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Messingham KN, Cahill MP, Kilgore SH, Munjal A, Schlievert PM, Fairley JA. TSST-1 +Staphylococcus aureus in Bullous Pemphigoid. J Invest Dermatol 2021; 142:1032-1039.e6. [PMID: 34606884 DOI: 10.1016/j.jid.2021.08.438] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Revised: 08/23/2021] [Accepted: 08/30/2021] [Indexed: 01/31/2023]
Abstract
A potential role of Staphylococcus aureus in bullous pemphigoid was explored by examining the colonization rate in patients with new-onset disease compared with that in age- and sex-matched controls. S. aureus colonization was observed in 85% of bullous pemphigoid lesions, 3-6-fold higher than the nares or unaffected skin from the same patients (P ≤ 0.003) and 6-fold higher than the nares or skin of controls (P ≤ 0.0015). Furthermore, 96% of the lesional isolates produced the toxic shock syndrome toxin-1 superantigen, and most of these additionally exhibited homogeneous expression of the enterotoxin gene cluster toxins. Toxic shock syndrome toxin-1‒neutralizing antibodies were not protective against colonization. However, S. aureus colonization was not observed in patients who had recently received antibiotics, and the addition of antibiotics with staphylococcal coverage eliminated S. aureus and resulted in clinical improvement. This study shows that toxic shock syndrome toxin-1‒positive S. aureus is prevalent in bullous pemphigoid lesions and suggests that early implementation of antibiotics may be of benefit. Furthermore, our results suggest that S. aureus colonization could provide a source of infection in patients with bullous pemphigoid, particularly in the setting of high-dose immunosuppression.
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Affiliation(s)
- Kelly N Messingham
- Department of Dermatology, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA.
| | - Michael P Cahill
- Department of Microbiology and Immunology, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Samuel H Kilgore
- Department of Microbiology and Immunology, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Ananya Munjal
- Department of Dermatology, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Patrick M Schlievert
- Department of Microbiology and Immunology, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
| | - Janet A Fairley
- Department of Dermatology, Carver College of Medicine, The University of Iowa, Iowa City, Iowa, USA
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Efficacy and safety of tetracyclines for pemphigoid: a systematic review and meta-analysis. Arch Dermatol Res 2021; 314:191-201. [PMID: 33774726 DOI: 10.1007/s00403-021-02216-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 02/16/2021] [Accepted: 02/26/2021] [Indexed: 10/21/2022]
Abstract
The aim of this review was to evaluate the efficacy and safety of tetracyclines for treatment of pemphigoid. We searched PubMed, EMBASE, Ovid, Web of Science, and the Cochrane Library for studies involving pemphigoid patients treated with tetracyclines published in English before 29 February 2020. References of included studies were also screened to widen the scope of the literature search. Data regarding predefined clinical outcomes of 341 patients from 77 studies were extracted and analyzed. A meta-analysis was conducted on the basis of 4 studies including 2 randomized controlled trials and 2 comparative studies. The patients had a mean age of 74.60 ± 13.18 years, 45.4% were males, and 54.6% were females. There were 185 patients with mild-to-moderate and 143 patients with severe disease. The average initial doses were 1.62 ± 0.39 g/day for tetracycline, 0.20 ± 0.01 g/day for doxycycline, and 0.11 ± 0.05 g/day for minocycline. The average time on tetracyclines was 3.74 ± 5.99 months, and 261 (81.3%) patients reported partial or complete remission. Relapses occurred in 72 (28.3%) cases. Adverse effects were experienced by 130 (41.9%) patients. The pooled ORs for short-term effectiveness, relapse, adverse effects, and 1-year survival in patients treated with oral tetracyclines vs. systemic corticosteroids were 0.40 (95% CI, 0.22-0.76), 0.69 (95% CI, 0.44-1.10), 0.47 (95% CI, 0.27-0.82) and 2.02 (95% CI, 1.16-3.50), respectively. Compared to doxycycline and minocycline, tetracycline was significantly associated with better treatment outcomes and fewer adverse effects (p < 0.05). This review revealed tetracyclines' efficacy and safety in pemphigoid treatment and may offer support for clinical use of tetracyclines in pemphigoid.
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Treatment of Bullous Pemphigoid in People Aged 80 Years and Older: A Systematic Review of the Literature. Drugs Aging 2020; 38:125-136. [PMID: 33230804 DOI: 10.1007/s40266-020-00823-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/13/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Bullous pemphigoid commonly affects older adults and has a detrimental effect on both quality of life and longevity. Systemic corticosteroids, the mainstay of therapy, may cause significant adverse effects, especially in older patients. Therefore, safer therapeutic options are being sought. OBJECTIVE The objective of this article was to systematically review the published evidence on the efficacy and safety of different treatment modalities for bullous pemphigoid in older patients. METHODS We performed a systematic review of all publications until May 2020 in PubMed, Google Scholar, and the ongoing trials registry of the US National Institutes of Health databases evaluating the efficacy and safety of bullous pemphigoid treatments in patients aged older than 80 years. The primary outcome was complete response. The secondary outcomes were partial response, complete remission on minimal therapy or during tapering, recurrence, adverse events, and mortality. RESULTS Twenty-eight publications were included: 2 randomized controlled trials, 5 prospective cohort studies, 10 retrospective cohort studies, and 11 case series, with a total of 153 older patients. The overall complete response rate was 31%. Topical corticosteroids had the highest complete response rate (55%) with a low side-effect profile. Biologics (omalizumab and rituximab) were effective in achieving complete remission on minimal therapy (29%) without recurrence, although rituximab was associated with a relatively high mortality rate (29%). CONCLUSIONS Current data suggest that topical corticosteroids are effective and safe and should remain the first line of treatment for bullous pemphigoid in older adults. However, their application is difficult and requires a high-functioning patient, third-party assistance, or a relatively mild disease. Biological agents are effective but warrant meticulous patient selection owing to the relatively high mortality rate associated with rituximab. CLINICAL TRIAL REGISTRATION PROSPERO registration number CRD42020186686.
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Amber KT, Murrell DF, Schmidt E, Joly P, Borradori L. Autoimmune Subepidermal Bullous Diseases of the Skin and Mucosae: Clinical Features, Diagnosis, and Management. Clin Rev Allergy Immunol 2018; 54:26-51. [PMID: 28779299 DOI: 10.1007/s12016-017-8633-4] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Autoimmune subepidermal blistering diseases of the skin and mucosae constitute a large group of sometimes devastating diseases, encompassing bullous pemphigoid, gestational pemphigoid, mucous membrane pemphigoid, epidermolysis bullosa acquisita, and anti-p200 pemphigoid. Their clinical presentation is polymorphic. These autoimmune blistering diseases are associated with autoantibodies that target distinct components of the basement membrane zone of stratified epithelia. These autoantigens represent structural proteins important for maintenance of dermo-epidermal integrity. Bullous pemphigoid (BP) is the most common subepidermal autoimmune blistering disease of the skin and mucosae. Although the disease typically presents with a generalized blistering eruption associated with itch, atypical variants with either localized bullous lesions or "non-bullous" presentations are observed in approximately 20% of patients. A peculiar form of BP typically associated with pregnancy is pemphigoid gestationis. In anti-p200 pemphigoid, patients present with tense blisters on erythematosus or normal skin resembling BP, with a predilection for acral surfaces. These patients have antibodies targeting the 200-kDa basement membrane protein. Epidermolysis bullosa is a rare autoimmune blistering disease associated with autoantibodies against type VII collagen that can have several phenotypes including a classical form mimicking dystrophic epidermolysis bullosa, an inflammatory presentation mimicking BP, or mucous membrane pemphigoid-like lesions. Mucous membrane pemphigoid (MMP) is the term agreed upon by international consensus for an autoimmune blistering disorder, which affects one or more mucous membrane and may involve the skin. The condition involves a number of different autoantigens in the basement membrane zone. It may result in severe complications from scarring, such as blindness and strictures. Diagnosis of these diseases relies on direct immunofluorescence microscopy studies and immunoserological assays. Management of affected patients is often challenging. We will here review the clinical and immunopathological features as well as the pathophysiology of this group of organ-specific autoimmune diseases. Finally, we will discuss the diagnostic approach and the principles of management in clinical practice.
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Affiliation(s)
- Kyle T Amber
- Department of Dermatology, University of California Irvine Health, 118 Med Surg 1, Irvine, CA, 92697, USA.
| | - Dedee F Murrell
- Department of Dermatology, St. George Hospital, Gray Street, Kogarah, Sydney, NSW, Australia
| | - Enno Schmidt
- Department of Dermatology, University of Lübeck, Lübeck, Germany
- Lübeck Institute of Experimental Dermatology (LIED), University of Lübeck, Lübeck, Germany
| | - Pascal Joly
- Department of Dermatology, INSERM U901, University of Rouen, Rouen, France
| | - Luca Borradori
- Department of Dermatology, University of Bern, Bern, Switzerland
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Yarom N, Zelig K, Epstein JB, Gorsky M. The efficacy of minocycline mouth rinses on the symptoms associated with recurrent aphthous stomatitis: a randomized, double-blind, crossover study assessing different doses of oral rinse. Oral Surg Oral Med Oral Pathol Oral Radiol 2017; 123:675-679. [PMID: 28411006 DOI: 10.1016/j.oooo.2017.02.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 01/30/2017] [Accepted: 02/14/2017] [Indexed: 01/10/2023]
Abstract
OBJECTIVE The aim of the study was to assess the efficacy of 2 different concentrations of minocycline mouthwashes on the symptoms of recurrent aphthous stomatitis (RAS). STUDY DESIGN The 2-year study was designed as a randomized, double-blind, crossover study. Healthy patients with frequent RAS episodes received 2 sealed and computer-randomized marked kits containing minocycline mouthwashes (0.2% and 0.5% solution). The patients were asked to use 1 of the kits on the first episode of RAS, starting with the first onset of prodromal symptoms, until the symptoms resolved or up to a maximum of 10 days (whichever came first). The patients were asked to use their second kit during a subsequent episode. RESULTS A total of 14 patients (8 males, 6 females) completed the 2 arms of the study. The mean intensity of pain was significantly lower when the 0.5% solution was used compared with the 0.2% solution (P = .027). The difference reached the level of statistical significance as soon as the end of the second day of use (P = .032). Only minor and temporary adverse reactions were documented. CONCLUSIONS We found that 0.5% minocycline mouth rinse was more effective than the 0.2% concentration, which had been suggested by our group in previous studies for the management of RAS.
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Affiliation(s)
- Noam Yarom
- Oral Medicine Unit, The Chaim Sheba Medical Center, Tel Hashomer, Israel; Department of Oral Pathology and Oral Medicine, The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel.
| | - Keren Zelig
- Department of Oral Pathology and Oral Medicine, The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Joel B Epstein
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, CA; and Consulting staff, City of Hope, Duarte, CA, USA
| | - Meir Gorsky
- Department of Oral Pathology and Oral Medicine, The Maurice and Gabriela Goldschleger School of Dental Medicine, Tel Aviv University, Tel Aviv, Israel
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Chalmers JR, Wojnarowska F, Kirtschig G, Nunn AJ, Bratton DJ, Mason J, Foster KA, Whitham D, Williams HC. A randomized controlled trial to compare the safety and effectiveness of doxycycline (200 mg daily) with oral prednisolone (0.5 mg kg(-1) daily) for initial treatment of bullous pemphigoid: a protocol for the Bullous Pemphigoid Steroids and Tetracyclines (BLISTER) Trial. Br J Dermatol 2015; 173:227-34. [PMID: 25683592 DOI: 10.1111/bjd.13729] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2015] [Indexed: 11/30/2022]
Abstract
BACKGROUND Bullous pemphigoid (BP) is the most common autoimmune blistering disease in older people, and is associated with significant morbidity and mortality. Oral corticosteroids are usually effective but the side-effects are thought to contribute to the high morbidity and mortality rate. Treatment with oral tetracyclines may be effective but high-quality, randomized controlled trials (RCTs) are needed to confirm this. OBJECTIVES To compare the effectiveness and safety of two strategies for treating BP. METHODS This is a two-arm, parallel group, 52-week RCT comparing doxycycline with prednisolone for initial treatment of BP. Dose is fixed for the initial 6 weeks of treatment (doxycycline 200 mg daily; prednisolone 0.5 mg kg(-1) daily), after which it can be adjusted according to need. A total of 256 patients with BP will be recruited in the U.K. and Germany. RESULTS The primary outcomes are: (i) effectiveness (assessor-blinded blister count at 6 weeks) and (ii) safety [proportion of patients experiencing ≥ grade 3 adverse events (i.e. severe, life: threatening or fatal) related to trial medication during the year of follow-up]. Primary effectiveness analysis will be an assessment of whether doxycycline can be considered noninferior to prednisolone after 6 weeks of treatment. Primary safety analysis is a superiority analysis at 12 months. Secondary outcomes include longer-term assessment of effectiveness, relapse rates, the proportion of patients experiencing any grade of adverse events related to treatment, quality of life and cost-effectiveness. CONCLUSIONS The trial will provide good evidence for whether the strategy of starting BP treatment with doxycycline is a useful alternative to prednisolone.
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Affiliation(s)
- J R Chalmers
- Centre of Evidence Based Dermatology, University of Nottingham, King's Meadow Campus Lenton Lane, Nottingham, NG7 2NR, U.K
| | - F Wojnarowska
- Nuffield Department of Clinical Medicine, Oxford University, Oxford, OX3 7BN, U.K
| | - G Kirtschig
- Centre of Evidence Based Dermatology, University of Nottingham, King's Meadow Campus Lenton Lane, Nottingham, NG7 2NR, U.K
| | - A J Nunn
- Medical Research Council Clinical Trials Unit, Aviation House 125 Kingsway, London, WC2B 6NH, U.K
| | - D J Bratton
- Medical Research Council Clinical Trials Unit, Aviation House 125 Kingsway, London, WC2B 6NH, U.K
| | - J Mason
- School for Medicine, Pharmacy and Health, Wolfson Research Institute, Durham University, Stockton on Tees, TS17 6BH, U.K
| | - K A Foster
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, C Floor South Block, Nottingham, U.K
| | - D Whitham
- Nottingham Clinical Trials Unit, Nottingham Health Science Partners, C Floor South Block, Nottingham, U.K
| | - H C Williams
- Centre of Evidence Based Dermatology, University of Nottingham, King's Meadow Campus Lenton Lane, Nottingham, NG7 2NR, U.K.,Dermatology Department, Queen's Medical Centre, University of Nottingham, Nottingham, NG7 2UH, U.K
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Venning V, Taghipour K, Mohd Mustapa M, Highet A, Kirtschig G, Hughes J, McLelland J, McDonagh A, Punjabi S, Buckley D, Nasr I, Swale V, Duarte Williams C, McHenry P, Wagle S, Amin S, Davis R, Haveron S. British Association of Dermatologists’ guidelines for the management of bullous pemphigoid 2012. Br J Dermatol 2012; 167:1200-14. [DOI: 10.1111/bjd.12072] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- V.A. Venning
- Department of Dermatology, Churchill Hospital, Old Road, Headington, Oxford OX3 7LJ, U.K
| | - K. Taghipour
- Department of Dermatology, Whittington Hospital, Magdala Avenue, London N19 5NF, U.K
| | - M.F. Mohd Mustapa
- British Association of Dermatologists, Willan House, 4 Fitzroy Square, London W1T 5HQ, U.K
| | - A.S. Highet
- York Hospital, Wigginton Road, York YO31 8HE, U.K
| | - G. Kirtschig
- Vrije Universtiteit, PO Box 7057, Amsterdam NL‐1007 MB, the Netherlands
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Miida H, Fujiwara H, Ito M. Association between effective dose of prednisolone, alone or in conjunction with other immunosuppressants, and titre of anti-bullous pemphigoid 180 antibody: a retrospective study of 42 cases. Clin Exp Dermatol 2011; 36:485-8. [PMID: 21392080 DOI: 10.1111/j.1365-2230.2010.04013.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND Corticosteroids, especially prednisolone or prednisone, are the most commonly used drugs for the treatment of bullous pemphigoid (BP). However, the appropriate initial effective prednisolone dose has not been established. Recently, a highly sensitive and specific ELISA for detection of autoantibodies to the non-collagenous extracellular domain (NC16A) of the 180 kDa transmembrane hemidesmosome component [bullous pemphigoid (BP)180] was developed, and the titre of anti-BP180 antibody was found to be closely related to disease activity. AIM To investigate the relationship between anti-BP180 antibody titre and effective prednisolone dose alone or in conjunction with other immunosuppressants. METHODS Anti-BP180 antibody titres were measured by ELISA for the NC16A domain of BP180 in the sera of patients with BP (n = 42) at the start of treatment. The effective prednisolone dose was calculated from the patients' records. RESULTS Higher anti-BP180 antibody titres correlated with a higher effective prednisolone dose. In particular, patients with antibody titres > 200 required a significantly higher effective prednisolone dose than did those with antibody titres ≤ 200. CONCLUSIONS A higher effective prednisolone dose may be necessary for patients who have both a high titre of anti-BP180 antibody and severe clinical disease.
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Affiliation(s)
- H Miida
- Division of Dermatology, Niigata University Graduate School of Medical and Dental Sciences, Chuo-Ku, Niigata, Japan.
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Elad S, Epstein JB, von Bültzingslöwen I, Drucker S, Tzach R, Yarom N. Topical immunomodulators for management of oral mucosal conditions, a systematic review; part II: miscellaneous agents. Expert Opin Emerg Drugs 2011; 16:183-202. [DOI: 10.1517/14728214.2011.528390] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Mutasim DF. Autoimmune bullous dermatoses in the elderly: an update on pathophysiology, diagnosis and management. Drugs Aging 2010; 27:1-19. [PMID: 20030429 DOI: 10.2165/11318600-000000000-00000] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Elderly individuals are susceptible to autoimmune bullous dermatoses (ABDs), which may be associated with high morbidity and mortality. ABDs result from an autoimmune response to components of the basement membrane zone at the dermal-epidermal junction or desmosomes. Bullous pemphigoid results from autoimmunity to hemidesmosomal proteins present in the basement membrane of stratified squamous epithelia. Patients present with tense blisters in flexural areas of the skin. Mild disease may be treated with potent topical corticosteroids, while extensive disease usually requires systemic corticosteroids or systemic immunosuppressive agents such as azathioprine. Mucosal pemphigoid affects one or more mucous membranes that are lined by stratified squamous epithelia. The two most commonly involved sites are the eye and the oral cavity. Lesions frequently result in scar formation that may cause blindness. Patients with severe disease or ocular involvement require aggressive therapy with corticosteroids and cyclophosphamide. Epidermolysis bullosa acquisita results from autoimmunity to type VII collagen in the anchoring fibrils of the basement membrane. Lesions may either arise on an inflammatory base or be non-inflammatory and result primarily from trauma. Treatment options include corticosteroids, dapsone, ciclosporin, methotrexate and plasmapheresis/immunoapheresis. Paraneoplastic pemphigus results from autoimmunity to multiple desmosomal antigens. The disorder is associated with neoplasms, especially leukaemia, lymphoma and thymoma. Patients present with stomatitis and polymorphous skin eruption. The disease may respond to successful treatment of the underlying neoplasm or may require immunosuppressive therapy.
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Affiliation(s)
- Diya F Mutasim
- Department of Dermatology, University of Cincinnati, College of Medicine, 231 Albert Sabin Way, P.O. Box 670592, Cincinnati, OH 45267-0592, USA.
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Florez, D Sanchez-Aguilar, J Toribi A. Treatment of generalized bullous pemphigoid with erythromycin and nicotinamide. J DERMATOL TREAT 2009. [DOI: 10.1080/09546630050517649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Kligman A. Comparison of a topical benzoyl peroxide gel, oral minocycline, oral doxycycline and a combination for suppression ofP. acnesin acne patients. J DERMATOL TREAT 2009. [DOI: 10.3109/09546639809160552] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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ITOH T, HOSOKAWA H, SHIRAI Y, HORIO T. Successful treatment of bullous pemphigoid with pulsed intravenous cyclophosphamide. Br J Dermatol 2008. [DOI: 10.1046/j.1365-2133.1996.131866.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Abstract
Autoimmune bullous diseases result from an immune response to molecular components of the desmosome or basement membrane. Bullous diseases are associated with a high degree of morbidity and occasional mortality. Therapy of bullous diseases consists of suppressing the immune system, controlling inflammation and improving healing of erosions. The therapeutic agents used in the treatment of bullous diseases may be associated with high morbidity and occasional mortality. Successful treatment requires understanding of the pathophysiology of the disease process and the pharmacology of the drugs being used.
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Affiliation(s)
- Diya F Mutasim
- Department of Dermatology, University of Cincinnati College of Medicine Cincinnati, OH, USA
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Voien NK, Hansen SK, Hattel T, Laurberg G. Oxytetracycline suppresses bulla formation in epidermolysis bullosa simplex. J Eur Acad Dermatol Venereol 2006. [DOI: 10.1111/j.1468-3083.1995.tb00330.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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17
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Hansen SK, Veien NK. Oxytetracycline in epidermolysis bullosa simplex. A double-blind, placebo-controlled trial. J Eur Acad Dermatol Venereol 2006. [DOI: 10.1111/j.1468-3083.1996.tb00185.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
Bullous pemphigoid (BP) is a chronic, autoimmune, blistering disease observed primarily in the elderly population. Several clinical variants have been described, including classic (bullous), localised, nodular, vegetating, erythrodermic, erosive, childhood and drug-induced forms. Autoantibodies target the BP230 and BP180 antigens, located in the hemidesmosomal complex of the skin basement membrane zone. Subsequent complement activation recruits chemical and cellular immune mediators to the skin, ultimately resulting in blister formation. Both autoantibodies and complement may be detected by various immunofluorescent, immune electron microscopy and molecular biology techniques. Recent trials suggest that potent topical corticosteroids should be considered as first-line therapy. Tetracycline with or without nicotinamide may benefit a subset of patients with mild BP. Oral corticosteroids should rarely exceed 0.75 mg/kg/day and corticosteroid-sparing agents may be useful for recalcitrant disease.
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Affiliation(s)
- Scott R A Walsh
- Division of Dermatology, University of Toronto, Toronto, Ontario, Canada
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Mutasim DF. Management of autoimmune bullous diseases: Pharmacology and therapeutics. J Am Acad Dermatol 2004; 51:859-77; quiz 878-80. [PMID: 15583576 DOI: 10.1016/j.jaad.2004.02.013] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Bullous diseases are associated with high morbidity and mortality. They result from autoimmune response to one or more components of the basement membrane or desmosomes. Management consists of treating the immunologic basis of the disease, treating the inflammatory process involved in lesion formation, and providing supportive care both locally and systemically. Therapeutic agents are chosen based on their known pharmacologic properties and evidence of effectiveness derived from observations and studies. Learning objectives At the completion of this learning activity, participants should be able to understand the pharmacology of drugs used in the treatment of bullous diseases, the principles of therapy for various such diseases, and a practical approach to the management of these diseases.
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Affiliation(s)
- Diya F Mutasim
- Department of Dermatology, University of Cincinnati, College of Medicine, OH 45267-0592, USA.
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Tsankov N, Broshtilova V, Kazandjieva J. Tetracyclines in dermatology. Dis Mon 2004. [DOI: 10.1016/j.disamonth.2004.05.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Chen S, Lu X, Zhou G. Mild pemphigus foliaceus responding to combination therapy with niacinamide and tetracycline. Int J Dermatol 2004; 42:981-2. [PMID: 14636199 DOI: 10.1111/j.1365-4632.2003.01478.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Assmann T, Voss R, Ruzicka T, Megahed M. [Therapy resistant pemphigus vulgaris. Combination therapy with methylprednisolone and doxycycline]. Hautarzt 2004; 54:979-81. [PMID: 14513248 DOI: 10.1007/s00105-003-0594-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- T Assmann
- Department of Dermatology, University of Duesseldorf
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Abstract
Elderly individuals are susceptible to autoimmune bullous dermatoses (in particular, pemphigoid, epidermolysis bullosa acquisita and paraneoplastic pemphigus). Bullous dermatoses are associated with high morbidity and mortality. Bullous dermatoses result from autoimmune responses to one or more components of the basement membrane or desmosomes. Pemphigoid results from autoimmunity to hemidesmosomal proteins present in the basement membrane of stratified squamous epithelia. Patients present with tense blisters in flexural areas of the skin. Mild or moderate bullous pemphigoid may be treated with potent topical corticosteroids while extensive disease usually requires systemic corticosteroids or systemic immunosuppressive agents such as azathioprine. Mucosal pemphigoid affects one or more mucous membranes that are lined by stratified squamous epithelia. The two most commonly involved sites are the eye and the oral cavity. Lesions frequently result in scar formation, which may cause blindness. Patients with severe disease or ocular involvement require aggressive therapy with corticosteroids and cyclophosphamide. Epidermolysis bullosa acquisita results from autoimmunity to type VII collagen in the anchoring fibrils of the basement membrane area. Lesions may either arise on an inflammatory base or be non-inflammatory and result primarily from trauma. The inflammatory type of the disease is more responsive to therapy than the non-inflammatory type. Treatment options include corticosteroids, dapsone, cyclosporin, plasmapheresis and immunoglobulin G. Paraneoplastic pemphigus results from autoimmunity to multiple antigens within the desmosomes. The disorder is associated with neoplasms, especially leukaemia and lymphoma. Patients present with severe stomatitis and polymorphous skin eruption. The mucosal and cutaneous involvement may respond to successful treatment of the underlying neoplasm or may require immunosuppressive therapy.
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Affiliation(s)
- Diya F Mutasim
- Department of Dermatology, University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA.
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Abstract
Bullous pemphigoid (BP) is the most frequent auto-immune blistering skin disease. Up to recently, it was treated with oral corticosteroids. High dose steroids are poorly tolerated in the elderly and probably contributed to the high mortality rates observed in several cohorts. For years, efforts have been devoted to looking for steroid sparing agents including immunosuppressive drugs, plasma exchanges, intravenous immunoglobulins, tetracycline. Many seemed useful in open series but proved ineffective or marginally effective when tested in randomized controlled trials. An important breakthrough was the demonstration by a large randomized trial that a "super-potent" topical corticosteroid (clobetasol propionate) was not only associated with a significant decrease in severe complications and mortality of BP patients but was also more effective than oral prednisone. New strategies for BP should include topical clobetasol propionate as the first line treatment and consider adjuvant therapy only in the very rare cases that are either resistant to or intolerant of this treatment.
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Affiliation(s)
- Juliette Fontaine
- Department of Dermatology of Hôpital Henri Mondor, Université Paris XII, Créteil, France
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Affiliation(s)
- Nikolai Tsankov
- Department of Dermatology and Venereology, Sofia University of Medicine, Bulgaria.
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Wojnarowska F, Kirtschig G, Highet AS, Venning VA, Khumalo NP. Guidelines for the management of bullous pemphigoid. Br J Dermatol 2002; 147:214-21. [PMID: 12174090 DOI: 10.1046/j.1365-2133.2002.04835.x] [Citation(s) in RCA: 108] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
These guidelines 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. The guidelines reflect data available from Medline, Embase, the Cochrane library, literature searches and the experience of the authors of managing patients with bullous pemphigoid in special and general clinics for over 10 years. However, caution should be exercised in interpreting the data obtained from the literature because only six randomized controlled trials are available involving small groups of patients.
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Affiliation(s)
- F Wojnarowska
- Department of Dermatology, Oxford Radcliffe Hospital, The Churchill, Old Road, Headington, Oxford OX3 7LJ, UK.
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Mueller RS, Fieseler KV, Bettenay SV, Rosychuk RAW. Influence of long-term treatment with tetracycline and niacinamide on antibody production in dogs with discoid lupus erythematosus. Am J Vet Res 2002; 63:491-4. [PMID: 11939308 DOI: 10.2460/ajvr.2002.63.491] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To evaluate the effect of long-term treatment with tetracycline and niacinamide on antibody production in dogs by measuring postvaccinal serum concentrations of antibodies against canine parvovirus and canine distemper virus. ANIMALS 10 dogs receiving long-term treatment with tetracycline and niacinamide (treatment group) and 10 healthy dogs (control group). PROCEDURE The treatment group included 9 dogs with discoid lupus erythematosus and 1 dog with pemphigus foliaceus on long-term treatment (> 12 months) with tetracycline and niacinamide. The control group included 10 healthy dogs with no clinical signs of disease and no administered medications for the past 3 months. Blood samples were obtained from all dogs by jugular venipuncture. Serum antibody titers against canine parvovirus and canine distemper virus antigens were measured, using hemaglutination inhibition and serum neutralization, respectively, and compared between groups. RESULTS A significant difference in antibody titers between treatment- and control-group dogs was not found. All dogs had protective antibody titers against canine distemper virus, and 8 of 10 dogs from each group had protective titers against canine parvovirus infection. CONCLUSION AND CLINICAL RELEVANCE These results provide evidence that long-term treatment with tetracycline and niacinamide does not interfere with routine vaccinations and thus does not seem to influence antibody production in dogs.
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Affiliation(s)
- Ralf S Mueller
- Department of Clinical Sciences, College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins 80523, USA
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Affiliation(s)
- G C Chaidemenos
- Hospital For Skin and Venereal Diseases, Department of Dermatology and Venereology, Thessaloniki, Greece.
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Affiliation(s)
- V Ruocco
- Department of Dermatology, Second University of Naples, Naples, Italy
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Abstract
The diagnostic workup for canine claw disease consists of a good history and complete clinical examination which may provide clues for a possible underlying disorder. In dogs with claw disease but no other clinical or historical signs, further recommended diagnostic procedures include cytological evaluation of impression smears or discharge from the claw fold, bacterial culture and sensitivity testing, biopsy of the claw matrix, and an elimination diet for 6 to 8 weeks. If no underlying disease can be identified, trial treatment with essential fatty acid supplementation, vitamin E, or a combination of doxycycline hydrochloride and niacinamide may be useful. In some patients, onychectomy of all claws may be considered.
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Affiliation(s)
- R S Mueller
- Animal Skin and Allergy Clinic, Mount Waverley, Australia.
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Abstract
Scleroderma, psoriasis, lichen planus, and other skin disorders may signal a more serious internal disease. Physicians who recognize such clues can initiate early treatment while disease is in its early stages. The authors of this article describe several of the more common dermatologic conditions linked to systemic disease, including connective tissue, inflammatory, immunobullous, and infectious diseases.
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Affiliation(s)
- R S Kirsner
- Department of Dermatology and Cutaneous Surgery, University of Miami School of Medicine, USA
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Fivenson DP, Kimbrough TL. Lichen planus pemphigoides: combination therapy with tetracycline and nicotinamide. J Am Acad Dermatol 1997; 36:638-40. [PMID: 9092758 DOI: 10.1016/s0190-9622(97)70260-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- D P Fivenson
- Department of Dermatology, Henry Ford Hospital, Detroit, Michigan, USA
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Abstract
PURPOSE Pemphigoid is a well-recognized cutaneous lesion, occurring rarely in peristomal skin. We report the diagnosis and successful treatment of localized pemphigoid lesions adjacent to a colostomy. METHODS We review the chart, immunofluorescence study, treatment, and follow-up of a patient with bullous lesions at a colostomy site. RESULT Pemphigoid of the pericolostomy skin was diagnosed by immunofluorescence study and successfully treated with antibiotic. CONCLUSION Diagnosis of bullous pemphigoid should be considered in the differential diagnosis of a bullous lesion adjacent to a colostomy site. Diagnosis is easily made, and treatment is simple and efficacious.
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Affiliation(s)
- D M Vande Maele
- Department of Colon and Rectal Surgery, St. Vincent Health Center, Erie, Pennsylvania, USA
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Hornschuh B, Hamm H, Wever S, Hashimoto T, Schröder U, Bröcker EB, Zillikens D. Treatment of 16 patients with bullous pemphigoid with oral tetracycline and niacinamide and topical clobetasol. J Am Acad Dermatol 1997; 36:101-3. [PMID: 8996271 DOI: 10.1016/s0190-9622(97)70336-0] [Citation(s) in RCA: 52] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- B Hornschuh
- Department of Dermatology, University of Würzburg, Germany
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Affiliation(s)
- R J Nisengard
- School of Dental Medicine, State University of New York, Buffalo, USA
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ITOH T, HOSOKAWA H, SHIRAI Y, HORIO T. Successful treatment of bullous pemphigoid with pulsed intravenous cyclophosphamide. Br J Dermatol 1996. [DOI: 10.1111/j.1365-2133.1996.tb06329.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Abstract
Pemphigus is an autoimmune blistering disease with high mortality if untreated. The cases of 10 patients who had minocycline 100 mg daily added as adjuvant therapy are reported. Prior to the use of minocycline, all patients had active disease, nine were on prednisolone (10-40 mg) and five were on azathioprine (100-200 mg). The response was assessed on clinical improvement and reduction of immunosuppressive (IS) drugs. It was graded into four categories: major, minor, equivocal and no significant response. A major response was seen in four patients, minor in two, equivocal in one and no improvement in three patients. The prednisolone dose in the six responders was reduced to 0-6 mg (0 mg in three patients), with an average decrease of 21 mg. The average time to respond was 8 months. Of the six responders, three were on azathioprine, which was ceased in two patients and reduced by two-thirds in the other patient. No patient ceased minocycline because of side effects. In conclusion, minocycline 100 mg daily is a simple, safe and well tolerated treatment that should be tried in patients with pemphigus to reduce disease activity and/or the dose of potent IS agents.
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Affiliation(s)
- Z S Gaspar
- Department of Dermatology, Churchill, Oxford Radcliffe Hospital, Headington, UK
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41
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Affiliation(s)
- J D Fine
- Department of Dermatology, University of North Carolina at Chapel Hill 27599, USA
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42
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Beckers RC, Brand A, Vermeer BJ, Boom BW. Adjuvant high-dose intravenous gammaglobulin in the treatment of pemphigus and bullous pemphigoid: experience in six patients. Br J Dermatol 1995; 133:289-93. [PMID: 7547400 DOI: 10.1111/j.1365-2133.1995.tb02631.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
At present, initial high-dose prednisone is the treatment of choice for patients with pemphigus and bullous pemphigoid. To reduce the risks associated with long-term corticosteroid treatment, other immunosuppressants are often given as steroid-sparing agents. Occasionally, the dose of steroids cannot be reduced. In this study, we report six patients with pemphigus vulgaris, pemphigus foliaceus and bullous pemphigoid, in whom the daily corticosteroid dose could only be tapered to acceptable, effective, maintenance levels following treatment with high-dose intravenous gammaglobulin.
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Affiliation(s)
- R C Beckers
- Department of Dermatology, University Hospital Leiden, The Netherlands
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Kolbach DN, Remme JJ, Bos WH, Jonkman MF, De Jong MC, Pas HH, van der Meer JB. Bullous pemphigoid successfully controlled by tetracycline and nicotinamide. Br J Dermatol 1995; 133:88-90. [PMID: 7669647 DOI: 10.1111/j.1365-2133.1995.tb02498.x] [Citation(s) in RCA: 56] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
In 1986, Berk and Lorincz reported the efficacy of tetracycline and nicotinamide in the treatment of bullous pemphigoid (BP). In the present study of seven patients with BP, we found that a regimen of 2 g tetracycline combined with 2 g nicotinamide daily was effective in clearing the skin lesions. Total remission was achieved within 6-8 weeks, after which the dose was gradually tapered. The mean duration of therapy was 7 months. No effect on the titre of antibasement membrane antibodies was observed. The mode of action of this therapy is unknown.
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Affiliation(s)
- D N Kolbach
- Department of Dermatology, Academisch Ziekenhuis, Groningen, Velsen, The Netherlands
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44
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Affiliation(s)
- S C Huilgol
- Department of Immunofluorescence, St John's Institute of Dermatology, St Thomas' Hospital, London, UK
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45
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Pereyo NG, Davis LS. Generalized bullous pemphigoid controlled by tetracycline therapy alone. J Am Acad Dermatol 1995; 32:138-9. [PMID: 7822510 DOI: 10.1016/0190-9622(95)90217-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- N G Pereyo
- Department of Dermatology, Medical College of Georgia, Augusta 30912-2900
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46
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Coskey RJ. Dermatologic therapy: 1993. J Am Acad Dermatol 1994; 31:764-74. [PMID: 7929923 DOI: 10.1016/s0190-9622(94)70239-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
This article reviews some therapeutic results reported in the English-language literature during 1993. Readers should review the original article in full before attempting any experimental or controversial therapy.
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Affiliation(s)
- R J Coskey
- Dermatology Department, Wayne State University School of Medicine, Detroit, Michigan
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47
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Affiliation(s)
- M J Fellner
- Department of Dermatology, Mount Sinai Medical Center, New York
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