and a JMML. Her mother and her brother also had cutaneous café-au-lait spots. Our patient was treated with mercaptopurine and improved. However, 9 months later she experienced a blastic transformation. The presence of xanthomagranulomas and NF1 in a young child should alert to a possible development of JMML, especially in patients with a family history of NF1.

Conséquences fonctionnelles des perturbations des lipides cutanés

Epidermal lipids constitute an ultimate frontier between the organism and its environment. Their essential role consists of providing a barrier limiting both transepidermal water loss and penetration of external factors, such as irritants. Efficacy of the barrier depends on the physicochemical properties of the substance applied to the skin surface and the increase in transepidermal water loss, which may be quantified, is proportional to the provoked perturbation in the barrier function. In atopic dermatitis epidermis, a significant decrease in the ceramide content and abnormally low levels of omega-6 fatty acids correlate with an increased rate of water loss at the skin surface--a sign of an impaired barrier. However, similar signs are observed in the atrophic epidermis provoked by long term local corticotherapy. Epidermal lipid profiles are also seriously modified in various ichthyoses, and are partially responsible for the hyperkeratosis observed clinically, e.g.: the recessive X-linked form is provoked by a mutation of the steroid sulphatase gene and the resulting accumulation of unconverted precursor of cholesterol. Modification of the lipid composition in acne contributes to comedo formation, whereas UV improves barrier function (and may provoke hyperkeratosis) through an increase in the stratum corneum lipid content. Another source of lipids at the epidermal surface is sebaceous glands. Waxes present in the sebum increase friction coefficient of the skin surface. Sebum also influences (decreases) the rate of penetration of lipophilic substances applied on the skin. Its role in the skin biology appears to be less vital than that of the lipids constituting the permeability barrier of the stratum corneum.

Intra-individual comparison of the cutaneous safety and efficacy of calcitriol 3 microg g(-1) ointment and calcipotriol 50 microg g(-1) ointment on chronic plaque psoriasis localized in facial, hairline, retroauricular or flexural areas

BACKGROUND

Psoriasis involving sensitive skin areas remains difficult to treat because of the side-effects of topical corticosteroids and the irritancy potential of vitamin D3 derivatives. Several clinical trials have demonstrated that calcitriol, the naturally occurring and hormonally active form of vitamin D3, is effective and safe at the dose of 3 microg g(-1) for the treatment of psoriasis affecting the trunk and limbs.

METHODS

We compared the safety and efficacy of calcitriol 3 microg g(-1) ointment and calcipotriol 50 microg g(-1) ointment in a multicentre, randomized, investigator-blinded, left-right comparison in mild to moderate chronic plaque psoriasis affecting sensitive areas, defined as being the face, hairline, retroauricular and flexural areas. One pair of symmetrical and bilateral target lesions was selected from each area and assessed for perilesional erythema, oedema, and stinging/burning. Global assessment of local tolerability and global improvement were rated by the investigator, and the subjects were asked to evaluate the tolerability and efficacy of each product and to express their global preference.

RESULTS

In the 75 subjects, calcitriol and calcipotriol both led to clearing of at least one target lesion in 21 (28%) of the subjects each. Perilesional erythema (P < 0.001), perilesional oedema (P < 0.02) and stinging/burning (P < 0.001) were all significantly less severe with calcitriol than with calcipotriol. The subjects' evaluation of local tolerability was significantly (P < 0.0001) in favour of calcitriol. Ten treatment-related dermatological events occurred in eight subjects, including one subject who experienced skin discomfort on both sides. All other events occurred only on the calcipotriol-treated side (irritant dermatitis, six subjects; contact dermatitis, one subject). Global assessment of improvement from baseline by the investigators was significantly greater for the calcitriol-treated lesions (P < 0.02). The subjects' global preference was significantly in favour of calcitriol (P < 0.02).

CONCLUSIONS

In the present study, calcitriol ointment was found to be better tolerated and would appear to be more effective than calcipotriol ointment in the treatment of psoriasis in sensitive areas.

Assessment of collagen lattice thickness by B-scan echography

BACKGROUND/AIMS

Collagen lattices are an in vitro dermal equivalent that has led to the development of an original model of dermal tissue. Fibroblasts cultured in three-dimensions in a collagen matrix differentiate similarly to in vivo. New technological performances in ultrasonic imaging can now provide precise measurements of tissue thickness with good resolution. The aim of this study was to assess, by B-scan echography, the correlation between collagen lattice thickness and various collagen and cell concentrations.

METHODS

Three concentrations of human dermal fibroblasts (F1 = 8.10(5)C/mL, F2 = 16.10(5)C/mL, F3 = 32.10(5)C/mL) and three concentrations of rat tail collagen (C1 = 2 mg mL(-1), C2 = 3 mg mL(-1), C3 = 4 mg mL(-1)) were prepared for five different kinds of collagen lattices: F(2)C(1), F(2)C(2), F(2)C(3), F(1)C(1) and F(3)C(1) (n = 5 per case). Ultrasonic imaging was performed on day 0, 4, 6, 10, 12 and 14 using a Dermcup 2020 scanner. The scans measured thickness in the centre and periphery of the lattice.

RESULTS

The collagen lattice echogenicity was similar to a dermis in vivo. For each assessment, the collagen lattice thickness increased until day 12 and then stabilized. The lattice was thicker when the cellular concentration was higher, (at day 14: F(1C1) = 0.66 mm, F(2C1) = 0.86 mm, F(3C1) = 1.21 mm). The collagen concentration did not significantly influence lattice thickness.

CONCLUSION

Collagen lattice thickness increased with retraction time and cellular concentration.