A randomized trial of the efficacy of a new micronized formulation versus a standard formulation of isotretinoin in patients with severe recalcitrant nodular acne

BACKGROUND

Isotretinoin is very frequently the drug of choice for the management of severe recalcitrant nodular acne. Recently, a new micronized and more bioavailable formulation of isotretinoin has been developed that permits once-daily administration in lower doses than usually used with standard isotretinoin (Accutane), regardless of whether it is taken with or without food.

OBJECTIVE

Our purpose was to determine whether micronized isotretinoin and standard isotretinoin are clinically equivalent.

METHODS

In this multicenter, double-blind, double-dummy study, 600 patients with severe recalcitrant nodular acne were treated with either 0.4 mg/kg of micronized isotretinoin once daily without food (n = 300) or 1.0 mg/kg per day of standard isotretinoin in two divided doses with food (n = 300). Lesion counts were monitored over 20 weeks.

RESULTS

Both treatment groups in this well-controlled clinical trial experienced an equivalent reduction in the number of total nodules (facial plus truncal). In addition, an equivalent proportion of patients achieved 90% clearance of the total number of nodules. Both formulations had similar results for other efficacy variables.

CONCLUSION

Once-daily use of the micronized and more bioavailable formulation of isotretinoin under fasted conditions is clinically equivalent to the standard twice-daily formulation under fed conditions in the treatment of severe recalcitrant nodular acne.

Safety of a new micronized formulation of isotretinoin in patients with severe recalcitrant nodular acne: A randomized trial comparing micronized isotretinoin with standard isotretinoin

BACKGROUND

Isotretinoin is a very effective drug for treating severe recalcitrant nodular acne. A new micronized formulation of isotretinoin has been shown to be clinically equivalent to standard isotretinoin with improved bioavailability and minimal food effect. The safety profile of the micronized formulation has not been described previously.

OBJECTIVE

The objective of this article is to report the incidence and intensity of adverse events found in a comparative, double-blind efficacy study that showed clinical equivalence of the new micronized formulation of isotretinoin and the standard isotretinoin formulation (Accutane).

METHODS

Six hundred patients with severe recalcitrant nodular acne were treated with micronized isotretinoin (n = 300) under fasted conditions or standard isotretinoin (n = 300) under fed conditions. One cohort received single daily doses of 0.4 mg/kg of micronized isotretinoin without food and the other cohort received 1.0 mg/kg per day of standard isotretinoin in two divided doses with food. Adverse events were monitored during 20 weeks of drug therapy.

RESULTS

The proportion of adverse events in most body systems was generally lower in patients receiving micronized isotretinoin than in those receiving standard isotretinoin.

CONCLUSION

Micronized isotretinoin appears to have a safety profile similar to that of standard isotretinoin and to carry a lower risk of mucocutaneous events and hypertriglyceridemia.

Health-related quality of life among patients with facial acne -- assessment of a new acne-specific questionnaire

The psychosocial effects of facial acne are well accepted but until recently few validated instruments existed which were suitable for use in clinical trials. The aim of this study was to assess measurement characteristics (reproducibility, correlation with acne severity, and sensitivity to detect change after acne therapy) of a new acne-specific quality of life instrument, the Acne-QoL. We found that the Acne-QoL is reliable, valid and able to distinguish differences across severity groups and improvement over 16 weeks of standard therapy. The use of the Acne-QoL should aid physicians in understanding the impact of facial acne on young adults, and may be useful in assessing therapeutic effects in acne clinical trials.

Treatment of acne with a combination clindamycin/benzoyl peroxide gel compared with clindamycin gel, benzoyl peroxide gel and vehicle gel: combined results of two double-blind investigations

BACKGROUND

It has previously been shown that a combination of erythromycin and benzoyl peroxide is superior to either ingredient when used alone in the treatment of acne. A clindamycin/benzoyl peroxide combination gel might have an advantage over erythromycin/benzoyl peroxide gel because the former does not require refrigeration after it is dispensed.

OBJECTIVE

Our purpose was to determine the efficacy and safety of a combination clindamycin/benzoyl peroxide gel when compared with benzoyl peroxide, clindamycin, or vehicle gels.

METHODS

In two double-blind, randomized, parallel, vehicle-controlled trials, patients were treated for 11 weeks with once-nightly application of one of the above preparations. Evaluations were performed at 2, 5, 8, and 11 weeks and included lesion counts and assessment of global responses and irritant effects.

RESULTS

A total of 334 patients completed the study. All three active preparations were significantly superior to the vehicle in global improvement and in reducing inflammatory lesions and noninflammatory lesions. The combination gel was significantly superior to the two individual agents in global improvement and reduction of inflammatory lesions and also to the clindamycin gel in reducing noninflammatory lesions. There was no significant difference in tolerance to the active gels versus the vehicle gel.

CONCLUSION

In the treatment of acne, topical clindamycin/benzoyl peroxide combination gel is well tolerated and superior to either individual ingredient.

Actinic damage and skin cancer in albinos in northern Tanzania: findings in 164 patients enrolled in an outreach skin care program

Persons with albinism are particularly vulnerable to the deleterious effects of UV light on their skin. We obtained histories and performed skin examinations on 164 albino patients living in equatorial Africa to determine their sun exposure, sun protection, and sun damage. Many patients did not wear hats and most wore short-sleeved shirts. Except for four infants, all patients had sunburned skin. Actinic cheilitis, actinic keratoses, and skin cancers were detected in many patients. Sun protection methods will be important for prevention of skin damage in albino patients.

Cutaneous metastases in patients with metastatic carcinoma: a retrospective study of 4020 patients

BACKGROUND

Most previous studies have found that cutaneous metastases occur infrequently and are rarely present at the time the cancer is initially diagnosed.

OBJECTIVE

We studied patients with metastatic cancer to determine the overall frequency of skin metastases, the frequency that these were the first sign of extranodal disease, and the clinical and histologic features of the cutaneous lesions.

METHODS

A 10-year period of tumor registry files was searched for patients with metastatic carcinoma and melanoma. For patients with skin metastases, medical records and pathology reports were also examined.

RESULTS

Of 4020 patients with metastatic disease, 420 (10%) had cutaneous metastases; in 306 of them the skin metastases were the first sign of extranodal metastatic Breast cancer and melanoma were the most common. Nodules were the most frequent clinical presentation, although inflammatory, cicatricial, and bullous lesions were also noted. Incisional metastases were common. Histologic findings most frequently revealed adenocarcinoma that was sometimes suggestive of the site of origin. After recognition of skin metastases, mean patient survival ranged from 1 to 34 months depending on tumor type.

CONCLUSION

Cutaneous metastases are not uncommon and frequently are the first sign of extranodal metastatic disease, particularly in patients with melanoma, breast cancer, or mucosal cancers of the head and neck.

A clinical and pathologic study of histiocytosis X in adults

BACKGROUND

Histiocytosis X is a neoplastic disorder of Langerhans cells that usually occurs in children. Because histiocytosis X rarely occurs in adults, the diagnosis can frequently be missed by both clinicians and pathologists.

OBJECTIVE

The purpose of this investigation was to characterize the clinical and pathologic findings of histiocytosis X in adults.

METHODS

A retrospective study of four adults with histiocytosis X was undertaken. Paraffin-embedded biopsy specimens were stained with a panel of antibodies including S-100, vimentin, Ham-56, leukocyte common antigen, proliferating cell nuclear antigen (PCNA), UCHL-1, CD43, and Ki-1.

RESULTS

The predominant lesions were papules and pustules that usually involved the groin, axilla, and scalp. Histologically the infiltrate exhibited a periappendageal distribution. Strong positive staining for PCNA appeared to correlate with the clinical course.

CONCLUSION

Histiocytosis X in adults has a predilection for skin sites rich in appendages and histologically shows a periappendageal infiltrate. PCNA staining of the histiocytes may indicate progressive disease and serve as a useful prognostic marker.

Verruciform xanthoma in an immunocompromised patient: a case report and immunohistochemical study

The etiology of verruciform xanthoma, a rare lesion that usually occurs in the oral mucosa, is unknown. A viral etiology has been speculated since extraoral lesions usually occur in the genitalia. We present, to the best of our knowledge, the first reported case of verruciform xanthoma in an immunocompromised patient with chronic graft versus host disease. Immunohistochemical studies showed a few Ham 56 (a macrophage marker) positive foam cells, both in the dermis and within the epidermis, supporting a role for an epidermal process in production of the foam cells. Staining for human papillomavirus protein (HPV) showed reactivity of some of the nuclei in the dermal histiocytes, but in situ hybridization for HPV types 6/11, 16/18, and 31, 33 was negative. These results support an epidermal process as the stimulus for the foam cell formation but fail to demonstrate HPV as the cause.

Inocoterone and acne. The effect of a topical antiandrogen: results of a multicenter clinical trial

BACKGROUND AND METHODS

Because acne is androgen dependent, antiandrogen therapy might improve the condition. Inocoterone acetate (RU 882) is a nonsteroidal antiandrogen that binds to the androgen receptor and has antiandrogenic activity in animal models. To test its topical effect on acne, 126 male subjects with facial acne completed a 16-week, multi-center, double-blind study in which the twice-daily application of a 10% solution of inocoterone was compared with vehicle solution. Baseline and monthly examinations included acne lesion counts and general and endocrine laboratory tests.

RESULTS

Inflammatory papules and pustules showed greater reduction in the inocoterone-treated subjects than in the subjects treated with vehicle. This difference achieved statistical significance by week 12 (24% reduction vs 10%) and week 16 (26% reduction vs 13%) and, with longitudinal analysis, throughout the course of the study. Global assessments and changes in comedo counts and sebum excretion rates were not significantly different between the groups. No serious adverse reactions were encountered.

CONCLUSIONS

In this double-blind study of 126 male subjects with acne, a topical solution of the antiandrogen inocoterone, compared with vehicle, produced a modest but statistically significant reduction in the number of inflammatory acne lesions.

Clinical and biochemical parameters of androgen action in normal healthy Caucasian versus Chinese subjects

Stimulation of androgen-sensitive hair follicles is mediated by dihydrotestosterone (DHT), which is formed in these tissues by 5 alpha-reduction of testosterone. A possible mechanism for increased body hair in some human populations might, therefore, be an increase in 5 alpha-reductase activity, resulting in elevated tissue levels of DHT. If present, this finding could have other important clinical implications, since the 5 alpha-reductase enzyme is pivotal in the pathophysiology of prostatic disease. To explore differences in clinical and biochemical parameters of androgen action, we conducted a study of 184 caucasian and Chinese subjects in whom we evaluated chest hair density and serum levels of androgen precursors and 5 alpha-reduced androgen metabolites. Differences in chest hair density were most notable in the men, in whom comparative mean chest hair scores (using a scale of 0-4) were 3.0 vs. 0.8 (P less than 0.0001), caucasian vs. Chinese. Levels of 5 alpha-reduced androgen products were also strikingly higher in the caucasian vs. Chinese subjects. Serum 3 alpha-androstanediol glucuronide levels (nanomoles per L) were 34.7 +/- 2.4 vs. 19.7 +/- 0.9 (P less than 0.001) for the men and 21.5 +/- 3.2 vs. 9.4 +/- 0.6 (P less than 0.001) for the women, and serum levels of androsterone glucuronide (nanomoles per L) were 179 +/- 26 vs. 107 +/- 7 (P less than 0.01) for the caucasian vs. Chinese men and 173 +/- 23 vs. 81 +/- 9 (P less than 0.001) for the women. Serum levels of total and bioavailable testosterone did not differ between the racial groups, but serum levels of the precursor androgens, dehydroepiandrosterone sulfate and androstenedione, were significantly higher in the caucasian vs. Chinese men, but not in the women. We conclude that increased serum levels of 5 alpha-reduced androgen metabolites in caucasians vs. Chinese subjects provide circumstantial evidence for a racial difference in 5 alpha-reductase activity and suggest a mechanism for the increased body hair observed in the caucasian men. Increased levels of precursor androgens may also play a role.

Cutaneous manifestations of multiple myeloma

We report the cutaneous manifestations of multiple myeloma, using a retrospective review of 115 patients' records obtained from tumor registry files. Five patients were found to have biopsy-proved extramedullary plasmacytomas without extension from an underlying bony focus. Twelve patients had ecchymoses without thrombocytopenia; two of them had biopsy-proved amyloidosis. One patient presented with pyoderma gangrenosum and was subsequently diagnosed with multiple myeloma. The last patient initially presented with what clinically appeared to be leukocytoclastic vasculitis, and, in the course of a standard workup, he was diagnosed with multiple myeloma. These findings are discussed with regard to the current literature on the cutaneous manifestations of multiple myeloma.

A novel X-linked combined immunodeficiency disease

A novel X-linked combined immunodeficiency disease was found in five living males in an extended family in the United States. The age of the affected males ranged from 2.5 to 34 yr. The most prominent clinical abnormalities were a paucity of lymphoid tissue; recurrent sinusitis, otitis media, bronchitis, and pneumonia; severe varicella; and chronic papillomavirus infections. The principal immunologic features of the disorder were normal concentrations of serum immunoglobulins but restricted formation of IgG antibodies to immunogens; normal numbers of B cells and NK cells but decreased numbers of CD4+ and CD8+ T lymphocytes, particularly the CD45RA+ subpopulations; diminished proliferative responses of blood T cells to allogeneic cells, mitogens and antigens; and decreased production of IL-2 by mitogen stimulated blood lymphocytes. Thus, affected males in this family carry an abnormal gene on their X chromosome that results in a combined immunodeficiency that is distinct from previously reported disorders.

Skin involvement as the presenting sign of internal carcinoma. A retrospective study of 7316 cancer patients

From tumor registry data of 7316 cancer patients, we found 367 cases (5.0%) with skin involvement. Skin involvement was present at the time of presentation in 92 patients (1.3%), only 26 of whom had remote metastases. Skin involvement was the first sign of cancer in 59 patients (0.8%); 22 had direct extension of their tumor into the skin, 20 had local metastases, and 17 had distal metastases. Direct invasion was most common with breast cancer and second most common with oral cavity cancer. Local metastases were also most frequently caused by breast cancer but occurred in surgical scars in three women with pelvic cancer and in perianal abscesses in one patient with rectal carcinoma as well. Except for metastases from unknown primary sites, distant metastases were rare as presenting signs, and their origins were widely distributed. Our data show that internal cancer uncommonly presents with skin involvement. Nevertheless, an index of suspicion should be maintained and biopsy performed, particularly for nonhealing ulcers, persistent indurated erythema, and unexplained skin nodules.

Immunosuppression in men with bowenoid papulosis

The immune status of four men with bowenoid papulosis was evaluated. Each case had been refractory to multiple methods of treatment. Three of the men had other infections and demonstrated a depletion of T4-helper cells. Two of these patients were anergic on skin testing, and the third showed weak reactivity. The fourth patient, who had no evidence of additional infections, had a normal T4 value and T4/T8 ratio, but was anergic on skin testing. All the men were serologically negative for human immunodeficiency virus antibodies. One of the immunosuppressed patients developed squamous cell carcinoma of the tongue, which, along with his bowenoid papulosis, contained human papillomavirus 16 DNA. We suggest that patients with persistent bowenoid papulosis be investigated for altered immune status and followed up as potential candidates for the development of epithelial malignant neoplasms.

Correlation of serum 3 alpha-androstanediol glucuronide with acne and chest hair density in men

Serum 3 alpha-androstanediol glucuronide (3 alpha-Adiol-G) is considered to be an indicator of peripheral tissue androgen metabolism. Precursor circulating androgens are converted in peripheral tissue to dihydrotestosterone (DHT), which is ultimately metabolized to 3 alpha-Adiol-G and secreted from the cell. Elevated serum 3 alpha-Adiol-G concentrations have been reported in women in hyperandrogenic states. We studied 44 consecutive male medical students for chest hair density, acne, and serum dehydroepiandrosterone sulfate (DHEA-S), total testosterone (total T), free and albumin-bound (bioavailable) T (bio T), and 3 alpha-Adiol-G concentrations. Although there was considerable overlap of serum 3 alpha-Adiol-G values among the groups defined by hair density or acne scores, we found statistically significant correlations between serum 3 alpha-Adiol-G and chest hairiness (P = 0.0034), acne (P = 0.0005), and a combined chest hairiness and acne score (P = 0.0018). There was no significant correlation between these clinical parameters and the levels of precursor androgens. There was, however, a strong correlation between serum 3 alpha-Adiol-G and bio T (P = 0.0005), suggesting that in men serum 3 alpha-Adiol-G levels may be dependent upon available free and albumin-bound T. The correlations in men of serum 3 alpha-Adiol-G with chest hair density, acne, and the hairiness and acne index supports the hypothesis that the serum levels of 3 alpha-Adiol-G reflect the extent of androgen action in peripheral tissues.

Effect of isotretinoin on serum levels of precursor and peripherally derived androgens in patients with acne

Sebaceous glands are stimulated by androgens and can convert them to more active forms. Isotretinoin, however, has a profound inhibitory effect on sebaceous gland size and function. This study evaluated the effect of isotretinoin on serum levels of precursor and tissue-derived androgens. Twenty-four subjects (15 men and nine women) were treated for 20 weeks with 1 mg/kg/d of isotretinoin. Serum samples were obtained at baseline, 8, 16, and 24 weeks, and assayed for precursor androgens--total testosterone (TT), free testosterone (free T), dehydroepiandrosterone (DHEA), dehydroepiandrosterone-sulfate (DHEA-S); and tissue androgens--dihydrotestosterone (DHT), and its metabolite, 3 alpha-androstanediol glucuronide (3 alpha-diol G). Isotretinoin had no meaningful effects on precursor androgens, except for producing an elevation of free T in women. In contrast, isotretinoin produced depressions in the serum levels of DHT and 3 alpha-diol G in women and in 3 alpha-diol G in men. These decreases are believed to be the result, rather than the cause, of a reduction in the size of the sebaceous glands: The magnitude of the observed decreases may represent the amount of tissue-derived androgens that sebaceous glands normally contribute to the circulating pool.

Yield from a complete skin examination. Findings in 1157 new dermatology patients

A complete skin examination has been recommended by many dermatologists. The purpose of this study was to determine the yield of this examination. Of 1157 consecutively treated new dermatology patients, 1106 (96%) agreed to a total skin examination. Important incidental lesions were found in 162 (15%) of these patients. The types of incidental findings included (1) rashes helpful in establishing the primary diagnosis--20 patients (1.8%); (2) important rashes unrelated to the primary diagnosis--37 patients (3.3%); (3) malignant tumors--22 patients (2.0%); (4) clinically dysplastic nevi--25 patients (2.3%); and (5) congenital nevi--31 patients (2.8%). One patient had an incidental melanoma and another was found to have Kaposi's sarcoma, which led to the diagnosis of acquired immunodeficiency syndrome (AIDS). It is concluded that a complete skin examination is productive and it is recommended for all new dermatology patients.

Effects of relaxation therapy and hypnotizability in chronic urticaria

The therapeutic results of hypnosis with relaxation therapy were evaluated in 15 patients with chronic urticaria of 7.8 years' average duration. Compared with baseline and control session values, the hypnosis session provided relief of pruritus as measured by three self-report parameters. There was no change in the number of hives. All subjects were given a standard test for hypnotizability. Assuming that the results were not biased by their preceding relaxation sessions, we determined that six subjects were hypnotizable and nine were nonhypnotizable. Subjects in both groups improved symptomatically, but hypnotizable subjects had fewer hives and became more symptomatic during the control (testing and history taking) session. Hypnotizable subjects also more frequently related stress as a causative factor. At a follow-up examination five to 14 months after the completion of the experimental sessions, six patients were free of hives and an additional seven reported improvement.

Human papillomavirus type 16 in bowenoid papulosis, intraoral papillomas, and squamous cell carcinoma of the tongue

A 33-year-old immunosuppressed man developed bowenoid papulosis on his genitalia, velvety papules and plaques in his mouth, and invasive squamous cell carcinoma of his tongue. All three lesions were positive for human papillomavirus type 16 (HPV-16). The case provides further circumstantial evidence for a role of HPV-16 in epithelial neoplasia. The possible roles of a second HPV infection and of immunosuppression are also discussed.

Histologically proven leukemia cutis carries a poor prognosis in acute nonlymphocytic leukemia

A retrospective study of fifty-eight patients with acute nonlymphocytic leukemia was undertaken to determine the incidence of leukemia cutis and whether skin involvement serves as a prognostic indicator. A clinical diagnosis of leukemia cutis was made in eleven patients (19 percent), and five patients (8.6 percent) had biopsy-confirmed skin involvement. Patients with biopsy-proven leukemia cutis had a median postdiagnosis survival of only 12.5 weeks compared with fifty weeks for the group without skin involvement. We conclude that leukemia cutis is a biopsy diagnosis that occurs in a minimum of 8.6 percent of patients with acute nonlymphocytic leukemia in whom survival appears to be shortened.

A direct gravimetric technique for measuring sebum excretion rate

The standard gravimetric method for measuring sebum excretion rates involves ether extraction of the collected sebum. We have evaluated a more direct method in which the collecting papers were pre- and post-weighed in glass beakers under conditions of stable temperature and humidity. Weights were adjusted allowing for control weight gain or loss, due mainly to day to day changes in weight room humidity. The direct method compared favourably with the ether extraction method in determining: (1) sebum collected from 43 subjects (r = 0.991, P less than 0.001), (2) left versus right forehead comparisons in 19 subjects (direct method: r = 0.966, P less than 0.001; ether extraction method: (r = 0.963, P less than 0.001), and (3) recovery of sebum from 32 premeasured standards (r = 0.997, P less than 0.001). The findings demonstrate the accuracy of the direct gravimetric procedure which is also simpler, safer and less expensive than methods currently in use.

Tissue production of androgens in women with acne

Precursor and target tissue-produced androgens were measured in the plasma of eighteen women with mild to moderate acne. Mean plasma levels of the precursor androgens (total testosterone, free testosterone, androstenedione, and dehydroepiandrosterone sulfate) wer similar to levels in a group of carefully selected acne-free and hirsute-free, age-matched female controls. In contrast, plasma 3 alpha-androstanediol glucuronide (3 alpha-diol G) values were elevated in 13 of the patients, with a mean value for the entire group nearly threefold that of the normal controls (117 vs 43 ng/dl; p less than 0.001). These results support the concept that target tissue androgen production plays an important hormonal role in the pathogenesis of acne in women and that plasma 3 alpha-diol G may be the most sensitive marker of this process.

Herpes zoster and occult malignancy

Herpes zoster and malignancy have both been associated with conditions of immune suppression. It has been well documented that herpes zoster occurs more frequently in patients with a previously diagnosed malignancy, especially lymphoma. To determine whether there is an increased frequency of malignancy subsequent to the diagnosis of herpes zoster, we studied fifty outpatients with herpes zoster and compared them with fifty control patients with psoriasis. In a follow-up period ranging from 24 to 68 months, one individual in the herpes zoster group developed a subsequent malignancy, in comparison to none in the control population and to 1.5 cancer cases expected in the general population. These results support the view that herpes zoster is not a marker for an occult malignancy.

Sunscreen use and sun exposure. Trends in a white population

Four hundred eighty-nine patients were surveyed during the summer months to evaluate their sun-exposure habits and beliefs, and their use of sunscreens. Seventy-one percent had one or more hours of sun exposure on at least one day per week. Men had more sun exposure than women. Subjects 30 years old and younger spent more time in the sun than those older than 30 years. Subjects with skin types 1 and 2 were least frequently sun exposed and tended to use sunscreens most often. Overall, sunscreens were used by 41% of the subjects, one third of whom used them with the belief that tanning would be promoted. In a four-week follow-up evaluation, 342 patients were contacted by telephone. Knowledge of the sun protection factor and sun-exposure risks was improved, presumably by reading an informational pamphlet provided; but sunscreen use improved very little.

Generalized epidermolytic hyperkeratosis in the child of a parent with nevus comedonicus

Nevus comedonicus (NC) is rarely associated with the histopathologic changes of epidermolytic hyperkeratosis (EH). A parent with mild focal NC had a child with severe generalized EH. The histopathologic findings of skin biopsy specimens from parent and child showed the distinctive granular and spinous layer vacuoles and coarse keratohyaline granules of EH. This parent and child may be examples of the extremes in expression of an autosomal dominant trait.

Generalized pruritus and systemic disease

A retrospective study of 44 cases of generalized pruritus (GP) was undertaken to determine the incidence of systemic disease in this population. This data was compared to that of a group of 44 age- and sex-matched psoriatic controls. We found 13 (30%) of the GP cases to have a systemic disease that in the literature is believed to be associated with GP, versus 10 (23%) in the psoriasis group. Excluding hypothyroidism and diabetes mellitus, two disorders with questionable relationship to GP, the number of pruritus patients with an associated systemic disease was reduced to 8 (18%) compared to only 1 (2%) psoriatic patient, a difference which is statistically significant (p less than 0.02). In 6 (14%) of the GP patients a temporal relationship of systemic disease and GP was suggested. Recommendations for outpatient workup of GP are given. Patient follow-up of 1 to 6 1/2 years revealed that 29 (66%) of the patients had persistent itching. The mean duration of itching to the time of the present follow-up was 57.7 months.

Prophylaxis of radiation dermatitis with a topical cortisone cream

Nineteen cancer patients receiving radiation therapy to the head, neck, chest wall, or abdomen were evaluated in a double-blind study to determine the effectiveness of 0.2% hydrocortisone valerate vs. placebo in reducing acute radiation dermatitis. Patients applied hydrocortisone valerate to one-half of the irradiate area and the placebo to the other half beginning two weeks after the initiation of radiotherapy and continuing until three weeks after completion. Left and right sides were scored each week with respect to erythema, dry desquamation, moist desquamation, ulceration, and the duration and intensity of symptoms such as soreness, burning, and itching. No statistically significant difference was found between the 0.2% hydrocortisone valerate and the placebo in the acute skin response or the symptoms of radiation dermatitis. The patients were evaluated three months following radiotherapy for evidence of skin atrophy. There were no differences found between hydrocortisone valerate and the placebo with respect to the late effects of radiation therapy.

Captopril-induced skin eruptions

Seven of 23 hypertensive patients treated with captopril (SQ 14,225), an orally active converting enzyme inhibitor, developed a pruritic, erythematous, macular, and papular eruption of the trunk, face, and proximal extremities. The eruption appeared one to 31 weeks after initiation of captopril therapy and was associated with diarrhea (three patients), fever (two patients), and generalized arthralgias (one patient). Six patients had an increased percentage of band cells (5 to 34 per cent) on peripheral smear without an associated leukocytosis. In one patient, the skin rash was associated with a peripheral eosinophilia (20 per cent). Coombs-positive hemolytic anemia, and acute renal failure with eosinophiluria. There were no changes in BUN, creatinine, or urinalyses in the remaining patients. Four patients showed a transient rise in plasma PGE without concomitant changes in plasma PFG2 alpha or 6-keto PGF1 alpha, and three patients had slight elevations in the erythrocyte sedimentation rate. Skin biopsies revealed a perivascular and perifollicular lymphocytic and histiocytic infiltrate with negative immunofluorescence to IgG, IgM, IgA, and beta 1 C. The skin eruption and associated symptoms resolved in all patients, even though captopril administration was continued in six of the seven patients.

Skin infiltration in Hodgkin's disease

Hodgkin's disease involving the skin is an unusual occurrence and often portends a poor prognosis. We present a case of Hodgkin's disease and extensive skin infiltration with a favorable outcome. A variety of therapeutic modalities, including a mixture of mechlorethamine hydrochloride, vincristine sulfate, prednisone, and procarbazine; electron-beam radiation; topical mechlorethamine hydrochloride; and intravenous vinblastine sulfate were employed with moderate success.

Bacteriology of chronic leg ulcers

The quantitative bacteriology of 13 chronic leg ulcers was sequentially assessed by both swab and biopsy culture techniques, and the effect of either a 10% benzoyl peroxide lotion or placebo lotion was evaluated. There was good correlation between the swab and biopsy culture techniques in 12 of the 17 instances where simultaneous swabs and biopsies were done. Though the benzoyl peroxide did not favorably affect the bacterial flora, ulcer healing did appear to correlate with quantitative bacterial counts. THREE of five ulcers containing fewer than 10(5) organisms per gram of tissue or per centimeter of ulcer surface area healed, while none of eight ulcers containing more than 10(5) organisms healed. Quantitative bacteriological measurements can serve as useful tools in evaluating healing of leg ulcers.