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This article reviews how the drug thalidomide can be used for various dermatologic disorders. Also included is a short discussion of the chemistry and physiologic mechanisms of thalidomide. Thalidomide, now available again in the United States, is another drug that can be considered by dermatologists for some severe, unusual disorders.
This study investigated the relationship between the National Board of Medical Examiners (NBME) Part I and Part II examination scores and subsequent performances on the 1991 certification examinations of the American Boards of Orthopaedic Surgery (ABOS), Dermatology (ABD), and Preventive Medicine (ABPM). There were significant correlations between scores on all specialty board examinations and all NBME scores, with higher correlations for subscores more closely related to specialty content. Both NBME Part I and NBME Part II were useful predictors; however, the relationships with NBME Part II were generally stronger. Strong relationships were observed between specialty board pass-fail outcomes and NBME scores: examinees whose NBME scores were below 400 were at much greater risk for failing their specialty board examinations.
A postal survey of dermatologists identified 365 patients with a presumptive diagnosis of delusional parasitosis. One hundred and forty-four dermatologists had seen at least 1 such patient in the previous 5 years and 78 were current. The data provided on 53 patients who met the study criteria were examined in more detail. Racial origin, marital status and age at presentation varied widely. Females predominated in the older age-groups, but there was an equal sex distribution under the age of 50. Abnormal personality traits were commonly identified, especially of the obsessional type. Physical disorders associated with pruritus co-existed in a substantial minority. Previous dermatological and psychiatric disorders were uncommon and non-specific. The disorder was often, though not invariably, of long duration. Relatively few patients were successfully referred to psychiatrists. Dermatologists often treated the disorder effectively, especially when neuroleptic agents were employed. Pimozide appeared to be particularly helpful in many patients.
The future of a drug depends upon what it can do in the hands of the practitioner. Medicine is practiced on the basis of probabilities, and treatment must be selected which has the best chance of helping the patient, with the least amount of harm. There are many new drugs available for dermatologic therapy in other developed countries which are not available in this country, due to peculiarities of federal drug regulations.
BACKGROUND: The number of methicillin-resistant STaphylococcus aureus (MRSA) infections in the hospital setting is increasing but little is known of its prevalence in the community. In a 1986-1987 study, the prevalence in dermatology outpatient clinics was <0.9%. This study reports changes in the same facilities from 1988 through 1996. METHODS: Culture results and antimicrobial susceptibility patterns were reviewed for the population for the period 1988 through 1996. RESULTS: We report a gradual increase of MRSA from 1.5% of all strains of Staphylococcus aureus in 1988 to 11.9% in 1996 in these outpatient facilities. Susceptibility data indicate that the MRSA strains isolated in 1996 are more resistant to oral agents such as ciprofloxacin and tetracycline, while all strains remain susceptible to the intravenous agent vancomycin. CONCLUSION: The prevalence of MRSA in the community is increasing and should be considered when selecting a treatment regimen for staphylococcal infections.
The field of pediatric dermatology continues to be enriched by the insights offered through molecular genetics. For some genetic skin disorders, including neurofibromatosis, tuberous sclerosis complex, and several forms of epidermolysis bullosa, genetic research has resulted in an evolving understanding of the relationship between genotype and phenotype, with the ability to predict some of the features of these disorders on the basis of the genetic defect. However, widespread use of molecular genetics for diagnostic testing of these disorders has not been possible because of genetic heterogeneity, limited availability, and reduced sensitivity. The appropriate use of genetic services is emphasized in this, the molecular era.
Private-sector funding of biomedical research within academia may come from industry, foundations, the dermatologists themselves, and the public at large. Industry-funding is of benefit to both academia and industry. Industry may fund clinical and basic research and product testing. Industry is more willing to fund product testing and clinical research than basic research. Funds for dermatologic research may be obtained from manufacturers of drugs, medical devices, cosmetics, soaps, and detergents. Questions of academic freedom arise when research is funded by industry. The results of academic research are in the public domain; the results of intramural industry research are often proprietary, i.e., "trade secrets." When there is industry funding within academia, any restraints on publication should be held to a minimum and be temporary. Publication should occur in a timely fashion, although recognizing the need for delayed publication if the results concern patentable material. When there is a consultantship, pre-arranged terms of agreement may restrict communication. Patents usually are held by the investigator's institution. The funding company may be granted world-wide, royalty-bearing licenses. Conflicts of interest may arise during any research endeavor; this warrants close attention when the research is industry funded. Stock ownership, speaker fees, blind contracts, etc., should be avoided. In any communication, funding agreements should be stated. Indirect costs are a "necessary evil." There are non-research expenditures associated with all research projects for which the institution is justified in requesting compensation. Indirect costs must have definite connections to a project. As industrial funding of research within academia increases, various facets of the academia-industry relationship are receiving increasing attention. Several aspects of conflicts of interest and indirect costs must yet be resolved. When faced openly and directly, all of these issues are manageable and need not reduce the benefits to both industry and academia that are inherent in this relationship. Federal funding of academic research uses tax dollars; industry funding comes from private capital. Academia will benefit from the funding of academic biomedical research by industry. The ultimate beneficiary of the funding of academic research by industry, however, will be society at large as the medical advances derived from sound biomedical research and carefully controlled clinical trials aid patients. A solidly established academia-industry relationship is essential to the effective funding by industry of biomedical research within academia.
Great progress has been made during the past 25 years in biochemical studies and similar progress has been made in investigative dermatology. The progress originally depended upon the development of a group of leaders who won support for research endeavors, and in the future its continuation will depend upon support for basic support for basic research in clinical departments. Current studies on melanocyte-stimulating hormone receptors, the role of filaments in pigment cells, and the role of cyclic AMP in melanocytes are reviewed.
BACKGROUND: The career choices of Mohs fellows have important implications for ensuring the quality of dermatologic surgery training during residency. No published data examine the career choices of fellows in Mohs micrographic surgery. OBJECTIVE: To determine the number of Mohs fellows entering academics and to examine the influence of fellowship characteristics, scholarly activities, and personal background on career decision. METHODS: A voluntary survey was distributed by mail in June 2004 to all Mohs fellows-in-training during 2003-2004. RESULTS: Twenty-nine percent (12 of 42) of the fellows chose jobs in an academic or university setting. The practice setting of the fellowship, personal factors, and scholarly activities prior to fellowship did not correlate with career decision. By contrast, increased scholarly activities during fellowship and an interest in teaching did correlate with the choice to enter academics. CONCLUSIONS: A significant percentage of Mohs fellows pursued academics. Increased academic productivity during the fellowship and an interest in teaching correlated with the decision to pursue an academic career. Fellowship directors interested in encouraging academic careers may find these data useful to structure their curricula and to mentor fellows inquiring about academic careers.
The development of Japanese dermatology is reviewed from the times of the founding fathers and Keizo Dohi to today. Tribute is paid to the heroes of the first hour. Thereafter, an evaluation of Japanese-authored papers in the leading journal of the field (JID) over four decades is presented, taking a triennial slot in each. The contribution of Japanese- authored papers has increased substantially over this period.
The availability of a local dermatological photobiology facility has proved to be of great value in the management of patients with photodermatoses, especially those with chronic actinic dermatitis. It is our belief that clinically useful results can only be achieved if careful attention is paid to technical factors such as radiation measurement.
The ultraviolet radiation (UVR) doses received by staff who are occupationally exposed to artificial sources of UVR found in dermatology departments have been measured using personal UV monitors. The results show that staff may receive actinic (UVB and UVC) doses which are in excess of recommended maximum permissible limits for occupational exposure, but that the UVA doses are well within these limits.
Patients' attitudes to the supply and quality of information provided about their condition were examined by questionnaire before (n = 852) and after exposure to an information leaflet campaign (n = 560) in the dermatology out-patient waiting area. A high expectation of this service was demonstrated, particularly from patients under 60 years of age with chronic diseases. A variety of information sources, other than doctors, were identified which could be improved (video-systems, specialist nurses, leaflets, posters). The campaign significantly increased the percentage of patients who derived information from the leaflet source (5.6-18.8%, P < 0.001) and it reduced a demand for leaflets (16.4-9.1%, P < 0.001). However, the campaign did not alter patients' perceived need to spend more time with a dermatologist. In order to achieve a greater impact on patient satisfaction, a combination of information sources in the out-patient department should be targeted at young adults with chronic diseases.
Lasers have many applications in dermatology. Recent developments in laser technology have produced significant therapeutic advances in several areas. The introduction of pulsed tunable dye lasers has considerably improved the treatment of vascular lesions, particularly port wine stain malformations in children. A wider range of continuous-wave and quasi-continuous-wave lasers have also become available for treating vascular lesions, and their use in conjunction with automated delivery systems has improved results whilst reducing adverse effects. Increasing interest in treatment of pigmented lesions and tattoos has led to investigation of a range of high-power short-pulse lasers, and early results look very promising. However, further work is needed in all these areas to determine which lesions respond best to each laser system, and which treatment techniques are optimal.
Following publication of treatment guidelines for patients with psoriasis, a six-centre audit was undertaken to assess current therapeutic practice for two second-line treatments, PUVA and methotrexate. The audit consisted of random sampling of casenotes by external auditors from a paired dermatology department, and assessment by questionnaire. One hundred and eight PUVA and 118 methotrexate casenotes were audited. The commonest indications for treatment were: (a) failure of tropical therapy--PUVA (mean 81% of casenotes), methotrexate (84%); (b) repeated hospital admissions--PUVA (16%), methotrexate (25%). For both PUVA and methotrexate, some aspects of treatment were well documented: PUVA--psoralen dosage (91%), response to PUVA (89%), cumulative lifetime UVA dosage (81%); methotrexate--pretreatment assessment of full blood count (91%), urea and electrolytes (85%), liver function tests (84%). For other aspects documentation was less complete: PUVA--no documentation of presence/absence of skin cancer history (66%), note of photoactive drugs (32%); methotrexate--concurrent medication (69%), history of presence/absence of liver disease (36%). Another aspect which was poorly documented in both PUVA and methotrexate notes was whether advice on contraception/fertility had been given. There was no indication in 29 of 32 casenotes of females of child-bearing age receiving PUVA, and 52 of 63 case notes of relevant patients on methotrexate. This project has demonstrated that formal, multicentre audit based on published guidelines is a practical proposition.
Cyclosporin is a highly effective treatment for psoriasis, atopic dermatitis and many other inflammatory dermatoses. Absorption of cyclosporin from the traditional Sandimmun formulation is influenced by many factors, including bile flow, food and gastrointestinal motility. As a consequence, the bioavailability of Sandimmun is low and highly variable, both within and between patients. Neoral is a microemulsion preconcentrate formulation that has self-emulsifying properties and immediately forms a microemulsion in aqueous fluids, allowing rapid and consistent absorption of cyclosporin from the gastrointestinal tract. Benefits in dermatology are likely to be more patients responding at lower doses, a faster onset of action and a more predictable response to a given dose allowing for fewer dose adjustments. In the future these benefits of Neoral may lead to the simplified management of cyclosporin treatment and less frequent safety monitoring.
Thalidomide was first introduced in the 1950s as a sedative but was quickly removed from the market after it was linked to cases of severe birth defects. However, it has since made a remarkable comeback for the U.S. Food and Drug Administration-approved use in the treatment of erythema nodosum leprosum. Further, it has shown its effectiveness in unresponsive dermatological conditions such as actinic prurigo, adult Langerhans cell histiocytosis, aphthous stomatitis, Behçet's syndrome, graft-versus-host disease, cutaneous sarcoidosis, erythema multiforme, Jessner-Kanof lymphocytic infiltration of the skin, Kaposi sarcoma, lichen planus, lupus erythematosus, melanoma, prurigo nodularis, pyoderma gangrenosum and uraemic pruritus. This article reviews the history, pharmacology, mechanism of action, clinical uses and adverse effects of thalidomide.
Most hospitals now have acquired trust status and managers have started the process of setting contracts with purchasers. In order to assess quality content of contracts for dermatology services, a survey was performed on behalf of the British Association of Dermatologists' (BAD) Audit Subcommittee. A letter was sent to 278 consultant members of the BAD, requesting a copy of their contract: 171 (62%) replies were received. Seventy-four consultants had formal contracts with purchasers, but only 25 (34%) of these had been involved in contract preparation. Several consultants were unsure whether formal contracts existed and many had difficulty in obtaining the documents. The 20 contracts received were highly variable, with a median of 13 (range 0-89) quality clauses per contract. These mostly related to the process of care, particularly waiting times and communication with general practitioners (GPs). Sometimes the structure for delivering care was specified, but only occasionally were outcome measures mentioned. The specified maximum waiting time for a new patient appointment ranged between 4 and 30 weeks (median 13). GPs were to be sent out-patient letters within 3-10 days (median 10) of patient attendance. Following in-patient care a notification was to be sent within 1-3 days (median 2) of discharge and a full summary within 7-21 days (median 12). A requirement for patient satisfaction surveys was included in only six contracts. Greater involvement of consultant dermatologists in setting contracts with purchasers should lead to the inclusion of more consistent and appropriate quality clauses.(ABSTRACT TRUNCATED AT 250 WORDS)