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New treatments for skin disease continue to evolve. This article summarizes recent advances in dermatologic therapy and suggests various alternative approaches for situations in which more conventional modalities are unavailable, ineffective, or contraindicated.
Genetic diseases often have cutaneous manifestations, which can be the first or most prominent signs of the underlying problem. Recognition of these dermatologic clues allows prompt diagnosis and intervention. In this article, the authors have attempted to outline several important examples of genodermatoses.
INTRODUCTION: Cutaneous hematomas are a cause of hospitalization in departments of dermatology. Their clinical diagnosis can be difficult, particularly since they can masquerade as thrombophlebitis or abscesses. We conducted a retrospective study so as to specify their frequency, clinical aspects and circumstances of occurrence. PATIENTS AND METHODS: The search for hospitalizations was conducted, using a computer data coding and key word "hematoma", from January 1997 to March 2003. The following items were studied: age, gender, clinical aspect on admission, topography, use of anti-platelets or anticoagulants, the existence of documented overdosing, treatment before hospitalization and existence of fever. RESULTS: The 17 patients hospitalized for hematomas were 9 women and 8 men with a mean age of 71 years. Thirteen patients were treated with: antivitamin K (5 cases), low molecular weight heparin (3 cases), anti-platelets (4 cases), or a combination of antivitamin K and anti-platelets (1 case). Four patients had no antivitamin K or anti-platelet treatment; their coagulation control was normal and they were younger than the patients taking a treatment (55 versus 76 years). The hematomas always involved the lower limbs. The clinical aspect was: simple hematoma (3 cases), inflammatory or over-infected hematoma (11 cases) and post-hematoma ulceration (3 cases). Seven patients were febrile either before or during their hospitalization. A context of trauma was noted in 10 patients. In the 9 patients treated with antivitamin K or low molecular weight heparin, overdosing was documented in 5. The treatments received before hospitalization were: general antibiotherapy (7 cases), local antibiotherapy (1 case) and low molecular weight heparin (7 cases). DISCUSSION: Hematomas of the legs usually occur in elderly patients, treated with anticoagulants or anti-platelets. They present in the form of ecchymotic tumefaction, frequently inflammatory or febrile. Therapeutic overdosing is common. The ratio with the erysipelas hospitalized in our department is of 1/8; over the past 5 years we have observed a mean of 3 cases per year. Hence they are not uncommon and dermatologists must be aware of their clinical aspects and the circumstances in which they occur.
INTRODUCTION: Histamine is an inflammation mediator that is fundamental for the development of some allergic reactions and is also implied in several common dermatological affections. Anti-H1s are molecules capable of couteracting the effect of histamine on its specific receptors. There are two types: first generation anti-H1 and second generation anti-H1. OBJECTIVE: To assess the efficacy of anti-H1 in the treatment of skin diseases. PATIENTS AND METHODS: A reference search was made using the Pubmed data bank. Critical analysis was made of the articles selected based on their evidence. RESULTS AND CONCLUSION: Demonstration of the efficacy of anti-H1 was only confirmed in a few dermatitis. Urticaria is the indication of choice. The symptomatic use of anti-H1 may be justified within the context of other dermatitis. The second rather than the first generation molecules should be preferred because of the lesser side effects and improved pharmacokinetic profile.
Blepharoconjunctivitis developed as a side-effect of treatment of patients with basal cell carcinomas, keratinizing dermatoses, and cystic acne with oral 13-cis-retinoic acid. Forty-two of the 97 dermatologic patients had signs and symptoms of blepharoconjunctivitis that were dose related and abated one week after discontinuation of the medication. About half of the patients had a history of similar symptoms prior to treatment. Staphylococcus aureus was present in eye cultures of 73% to 79% of the patients, whether symptomatic or not. Patients whose clinical appearance was that of staphylococcal blepharoconjunctivitis and whose cultures grew S aureus were successfully treated with topical erythromycin ointment to the lids even while being treated with the 13-cis-retinoic acid.
OBJECTIVE: We examined the association of dermatological signs such as baldness, thoracic hairiness, hair greying and diagonal earlobe crease with the risk of myocardial infarction in men under the age of 60 years. METHODS: A hospital-based, case-control study included 842 men admitted for the first non-fatal myocardial infarction, the controls were 712 men admitted with noncardiac diagnoses, without clinical signs of coronary disease. The relative risks were estimated as odds ratios. Logistic regression was used to control for the confounding variables. RESULTS: Baldness, thoracic hairiness and earlobe crease were approximately 40% more prevalent in cases (P<10(-6) in each case). In both cases and controls, baldness and thoracic hairiness were frequently coexistent, as well as hair greying and earlobe crease (P<10(-4) in each case). After allowing for age and other established coronary risk factors, the relative risk of myocardial infarction for fronto-parietal baldness compared with no hair loss was 1.77 (95% CI 1.27-2.45) and it was 1.83 (95 CI 1.4-2.3) for men with thick, extended thoracic hairiness. The presence of a diagonal earlobe crease yielded a relative risk of 1.37 (95% CI 1.25-1.5), while hair greying was associated with myocardial infarction only in men under the age of 50 years. CONCLUSION: It appears that baldness, thoracic hairiness and diagonal earlobe crease indicate an additional risk of myocardial infarction in men under the age of 60 years, independently of age and other established coronary risk factors.
Viruses are important pathogens in tropical areas; most of them, especially the tropical hemorrhagic fevers, produce mucocutaneous manifestations. More than any other kind of pathogen, viruses have the possibility for being widespread, since they have a greater probability of mutation than do bacteria, can cross species barriers easily, and infect both human beings and animals in habitats with a great biodiversity. Tropical habitats also have been subject to major ecologic changes in the last few decades, exposing humans to direct contact with these viruses and allowing hemorrhagic fevers due to new emergent viruses such as flaviviruses, filoviruses, arenaviruses, and hantaviruses to become major threats to public health. The collapse of eradication programs in many countries, as well as population increases and ecologic modifications, have led to the spread of dengue and yellow fever to large portions of the world owing to the dissemination of vectors, especially mosquitoes, with broad ecologic ranges. Viruses previously restricted to some geographic areas, such as Rift Valley fever, Crimean-Congo hemorrhagic fever, West Nile fever, and monkeypox are now affecting new countries and populations. Other viruses such as herpes B infection often affect travelers and animal handlers in most parts of the world. Dermatologic lesions occur in all these diseases and can facilitate a rapid diagnosis, leading to control of the virus and helping prevent possible outbreaks.
Although dapsone and sulfapyridine have been used for years in dermatology, there has not always been a clear understanding of how these agents work. Recent investigation, however, has shed new light on thes agents which now allows a more rational approach to their use. This review is an attempt to familiarize the clinician with how these agents work, in what disease states they are effective, how to administer them, what adverse effects may occur, and how to monitor the patient to detect these adverse effects.
Skin diseases are frequently genetic in origin; knowing basic genetic principles allows the clinician to understand hundreds of diverse conditions. The structural basis of genetic disease is related to the multiple steps in DNA replication, messenger RNA (m-RNA) production and modification, protein synthesis, and the posttranslational modification of proteins. The multiple steps in these processes are reviewed. Metabolic processes are connected and interconnected by pathways and networks. The general principles of their control are discussed. The modes of inheritance and their distinguishing characteristics are emphasized, as are factors causing variability among those with the same genetic disease. Tables categorizing many genetic diseases are presented, as is a detailed guide to the literature relevant to modern dermatologic genetics.
PUVA, the combination of psoralen (P) and long-wave ultraviolet radiation (UVA), is being used increasingly in the management of psoriasis and several other dermatologic disorders. While the acute toxicity of this modality, which includes erythema and blistering of the skin, can be avoided with careful monitoring of the dosimetry of the administered radiation, the potential chronic toxicity remains a source of concern. Since psoralens and UVA are clearly mutagenic, carcinogenic, cataractogenic, and may have as yet poorly understood effects on the immune system, it is imperative that all patients treated with this modality be carefully monitored for the development of neoplasia and cataracts. PUVA therapy should only be administered using specialized equipment that can be accurately monitored for its spectral irradiance by physicians thoroughly familiar with the risks and benefits of the modality.
The logical processes of application of criteria to make diagnoses in dermatology and dermatopathology are examined. The limitations of use of a single criterion are delineated, and the advantages and limitations of multiple criteria are defined. It is important that all diagnostic criteria be applied with careful attention to the frequency of the designated entity in the study population and the sensitivities and specificities of the criteria used. The exclusive use of single, "favorite" criteria should be avoided, and multiple criteria should be applied, whenever possible.
Over the past few decades, the computer has been utilized in various ways to assist physicians in formulating their differential diagnoses, usually on an experimental basis. Following a review of the three major technics employed in computer-assisted diagnosis, statistical pattern classification, production rules, and cognitive models, a new system (DIAG) is described. The sole function of DIAG is to assist in the formulation of the differential diagnosis of skin diseases. At the beginning of the fourth year of development, the accuracy of the program in reaching diagnoses has been shown, on many occasions, to be comparable to its expert counterparts. However, it has been demonstrated that the system is not utilized within the dermatology clinic routinely. In response to this, aspects of DIAG have been modified in order to improve its clinical acceptability. Until this acceptance is achieved, these tools will not fulfill their potential to affect patient care.
There are indications for the use of cytotoxic drugs in some dermatologic diseases. These drugs may be lifesaving for patients with diseases such as pemphigus, lymphomas, and vasculitis or they may merely offer an improved quality of life for patients who have diseases such as psoriasis, progressive systemic sclerosis, or sarcoidosis. In either set of circumstances, in the properly monitored patient cytotoxic drugs may be used safely and effectively, offering very few problems for the patient or the therapist. The dermatologist who is interested in offering his/her patients the best medical care possible will wish to become proficient in the use of cytotoxic drugs, just as he/she is proficient in the use of the tetracyclines, systemic corticosteroids, and other powerful, but useful, agents.
Human leukocyte antigen (HLA) associations with different clinical and serologic subsets of lupus erythematosus are providing important clues to genetic predisposition and pathogenesis. The evolving complexity of the HLA-D region is described, and currently recognized HLA-region associations with systemic lupus erythematosus, subacute cutaneous lupus erythematosus, homozygous C2-deficient lupus, Sjögren's syndrome, and the neonatal lupus syndrome are reviewed. The striking relationship between the Ro/SSA-La/SSB antibody responses and HLA-DR2 and DR3 are emphasized. Other dermatologic conditions associated with HLA are also noted.
Iontophoresis, the process of increasing the penetration of drugs into surface tissues by the application of an electric current, has been applied to a great many disease conditions over its 200-year history. Although its greatest success has been in the treatment of hyperhidrosis, it is steadily finding new applications. Many aspects of the mechanisms of iontophoresis have yet to be studied before the technic is both fully understood and maximally utilized. In this article we review the literature on iontophoresis as it pertains to dermatology, including the basic principles, engineering aspects.
We present a review of the spectrum of human T-lymphotropic virus type III (HTLV-III) infection with particular emphasis on cutaneous manifestations in 217 patients. Correlations are made with immunodeficiency as measured by absolute T-helper cell number. A classification is presented of these dermatologic findings.
We report a case of toxic shock syndrome occurring after an excisional skin biopsy in an otherwise healthy woman. Her clean-appearing wound grew Staphylococcus aureus and was implicated as the source of toxin. Dermatologists should be aware that toxic shock syndrome may occur as a complication of simple dermatologic surgery.
This report discusses some of the newly described diseases in pediatric dermatology and recent developments in other diseases that are pertinent to this field.