Reliability of counting actinic keratoses before and after brief consensus discussion: the VA topical tretinoin chemoprevention (VATTC) trial

OBJECTIVE

To assess the reliability of counts of actinic keratoses (AKs) and the effect of a brief joint discussion of discrepancies on that reliability.

DESIGN AND INTERVENTION

Seven dermatologists independently counted AKs on the face and ears before and after a brief joint discussion of discrepancies.

SETTING AND PATIENTS

A volunteer sample of 9 patients from the ongoing VA (Department of Veterans Affairs) Topical Tretinoin Chemoprevention (VATTC) Trial. All participating individuals are veterans and have had 2 or more keratinocyte carcinomas (basal or squamous cell carcinoma) in the 5 years before enrollment in the study.

MAIN OUTCOME MEASURE

Standard deviation of estimates of the Poisson regression parameter for the dermatologists.

RESULTS

Substantial variation was found among the dermatologists in their AK counts. The SD of the parameter estimates for the dermatologists decreased from 0.45 to 0.24 after the brief joint discussion, a 47% decrease (P =.076). The variation attributable to the dermatologists also decreased substantially (chi(2)(6) decrease, 94 to 12).

CONCLUSIONS

Actinic keratoses are common, and there is a continuous spectrum of lesions that ranges from sun-damaged skin to squamous cell carcinoma in situ. Clinical distinguishing features may be difficult to delineate precisely. Counts of AK are commonly performed, but appear to be unreliable, even when performed by experienced dermatologists. Joint discussion of discrepancies may enhance the reliability of these counts, although substantial variation remains. Research that relied on these counts must be reevaluated in light of the marked variation among expert observers. Future studies should consider measures to assess and enhance reliability.

The effects of finasteride on scalp skin and serum androgen levels in men with androgenetic alopecia

BACKGROUND

Data suggest that androgenetic alopecia is a process dependent on dihydrotestosterone (DHT) and type 2 5alpha-reductase. Finasteride is a type 2 5alpha-reductase inhibitor that has been shown to slow further hair loss and improve hair growth in men with androgenetic alopecia.

OBJECTIVE

We attempted to determine the effect of finasteride on scalp skin and serum androgens.

METHODS

Men with androgenetic alopecia (N = 249) underwent scalp biopsies before and after receiving 0.01, 0.05, 0.2, 1, or 5 mg daily of finasteride or placebo for 42 days.

RESULTS

Scalp skin DHT levels declined significantly by 13.0% with placebo and by 14.9%, 61.6%, 56. 5%, 64.1%, and 69.4% with 0.01, 0.05, 0.2, 1, and 5 mg doses of finasteride, respectively. Serum DHT levels declined significantly (P <.001) by 49.5%, 68.6%, 71.4%, and 72.2% in the 0.05, 0.2, 1, and 5 mg finasteride treatment groups, respectively.

CONCLUSION

In this study, doses of finasteride as low as 0.2 mg per day maximally decreased both scalp skin and serum DHT levels. These data support the rationale used to conduct clinical trials in men with male pattern hair loss at doses of finasteride between 0.2 and 5 mg.

Reversal of erythema multiforme major with cyclophosphamide and prednisone

OBJECTIVE

To report a case of erythema multiforme (EM) major treated with cyclophosphamide and prednisone.

SETTING

General medicine and dermatology consult services, Department of Veterans Affairs Medical Center.

CASE SUMMARY

A 44-year-old man with C4-C5 quadriplegia developed a skin reaction characterized by a painful, generalized maculopapular rash, bullae, ulceronecrotic lesions, and mucosal and epidermal sloughing after taking trimethoprim/sulfamethoxazole. The patient was treated with intravenous cyclophosphamide 150 mg infused over 1 hour every 24 hours and oral prednisone 15 mg every 6 hours. After two doses of cyclophosphamide, formation of bullae and epidermal sloughing had ceased, and the erythema was markedly diminished. Cyclophosphamide was discontinued before the third dose because of evolving leukopenia. Prednisone therapy was continued until the patient was discharged on hospital day 5, at which time the dosage was tapered.

DISCUSSION

Cyclophosphamide has been used extensively for other dermatologic reactions. Relief of pain and regression of the lesions in our patient occurred more quickly than anticipated.

CONCLUSIONS

Treatment of EM major with cyclophosphamide combined with prednisone appeared to be highly successful in this patient. Cyclophosphamide may be an effective, empiric initial treatment in reversing EM major.

Iatrogenic transplantation of osteosarcoma

We report a case in which a patient having curettage and resection of a presumed benign lesion of the tibia (later recognized as osteosarcoma) had probable iatrogenic transplantation of tumor to the contralateral iliac crest, which had served as a donor site for bone chips used to pack the tibial lesion. The patient later had above-knee amputation for the primary tumor and eventually required contralateral hemipelvectomy when tumor developed in the iliac crest donor site. We discuss the literature of tumor transplantation and seeding in operative settings and stress the clinical importance of avoiding possible tumor contamination of operative fields by meticulous instrument changes and by isolation of multiple surgical fields.

Clinical comparison of cefuroxime axetil, cephalexin and cefadroxil in the treatment of patients with primary infections of the skin or skin structures

This study was designed to compare the clinical and bacteriological efficacy of three oral cephalosporins, cefuroxime axetil, cephalexin and cefadroxil, in the treatment of patients with mild to moderate infections of the skin or skin structures. A total of 330 patients were enrolled at 10 centers and were randomly assigned to receive cefuroxime axetil 250 mg (n = 107), cephalexin 500 mg (n = 111) or cefadroxil 500 mg (n = 112), twice daily for 10 days. Patients were assessed for their clinical and bacteriological responses once during treatment (3-5 days) and twice after treatment (1-3 and 10-14 days). A total of 353 bacterial isolates were obtained: Staphylococcus aureus (41%), Staphylococcus epidermidis (33%) and Streptococcus pyogenes (5%). A satisfactory clinical outcome (cure or improvement) was achieved in 97% (89/92), 89% (80/90) and 94% (82/87) of the clinically evaluable patients treated with cefuroxime axetil, cephalexin or cefadroxil, respectively (p = 0.047, cefuroxime axetil vs. cephalexin). With respect to the eradication of the bacterial pathogens, a satisfactory outcome (cure or presumed cure) was obtained in 96% (69/72), 85% (60/71) and 93% (63/68) of bacteriologically evaluable patients treated with cefuroxime axetil, cephalexin and cefadroxil, respectively (p = 0.026, cefuroxime axetil vs. cephalexin). All three study drugs were well tolerated, with adverse events affecting the gastrointestinal system most commonly reported. There were no significant differences between treatment groups in the incidence of drug-related adverse events.

Neutralized lidocaine with epinephrine for local anesthesia--II

The pain usually associated with intradermal injection of lidocaine and epinephrine is significantly attenuated by the addition of either sodium bicarbonate or sodium hydroxide to 1% lidocaine with epinephrine. This suggests that sodium bicarbonate attenuates pain by increasing the pH of the anesthetic solution. The clinical effects of a solution of lidocaine (1%) with epinephrine (1:100,000) and sodium bicarbonate (80 meq/L) were assessed after infiltration in skin. Anesthetic stored for 1 week caused nearly equal areas of anesthesia and vasoconstriction as an identical solution prepared on the day of use.

An argument for circumcision. Prevention of balanitis in the adult

A cross-sectional study and a retrospective study were performed to determine the frequency of balanitis in a randomly selected group of dermatology patients. A total of 398 subjects were included in the cross-sectional study, 213 (53.5%) of whom had been circumcised. Balanitis was diagnosed in 2.3% of circumcised men and in 12.5% of uncircumcised men. In patients with diabetes mellitus, balanitis occurred with a prevalence of 34.8% in the uncircumcised population, compared with 0% in the circumcised population. Balanitis did occur with increased frequency in the diabetic population (16%), regardless of circumcision status, compared with the nondiabetic population (5.8%). Of 63 circumcisions performed at our institution between 1987 and 1989, 28.6% were for the treatment of balanitis; 44.4%, for phimosis (which was probably induced by chronic balanitis); 19% in preparation for placement of penile prostheses; and 8% for miscellaneous reasons. No complications of circumcision were reported. In this group of patients, balanitis was more frequent in diabetic than in nondiabetic uncircumcised men (50% vs 15.4%).

A comparison of a new oral antifungal, terbinafine, with griseofulvin as therapy for tinea corporis

Fifty patients with tinea corporis were treated with either 500 mg of griseofulvin (microsize) or 500 mg of terbinfine daily for 6 weeks. Thirty-three patients completed the study. Thirteen (87%) of 15 patients who took terbinafine were considered successfully treated, while 13 (73%) of 18 patients in the griseofulvin group noted resolution of their disease. Five patients taking griseofulvin were forced to discontinue the therapy because of side effects, compared with two patients taking terbinafine. This preliminary study indicates that a new oral antifungal agent of the allylamine class, terbinafine, may possess a safety and efficacy profile similar to that of griseofulvin.

Neutralized lidocaine with epinephrine for local anesthesia

The pain of infiltrating lidocaine with epinephrine into skin is reduced by the addition of sodium bicarbonate. The effect of varied concentrations of sodium bicarbonate on pain of infiltration of 1% lidocaine with epinephrine 1:100,000 was measured. Sodium bicarbonate at 40 and 100 meq/L of anesthetic solution caused significantly less pain than did 0 or 10 meq/L. The stability of epinephrine in a solution at pH 7.3 was also determined. Epinephrine concentration declined approximately 25% per week in anesthetic solution containing 100 meq/L sodium bicarbonate.

Mometasone furoate ointment and cream 0.1 percent in treatment of psoriasis: comparison with ointment and cream formulations of fluocinolone acetonide 0.025 percent and triamcinolone acetonide 0.1 percent

Mometasone furoate (Elocon) is a newly formulated and unique medium-potency synthetic 17-heterocyclic corticosteroid. The efficacy and safety of the ointment and cream formulations (0.1 percent) of the corticosteroid, administered once daily, were compared with those of the ointment and cream formulations of fluocinolone acetonide 0.025 percent administered three times daily and triamcinolone acetonide 0.1 percent administered twice daily in four multicenter clinical studies. They were conducted involving psoriasis patients with chronic and moderate to severe disease. Evaluation of change in disease sign scores indicated that mometasone ointment, applied once daily, was significantly more effective (P less than 0.01) than fluocinolone ointment, applied three times daily, and triamcinolone ointment, applied twice daily. The cream formulation of mometasone was significantly more effective (p less than 0.001) than fluocinolone cream, applied three times daily, and equivalent to triamcinolone cream, applied twice daily. The incidence of local adverse experiences following treatment with the ointment or cream formulations of mometasone was minimal. Mometasone ointment and cream provide a highly effective once-a-day treatment for moderate to severe psoriasis with minimal risk of side effects.

The effect of topical cyclosporin A on the elicitation phase of allergic contact dermatitis

The effect of cyclosporin A (CSA) on the elicitation phase of allergic contact dermatitis was investigated. Initially, the ability of CSA to penetrate normal human cadaver skin was determined using 3 different vehicles. 10% CSA in Labrafil was found to be the most effective combination at achieving skin penetration (0.33%). Patients with known contact sensitivities to a variety of allergens were selected. After a 48-h pretreatment with 10% CSA in Labrafil, skin sites were exposed to the appropriate contact allergen. 72 h later, the development of an eczematous patch test reaction was evaluated. Only 1 of 10 patients showed unequivocal signs of suppression of allergic contact dermatitis.

The measurement of the volume of leg ulcers

A method designed to measure the volume of cutaneous ulcers is described that utilizes a silicon rubber dental impression material. This technique is compared to the more popularly used computerized image analysis method in the determination of the size of cutaneous ulcers.

Hypomelanosis associated with a colonic abnormality. A possible result of defective development of the neural crest

A neonate born of black parents displayed a congenital, dramatic deficiency of most of his normal pigmentation. This was accompanied by a markedly dilated colon and various other defects. Light- and electron-microscopic examination revealed a deficiency in melanin content in the hypopigmented skin as compared to the normally pigmented areas. No other defects were noted. The possibility exists that a single aberration in neural crest development, a neurocristopathy, might be responsible for our patient's multiple congenital defects. Similar conditions in veterinary medicine and human disease are reviewed and compared to this case.

Chloracne from pentachlorophenol-preserved wood

A patient is presented who developed chloracne after exposure to lumber which was pressure-treated with pentachlorophenol (PCP). It was presumed that his disease arose via percutaneous absorption of polychlorinated aromatic compounds (dioxins and furans) which are known to contaminate technical grade PCP. The patient's condition improved after treatment with oral isotretinoin.

The adherence of Staphylococcus aureus to human corneocytes

Staphylococcus aureus has a peculiar ability to colonize the skin of patients with atopic dermatitis. We examined the possibility that this might be due to a specific ability of this pathogenic staphylococcus to adhere to atopic stratum corneum. We used an in vitro model to show that S aureus does have an unusual ability to adhere to atopic corneocytes when compared with corneocytes obtained from patients with other cutaneous diseases, including psoriasis. Protein A--a component of the staphylococcal cell wall--may be responsible in part for this adherence phenomenon. This trait did not extend to the other gram-positive bacteria tested.

Cyclosporine and murine allergic contact dermatitis

Cyclosporine is a new antilymphocytic, immunosuppressive agent currently being used primarily in experimental and human organ transplantation. The current study evaluated the effect of systemically administered cyclosporine on a cutaneous T-cell-mediated disorder by using the murine model of allergic contact dermatitis to dinitrofluorobenzene. Cyclosporine was found to significantly inhibit the ear swelling response, whether the drug was given during the early sensitization period or at the time of antigenic challenge to fully sensitized mice. This suppressive effect was reversible when mice were rechallenged with dinitrofluorobenzene 96 hours after the first challenge. Cyclosporine was not effective if given to sensitized animals as late as six hours after challenge. Lastly, the observed inhibition of the ear swelling response to cyclosporine closely paralleled a diminished degree of inflammation seen histopathologically.

SCH 370 (clotrimazole-betamethasone dipropionate) cream in patients with tinea cruris or tinea corporis

The safety and efficacy of SCH 370 (1 percent clotrimazole/0.05 percent betamethasone dipropionate) cream was compared with each of its individual components in 331 patients with tinea cruris or tinea corporis. The study was a multicentered, randomized, double-blind, parallel-groups design. The patients received one of three treatments applied twice a day for two weeks and returned for a follow-up visit two weeks after the last application. Total signs and symptoms scores of infections were evaluated at baseline, once between days three to five, and after weeks one, two, and four. Culture and potassium hydroxide preparations were done at baseline and weeks two and four. SCH 370 cream demonstrated more rapid therapeutic activity than the antifungal agent alone, resulting in significantly better clinical results in early treatment and in midtreatment. As expected with a steroid, betamethasone dipropionate achieved relief of inflammatory signs and symptoms early in the course of treatment, but SCH 370 was superior from one week on in the patients with tinea cruris and at post-treatment in the patients with tinea corporis. Mycologically, SCH 370 cream and clotrimazole were comparable at the end of the study and results were significantly better than those for betamethasone dipropionate. All three treatments were safe with no reports of unexpected or serious adverse experiences.

Scleredema diabeticorum: a common and distinct cutaneous manifestation of diabetes mellitus

Scleredema diabeticorum is characterized by a dramatic increase in the thickness of the skin of the posterior neck and upper back. Of the 17 scleredema patients diagnosed by us in the last 15 yr, 16 have had type II diabetes mellitus. In a prospective study of 484 diabetic outpatients we found the prevalence of scleredema to be 2.5%. Angina pectoris was the only complication that occurred significantly more frequently in scleredematous diabetic patients than in a control group of diabetic patients without scleredema. Scleredema diabeticorum is a distinct cutaneous condition peculiar to diabetic individuals and ought not to be confused with scleredema of Buschke or scleroderma.

An elastic tissue defect in dermatofibrosis lenticularis disseminata. Buschke-Ollendorff syndrome

A patient with dermatofibrosis lenticularis disseminata (Buschke-Ollendorff syndrome) was found to have a distinctive abnormality of the cutaneous elastic tissue. This abnormality, studied by histochemical and ultrastructural techniques, was characterized by the presence of hyalinized, thick fibers that entrapped normal bundles of collagen. Histochemically, these fibers stained like elastin but showed certain tinctorial characteristics of pre-elastin. Ultrastructurally, this elastin-like substance was composed of large clumps of electron-dense material with a fine fibrillar coating. The changes were sufficiently distinctive to be diagnosed by light microscopy.

The ultrasonic evaluation of skin thickness in scleredema

The skin thickness in a group of patients with scleredema was measured using ultrasonic techniques and then compared with a group of normal individuals. The mean dermal thickness in scleredema was 7.7 mm, compared to 3.3 mm in the normal control group. Ultrasonic evaluation of skin thickness may be of value in following the natural history or response to therapy of certain diseases that affect dermal thickness.

Type and hold system for better blood utilization

Blood bank personnel can convince surgeons to change their presurgical blood orders from a type-and-crossmatch to a type-and-hold approach. To do this, it is necessary to guarantee blood availability within a short time frame if blood should be unexpectedly required. Such a change in blood orders significantly reduced the number of unnecessary crossmatches and the amount of wasted outdated blood in our institution. Economic savings and conservation of resources were realized without compromising the patients' safety or the quality of our service.

Appropriate laboratory utilization and medical usefulness

When the hospital laboratory system is designed to meet clinical needs efficiently, more appropriate use of laboratory services is achieved. In this article, the author describes a system whereby test profiles are constructed to match the clinical problems, treatments, and test ordering patterns of clinicians.

Biochemical test profiles and laboratory system design

More appropriate utilization of laboratory services is achieved when the hospital laboratory system is designed to meet clinical needs efficiently. Structured test profiles should be constructed to match the clinical problems, treatments, and test ordering patterns of clinicians. Minor modifications in test composition may be necessary by the laboratory physician, but instrument configuration alone should not be the controlling factor. Structured test profiles reduce the number of communication and sample collection errors. More frequent scheduled sample collections and test "runs" reduce the number of emergency tests ordered. Computer analysis and transmission of test results reduce the number of telephone communications and increase the usefulness of data. When guidelines are provided to the clinician about test selection and result interpretation, the usefulness of laboratory information increases, personnel efficiency increases, personnel errors and staffing requirements decrease, the quality of service improves, and the rate of cost increase declines. Most clinicians willingly modify their test needs and the manner in which tests are ordered if the structured profiles are readily available and convenient to order, the measurements are made frequently and the results are reported promptly, more assistance is provided for test result interpretation, and the quality of the test results is high without an increase in cost.

The development of pseudo-Kaposi's sarcoma after placement of a vascular access graft

Pseudo-Kaposi's sarcoma developed on the skin overlying a vascular graft in a haemodialysis patient. After spontaneous thrombosis within the graft, the cutaneous lesions promptly resolved. Light and electron microscopic study of the lesions failed to distinguish them from those of true Kaposi's sarcoma.

Maximizing the efficiency of an admissions test profile in a 680-bed hospital

I describe the development and improved use of an efficient planned and scheduled approach to laboratory testing in a large tertiary-care hospital, which anticipates virtually all the usual needs of patient and clinician and which has been demonstrated to provide better service at lower cost.

Maximizing the efficiency of an admissions test profile in a 680-bed hospital

I describe the development and improved use of an efficient planned and scheduled approach to laboratory testing in a large tertiary-care hospital, which anticipates virtually all the usual needs of patient and clinician and which has been demonstrated to provide better service at lower cost.

Mycobacterium avium infection of the skin resembling lepromatous leprosy

A patient on systemic steroid therapy developed a cutaneous papule while histologically resembled lepromatous leprosy. Cultures of this lesion grew Mycobacterium avium. Since there was no evidence of disseminated infection the lesion was excised and the patient continues to do well.

Reference values based on hospital admission laboratory data

Laboratory values taken from more than 13,000 newly admitted patients to the University of Alabama Hospital were analyzed using a percentile ranking system, and histograms for 24 laboratory tests were prepared. The percentile system is a better way to express test results than the classic normal range. The ability to correlate a test result with a clinical problem rises proportional to the degree of deviation from the midrange. Minor deviations frequently are without explanation, even after intensive clinical investigation. Invariably, great deviations are explainable. If one limits the interpretation of results to three ranges--abnormally low, abnormally high, and normal--much of the value of laboratory test interpretation is lost.

Creatine phosphokinase isoenzyme fractions in the serum of a patient struck by lightning

Serial creatine phosphokinase (CPK) isoenzyme determinations were taken in an 8-year-old boy whose being struck by lightning resulted in prolonged cerebral anoxia, inferolateral myocardial infarction and death. All three isoenzyme levels (CPK-MM, CPK-MB, and CPK-BB) were elevated. The CPK-BB isoenzyme level increase was transient, being very high three hours postlightning strike and disappearing at approximately 24 hours.

Secondary syphilis presenting as a pruritic dermatosis

Three patients had secondary syphilis with severely pruritic skin lesions. This presentation contradicts several modern medical texts in which the lesions of secondary syphilis are described as nonpruitic.