Adapalene is a new chemical entity with retinoid activity.
0.1 p. 100 adapalene gel (Différine gel), 0.03 p. 100 adapalene gel and a commercially available 0.025 p. 100 tretinoin gel (Aberel gel) were compared in 89 male and female patients with acne.
Inflammatory, non inflammatory, total lesion counts, and the global facial acne grade regularly decreased as a function of time in the three treatment groups. No statistically or clinicaly significant differences were observed for these parameters between 0.1 p. 100 adapalene gel and 0.025 p. 100 tretinoin gel following a 12-week treatment. Conversely, both of these gels were significantly more effective than 0.03 p. 100 adapalene gel with regards to inflammatory and total lesion counts, and the global facial acne grade. The differences of efficacy seen between both adapalene gels demonstrate a dose-dependent activity of the drug in the topical treatment of acne. The three products induced retinoid-like skin irritation with significant differences in intensity in favour of adapalene for erythema, dryness, scaling and burning after application and in favour of tretinoin for persistent burning. No treatment-related medical events were reported and adapalene plasma levels were lower than 0.15 ng/ml (limit of detection of the analytical method).
The topical treatment of acne with adapalene gels was found to be safe and effective, with a dose-related response. The efficacy of 0.1 p. 100 adapalene gel and of 0.025 p. 100 tretinoin gel are not different but skin tolerance of 0.1 p. 100 adapalene gel is superior.
Systemic side effects of local corticosteroid therapy may occur when treating chronic inflammatory dermatoses in children. We compared the effect of micronized desonide cream 0.1 p.100 versus betamethasone dipropionate cream 0.5 p.100.
A randomized double-blind trial was conducted to assess the efficacy of micronized desonide cream 0.1 p.100 (group 1) versus bethamethasone cream dipropionate 0.05 p.100 (group 2) in children treated for atopic dermatitis and to compare their effects on serum cortisol levels 8 hours after administration. Twenty-nine patients, mean age 13.8 months were included (15 in group 1 and 14 in group 2). The creams were applied twice a day from day 1 to 5 then once a day from day 6 to 7 and finally once every two days to day 15.
The two treatments were effective with a decrease in body surface area involved and an improvement in lesion score from day 5 to day 20. Cortisolemia fell off significantly for both treatments between day 0 and day 5 (group 1: Deltad5=-4.74 mg/ml, p=0.01; group 2: Deltad5=-13.06 mg/ml, p<0.0001), only for group 2 between day 0 and day 20 (Deltad20=-7.38 mg/ml, p=0.02) and to a lesser degree between day 0 and day 30 (Deltad30=-3.18 mg/ml, p=0.06). The decrease was greater in group 2 than in group 1 on day 5 (p=0.01) and to a lesser degree at day 20 (p=0.06).
Micronized desonide cream 0.1 p.100 has less potential for suppressing the adrenal cortisol axis than betamethasone dipropionate cream 0.05 p.100 while the therapeutic effect on childhood atopic dermatitis is the same.
The proven value of tetracyclines and metronidazole administered orally in the treatment of the chronic and recurrent disease that is rosacea is tempered by the important undesirable effects observed in long-term therapy. The purpose of this study was to test the effectiveness of an 0.75 p. 100 metronidazole gel in the treatment of rosacea.
The study involved two groups of patients: one received the metronidazole gel and the other the vehicle of the gel used as placebo. The multicentre randomized trial was conducted in the double-blind fashion by 18 private dermatologists working in the Paris region. Fifty one patients who, since more than 3 months, had been presenting with rosacea, defined as at least 4 papulopustules associated with erythema and/or telangiectasia, entered the trial. Topical treatments and systemic treatments which had shown some activity against rosacea had been interrupted for 15 days or 2 months respectively. The product (or the placebo) was applied a.m. and p.m. on the whole dry face. The patients were seen on days 0, 21 and 42. The evaluation was purely clinical, and the principal criterion of judgement was a change in the number of papulopustules between days 0 and 42.
The metronidazole gel reduced the number of papulopustules between day 0 and day 42, and this reduction was significantly greater than that observed with the excipient alone. The active product began to be effective during the third week and remained so during the next three weeks. Both the metronidazole gel and its excipient seemed to be poorly tolerated, with frequent complaints of dry skin, but in 5 women of the metronidazole group this dryness was alleviated by application of moisturizers.
This study has demonstrated that the 0.75 p. 100 metronidazole gel is effective in the treatment of the papulopustular component of rosacea.
Systemic corticosteroids for the treatment of bullous pemphigoid are an accepted therapeutic measure among dermatologists. Nevertheless, the best initial dosage is still unknown. The purpose of the present study was to compare the efficacy and safety of two dosages of prednisolone used as a single therapeutic agent: 0.75 mg/kg/day versus 1.25 mg/kg/day for three weeks. Fifty patients with bullous pemphigoid confirmed by direct cutaneous immunofluorescence were included in this study in different centers. They were randomly assigned to one of two groups: 24 patients were treated with prednisolone 0.75 mg/kg/day (group I) and 22 patients were treated with 1.25 mg/kg/day (group II). Four patients had to be excluded from this study. The low and high dosage prednisolone groups do not show a statistically significant difference from each other after 51 days. At day 21, 58 p. 100 of the patients in group I were disease-free, and 64 p. 100 in group II. At day 51, after a slow decrease of prednisolone therapy (half of the initial dosage per day), 33 p. 100 of the patients in group I were still free of skin lesions, and 55 p. 100 in group II.
Actinic prurigo, as idiopathic skin reaction involving light-exposed areas, was first described in American Indians. Actinic prurigo was early considered to be a particular form at polymorphous phototoxicity, but can be identified as a specific entity on the bases of clinical features and epidemiological characteristics.
Three children in the same family developed photosensitive reactions early in childhood with characteristic polymorphous and persistent eczema-like or papulo-nodular pruriginous lesions which predominated in light-exposed areas and appeared several hours after exposure to sun. The lesions persisted during the winter season. The lesions followed a chronic course but tended to improve at puberty. Clinical laboratory tests, serum and urine porphyrin levels and antinuclear factors were normal. Histology and photobiology explorations gave non-specific results.
These observations have three points in common with actinic prurigo observed in American Indians. HLA typing showed that our three patients, as in white patients in Great Britain, had a significant association with a specific HLA DR1 subtype: DRB1*0407. This DRB1*0407 alleles could play a role in initiating the immune response to a light-induced peptide antigen. This particular genetic predisposition, if confirmed in other studies, would be an additional argument for distinguishing actinic prurigo as a specific polymorphous phototoxicity entity.
Clinical modifications are usually observed during the irradiation of a blood vessel with a laser. These modifications are due to the heating of the blood. Photothermal modifications of oxy-hemoglobin (Hb-O(2)) and des-oxyhemoglobin (Hb) induce formation of met-hemoglobin (Met-Hb), not normally present in healthy human blood. In the near-infrared, the optical absorption of Met-Hb is 3 to 4 times higher that the other chemical constituents of blood. Consequently, after the conformational change of the molecule of heme, the near-infrared (1.06 microm) absorption is considerably enhanced. In order to improve the Nd: YAG laser treatment of vascular lesions, using a non uniform pulse sequence appears to be a much better and safer solution than using a single pulse. The non uniform pulse sequence consists of 3 pulses. The first one induces the optical modification of the blood. After a few hundreds of milliseconds, a 2(nd) and a 3(rd), carrying an energy 3 to 4 times lower than the 1(st) one, are applied. These two pulses maintained a constant temperature inside the vessel. In order to achieve the complete destruction of the vessel, the total duration of the non uniform pulse sequence is similar to the thermal relaxation time of the blood vessel. In conclusion; a better knowledge of the laser tissue interaction process can lead to a better use of a laser. In this particular case, the efficiency of the Nd: YAG laser treatment of vascular lesions can be considerably improved while preserving non-targeted structures.
The authors present three familial cases of Schonfeld's type I pachyonychia. This syndrome represents the association of pachyonychia with palmoplantar keratodermia, frictionnal keratosis and bullae, hyperidrosis, oral leucokeratosis. This genotype is present in the remaining family. Traumatisms produce or increase several symptoms as: a) palmoplantar keratodermia: voluminous callus confined to site of pressure; b) hyperkeratosis of the nails, with hyperplasia and papillomatosis of the nail bed and the hyponychium due to the frequents microtraumatisms of the finger-pulps; c) oral leucokeratosis. The authors describe the painful character of the palmoplantar lesions: walking and working with the hands are very difficult. They assert the outstanding action of aromatic retinoid (RO 10.9359) which entertains a dramatic improvement of the palmoplantar and pachyonychia lesions, the decrease of the pain. Now, the patient life is normal. In these three cases, an hyperuricemia is associated: this feature is probably a fortuitous association. One of these patients has a Lesch-Nyhan's syndrome.
Several studies have shown a high prevalence of rash induced by nevirapine. However, there is little knowledge about the risk factors associated with nevirapine-induced rash. The aim of this study was to identify risk factors associated with the occurrence of rash during the treatment with nevirapine of HIV-infected patients.
A retrospective study was conducted in the dermatology department of Besançon university teaching hospital between November 1998 and September 2001. The study included all HIV-infected patients receiving HAART regimens that included nevirapine. The following data were collected: age, sex, CDC classification of HIV, CD4 and CD8 lymphocyte counts, plasma HIV RNA load, hepatitis B, C and cytomegalovirus serostatus, history of drug allergy, concomitant medication (other antiretroviral drugs, corticosteroids, antihistamines). Univariate analysis was performed using a Chi2 test or Fischer's test and Student's t test. Fischer's test and the Cox proportional hazards model were used in the multivariate analysis.
During the study period, 101 HIV-infected patients (74 men and 27 women; mean age: 41.6 +/- 10.3 years) were treated with HAART regimens including nevirapine. Fourteen developed cutaneous drug-reactions attributable to nevirapine (13.86%). We observed 13 cases of maculopapular exanthema and 1 case of DRESS. In the univariate analysis, female gender (p=0.002), plasma HIV RNA load > 10,000 copies/ml (p=0.05), heterosexual transmission (p=0.002) and abacavir treatment (p=0.05) constituted risk factors associated with rash. In the multivariate analysis, only female gender (p<0.0001) and plasma HIV RNA load > 10,000 copies/ml (p=0.0007) were associated with rash.
The results of this study confirm the high frequency of toxidermy associated with nevirapine therapy. The risk factors associated with occurrence of rash due to nevirapine therapy were female gender and plasma RNA > 10,000 copies/ml. Several studies showed absence of any protective effect of antihistamines and corticosteroids in preventing the cutaneous adverse reactions associated with nevirapine. The identification of risk factors closely associated with nevirapine-induced rash could help physicians determine new strategies for safer use of nevirapine in the HAART regimen.
Knowledge of the causes of melanoma and reasons for diagnosis delay is essential for early management.
One hundred two patients consulting for melanoma at the Saint-Louis Hospital in Paris from January 1, 1994 to December 31, 1995 were asked to respond to a standardized questionnaire. Time to diagnosis and the different time fractions were analyzed by socio-demographic characteristics and by pathology features.
Meantime from the first signs of a new lesion or modification of an old lesion to exeresis of melanoma was 20.4 months. Most of the delay prior to diagnosis was patient-related; lack of knowledge about the early clinical signs of melanoma appeared to be the most important cause of delay. Time to diagnosis was not significantly correlated to the thickness of the melanoma.
Our results are compared with two similar series reported in other countries during the last ten years. The lack of correlation between the thickness of the melanoma and time to diagnosis appears to be explained, at least in part, by the biological variability of melanomas.
Superficial and deep cold urticaria is a heterogeneous group of manifestations induced by exposure to cold (0 to 4 degrees C). Frequency is generally estimated at 2 to 3 p. 100. We studied retrospectively 104 patients meeting clinical, biological and therapeutic criteria of cold urticaria.
From 1981 to 1995, 1802 patients with urticaria were included in a standardized allergy survey. Among these patients, 104 met the criteria for the diagnosis of cold urticaria: positive test with 3 ice cubes placed on the skin for 5, 10 and 15 minutes or positive immersion test (immersion in 4 degrees C water for 15 minutes). Two groups of patients were excluded, those with systemic cold urticaria and those with minimal thermo-differential urticaria.
Cold urticaria was found in 5.7 p. 100 of our urticaria patients, predominantly in young women. The triggering effect of cold was found at history taking in 71 p. 100 of the cases. The urticaria was usually superficial, more rarely associated with deep and/or mucosal urticaria. General signs were uncommon. The three ice cube test demonstrated significative biological and immunological abnormalities. In 5 cases, discrete cryoprecipitate was found (4 cryoglobulins, 1 cryofibrinogen). Although the search for an infectious agent was not conducted in absolutely all cases, there was no apparently remarkable association with infection the exception of VIH infection. Anti-H1 agents were given in 88.3 p. 100 of the cases leading to short-term improvement. Follow-up is insufficient to evaluate long-term outcome.
This retrospective survey of 104 cases of cold urticaria was compared with data in the literature, particularly with the small number of studies including a large number of patients. We conclude that the diagnosis of cold urticaria can be based on history taking alone and the three ice cube tests (prognosis value, indication of reaction threshold). An exhaustive search for the cause is not indicated. A search for cryopathy should however always be done and followed by a complete work-up in case of positivity. Clinical signs other than cold urticaria suggesting a pathological response to cold require complete investigations.
The benefits of PUVAtherapy in many dermatological affections are well known. Its carcinogenic role in the long term has been assessed varyingly in American and European series.
The aim of this study was to assess the role of PUVA in the onset of cancers of the skin.
Retrospective study of patients presenting with psoriasis and followed-up in the phototherapy unit of the Michallon Hospital in Grenoble since 1976 and having received more than 150 sessions of PUVA. The parameters studied were: age, gender, phototype, age at the time of the first irradiation, type of phototherapy administered, total number of sessions, concomitant treatments, administration of retinoids and the appearance of skin cancers with the interval before their onset after the first session, their localization and their histological type.
One hundred six patients were retained among the 152 who replied to the inclusion criteria. Having died or been lost to follow-up, forty-six patients were excluded. Fourteen patients had presented at least one cutaneous tumor with a total number of 35. Excluding the keratoacanthomas, 13 patients had a non-melanic cutaneous cancer with a total number of 32 tumors. Ten out of the 14 were phototype III, 3 were phototype II and one was phototype IV. Nine out of 14 had received PUVAtherapy alone and 5 PUVAtherapy and broad spectrum UVB. The number of sessions of PUVA received in all the cases was more than 200 (220 to 780), corresponding to a total dose of UVA comprised between 1460 and 3882 Joules. The delay before onset of the tumors varied from 6 to 27 years after the first PUVAtherapy. The mean age at the time of the first irradiation was of 50.2 years (14-75 years). The mean duration of phototherapy was of 10 years (2.23 years).
Transthoracic endoscopic sympathectomy for palmar hyperhidrosis is a safe and effective method. However, no radical and definite treatment exists for plantar hyperhidrosis. We report our experience, immediate post-operative and mid-term results after transthoracic and lumbar endoscopic sympathectomy for palmar and plantar hyperhidrosis.
One hundred and seven of 117 patients cured between January 94 and December 98, answered a questionnaire regarding their past history, the early post-operative results, side effects and complications caused by the operation and mid-term results with particular emphasis on patient satisfaction.
Seventy-eight thoracic and lumbar endoscopic sympathectomies and 125 thoracic endoscopic sympathectomies were performed. The patients were 30 men (median age 30 years) and 77 women (median age 26 years). Only women underwent lumbar endoscopic sympathectomy because of risk of retrograde ejaculation. No severe complications were noted. The success rate was 96 p. 100 for palmar hyperhidrosis and 98,5 p. 100 for plantar hyperhidrosis. No recurrences were noted in 97 p. 100 of the patients with median follow-up of 28 months. The main side effect was compensatory sweating which was the reason for dissatisfaction for 5 p. 100 of the patients. Cutaneous dryness and gustatory sweating were also described. However, 95 p. 100 of the patients were "satisfied" or "very satisfied".
Our experience proved that lumbar endoscopic sympathectomy is as safe and effective for treatment of plantar hyperhidrosis, as thoracic endoscopic sympathectomy for palmar hyperhidrosis.
Recurrent perineal erythema is a rare toxin-mediated disease. We report the case of recurrent toxin-mediated perineal erythema in a child.
An 11-year-old boy was hospitalized for erythematous pustular eruption involving the perineum and the axillary area. This erythema started a few days after the onset of pharyngotonsillitis and the patient's personal history involved another episode of pharyngotonsillitis which was followed by an identical cutaneous eruption. Laboratory analysis confirmed the diagnosis of recurrent toxin-mediated perineal erythema. The skin disorder quickly improved and antistreptococcal antibiotic treatment was initiated to eradicate bacteria.
Recurrent toxin-mediated perineal erythema is a cutaneous disease mediated by superantigens which are toxins produced by staphylococci and streptococci. It is characterized by recurrent macular erythema involving the perineum. Streptococcus pyogenes is the most common cause of recurrent toxin-mediated perineal erythema, with Staphylococcus aureus being isolated most rarely. This observation emphasizes the possibility of atypical clinical presentation with pustular lesions, and dermatologists must be mindful of this aetiology in order to isolate bacterial toxins and to initiate appropriate antibiotics.
Immunologic data collected in 11 children (6 girls and 3 boys under fourteen) presenting with linear scleroderma were analysed in a retrospective study: 2 children presented with superficial linear scleroderma, 6 with monomelic scleroderma, 1 with dimelic scleroderma, 1 with the "en coup de sabre" variety associated with dimelic homolateral involvement, and another with "en coup de sabre" scleroderma combined with facial hemiatrophy: Antinuclear antibodies (ANA) were demonstrated in 9/11 cases (i. e. 81 p. 100). The immunofluorescence staining pattern was homogeneous in all nine with a low titer (less than 250 in 5 of them). ANA to single stranded DNA was present in 1/3. The demonstration of ANA in these 9 children was correlated with deep or extensive sclerosis with muscular involvement in 7. But neither the presence nor the titer of ANA were correlated with the subsequent development of osteoarticular sequelae. The level of total complement appeared to be lowered in 3/8 cases. No renal involvement was demonstrated. Blood tests for circulating immune complexes were positive in 4/8 patients. Skin biopsy for direct immunofluorescence was performed in 6 children and demonstrated immunoglobulin deposits in 4: three had IgM fixation on the dermo-epidermal junction, and one had speckled fixation of IgG on epidermal nuclei (this has not previously been reported in localized scleroderma). There data highlight: a--the high frequency of ANA in linear scleroderma.(ABSTRACT TRUNCATED AT 250 WORDS)
Temporal and frontotemporal skin defects can be repaired using various reconstruction procedures: temporojugal rotation-advancement flaps, frontotemporal advancement flaps, skin grafts, etc. We propose an alternative method using a rhomboid transposition flap, thus extending the possibilities for repair in this region.
This is a retrospective, non-comparative study of patients in whom a rhomboid transposition flap of the temporal or frontotemporal region was created between February 2008 and March 2010. Sex, age, hospitalization, histological type of the excised lesion, type of anaesthesia, defect size, possible occurrence of complications and outcome were compiled from the medical records.
Eleven patients (five women and six men) of average age 76years were included. The lesions were due in all cases to basal cell carcinoma. Five patients were ambulatory and seven were hospitalized. All patients underwent surgery under local anaesthesia in a single session. Hospitalized patients had more extensive cutaneous defects, were older and had more comorbidities. One patient presented incomplete lateral resection. The most frequent complication was bruising on the lower eyelid (5/11), and two more severe complications occurred: distal flap necrosis and haematoma. The aesthetic result was good for all patients after a mean 20months of follow-up.
Rhomboid transposition flaps appear to be a reconstruction option that warrants consideration in cutaneous defects in the temporal or frontotemporal region.
Antimalaria agents and thalidomide are two reference drugs for discoid lupus erythematosus. In non-responders or after secondary resistance or contraindications, there are a number of alternative therapeutics which are less effective and more toxic. We therefore conducted an open study in patients with discoid lupus erythematosus treated with sulfasalazine.
Seven men and four women (mean age 40 years) with severe discoid lupus erythematosus (mean duration of disease 14 years) were treated with sulfasalazine (2 g/d). This treatment was initiated after a previous failure or contraindication of antimalarial drugs or thalidomide. The acetylation phenotype was predicted in all patients with N-acetyltransferase 2 genotyping. Genome DNA was tested for mutations causing an N-acetyltransferase deficiency. Homozygous individuals or those with heterozygous composites for the tested mutations were predicted slow acetylators and those with a homozygous or heterozygous genotype for an allele carrying a normal sequence at the mutation sites were predicted rapid acetylators.
We had 7 complete responses, 1 partial response and 3 failures. Mean delay to efficacy was 7 weeks, longer for lesions involving the scalp (4 to 5 months). Six of the 8 responders were given sulfasalazine exclusively. The effect was suspensive and dose-dependent; the minimal effective dose was 1.5 g/d. Excepting light sensitization requiring discontinuation, there were no clinically significant side effects. Neutropenia occurred in one patient and moderate and transient live enzyme movements did not require treatment withdrawal. The only immunoallergic side effect (light sensitization) observed occurred in a slow acetylator. All responders except one were rapid acetylators.
Salazosulfapyridine, or sulfasalazine, is composed of a derivative of 5-aminosalicylic acid and a sulfamide fraction, sulfapyridine. It is only marginally used in dermatology except for psoriasis. Its efficacy in chronic lupus erythematosus has been reported in one case. We confirmed the role of this compound in the treatment of chronic lupus erythematosus. The rare observations of induced lupus and development of antinuclear antibodies are not a contraindication, but require close regular clinical and biological surveillance. The potential risk is that possible hypersensitivity could lead to reserving sulfasalazine for severe resistant chronic lupus erythematosus after failure with antimalarials and thalidomide. Nevertheless, our study demonstrates that the slow acetylator phenotype predicts immunoallergic events, as observed by other authors, and would be a factor predicting nonresponse. If these results are confirmed by other studies, it would be possible to propose sulfasalazine as a treatment for discoid lupus erythematosus in rapid acetylators.
TNFalpha blockers have recently extended the therapeutic arsenal available in dermatology. However, dermatologists must be informed of their potential adverse dermatological effects. While the chief adverse effect of TNFalpha blockers is risk of infection, cutaneous adverse effects have not yet been clearly elucidated and publications on this topic are few and far between. The aim of our study is to report various dermatological problems noted during treatment with TNFalpha blockers.
This was a retrospective study of patient files. The study population comprised patients receiving TNFalpha blockers and presenting cutaneous reaction, and seen in the dermatology department between August 2001 and December 2004.
Eleven patients were included. The following cutaneous reactions were seen: delayed skin rash (1 case), lupus syndrome (1 case), cutaneous vasculitis (2 cases), palmoplantar pustulosis (2 cases), psoriasis vulgaris (1 case), atopic dermatitis (1 case), lichenoid rash (1 case), purpuric capillaritis (1 case) and melanoma (1 case).
The cutaneous manifestations seen represented a wide range of different clinical pictures. Dermatologists must be aware of these potential adverse effects. Future improvement of knowledge of the physiopathological mechanisms as well as the institution of prospective cohort studies should provide clearer guidance on the management of such symptoms.
Piedra (stone in Spanish) is the name given to a trichomycosis characterized by the formation of nodules resembling small stones. There are two varieties of the disease, depending on the colour of the nodules: white piedra and black piedra. Black piedra sharply differs from white piedra on three main scores: a) the causative agent is a black filamentous and sexed dematicious fungus, Piedraia hortai; b) the disease exclusively affects the scalp, and c) the geographical distribution of human black piedra is limited to tropical and subtropical areas (South America, South-East Asia). White piedra has a different aetiology, being caused by an asexual fungus, Trichosporon beigeli. The genus Trichosporon (Behrend, 1890) and the species T. beigeli (Vuillemin, 1902) were created from a case of piedra of the moustache. White piedra may involve hairy regions other than the scalp, such as the beard and moustache, less frequently the armpits, eyebrows, eyelashes and pubic hair. The disease has been observed in all continents, except Africa, and under all climates, although it is exceptionally found in cold areas (two indigenous cases in Finland). The observatio princeps of white piedra (on a false chignon) was published in 1865 by Beigel, in London. In France, only three cases, all concerning the moustache, were reported at the very beginning of this century No other case has been published in that country in the east 80 years. T. beigeli is a common saprophyte in nature. It has been found in soil, water, fruit, rotten vegetables, sawdust, as well as in man (skin, skin appendages, mucosae) and in animals (mammals, insects, mussels).(ABSTRACT TRUNCATED AT 250 WORDS)
Piroxicam (Feldene) and isoxicam (Vectren) form a part of a new family of non-steroid anti-inflammatory drugs (NSAID) highly used in France: the oxicams. The cutaneous accidents of all kinds are frequent, estimated from 1 to 3 p. 100 of the patients with piroxicam (16, 20). In addition to the maculo-papular eruptions, there has been reported: lichenoid eruption (21), erythroderma (7), purpuric vasculitis (1, 10, 21), pemphigus (12, 14), bullous dermatosis difficult to classify (15), erythema multiforme and Stevens-Johnson's syndrome (3, 6, 7, 9, 13, 21, 23) and at last many photosensitization accidents (3, 8, 11, 19, 20, 21). We report 11 observations of Lyell's syndrome (8 cases) or Stevens-Johnson's syndrome (3 cases) occurred during treatments by isoxicam or piroxicam. Eight women and 3 men aged from 35 to 80 years begin a Lyell's syndrome or a Stevens-Johnson's syndrome after 9 to 45 days (at an average of 16 days) of a treatment by isoxicam (6 cases) or piroxicam (5 cases). Five patients attacked by a Lyell's syndrome are intubated and ventilated and 2 patients die of a septic shock at the ninth and the thirteenth day of evolution: the duration of hospitalization is from 11 days to 3 and a half months for the Lyell's syndromes survivors and from 7 to 19 days in the cases of Stevens-Johnson's syndrome: 7 surviving patients have ocular sequelae with in 2 cases a complete or partial blindness. A slight hepatic cytolysis is observed 5 times and a neutropenia mainly as a lymphopenia 4 times. In 2 observations, the CMV serology is positive.(ABSTRACT TRUNCATED AT 250 WORDS)
UVA-1 phototherapy is used to treat various connective tissues disorders including systemic lupus erythematosus (SLE) and systemic sclerosis (SS). We conducted an open study to investigate the efficacy of this therapy on connective tissue disorder-related acrosyndrome.
Eleven patients with Raynaud's phenomenon refractory to the standard therapy (six SLE and five SS) were treated with UVA-1 in an open study. Whole-body phototherapy was given in seven cases but was restricted to the hands in four cases. The results were evaluated by comparing status before and after treatment using semi-quantitative tools in terms of daily frequency and intensity of spastic phenomena, pain, overall patient satisfaction, improvement of cutaneous lesions, trophic disorders and distal cutaneous flexibility for patients with ScS.
After treatment, Raynaud's phenomenon improved in terms of both frequency and severity in 9/11 patients (82%: 4/6 SS and 5/5 SLE). Likewise, pain decreased in 8/11 cases (73%: 3/6 SS and 5/5 SLE). 7/12 patients felt their condition had improved (64%: 3/6 SS and 4/5 SLE). Cutaneous lesions improved in 5/11 patients (45%: 2/6 SS and 3/5 SLE), especially for lupus-related lesions including chilblains and in idiopathic chilblains that totally subsided within one month. Digital ulcers improved in all cases, with complete healing in 3/4 patients (75%). In SS, cutaneous flexibility significantly improved in 2/6 cases (33%). No major adverse effects were seen in patients treated with hand-only phototherapy but a slight and spontaneously reversible cutaneous rash, reminiscent of lupus lesions, occurred in one female patient receiving whole-body phototherapy.
This study is the first to provide a precise evaluation of the efficiency of UVA-1 phototherapy on connective tissue disorder-related acrosyndrome. This therapeutic effect is not necessarily restricted to the laboratory effects of UVA-1 since the favourable impact of infrared radiation and a placebo effect cannot be ruled out. Although its methodological limitations are obvious, our study also confirms dare data in the recent literature data by demonstrating significant improvement in cutaneous lesions, trophic ulcers and Raynaud's phenomenon in patients presenting connective tissue disorders, including SS, without any major adverse effects.
Although these preliminary results remain to be confirmed by large-scale, randomized studies, UVA-1 phototherapy clearly offers a new and valuable therapeutic option in connective tissue disorders associated with acral manifestations and/or lesions, including SLE and SS.
Human papilloma virus is highly prevalent, but rarely localized in the conjunctiva.
A 19-year-old man with no past history of skin or mucosal disease consulted for tumefaction of the conjunctiva. Exeresis revealed a viral papilloma. In situ hybridization was positive for human papilloma virus 6/11.
Conjunctival lesions of human papilloma virus are often located in the caroncula as in our patient. The papillomatous aspect of the tumour may suggest squamous cell carcinoma (sometimes induced by human papillomavirus 16/18). Contamination may be manual or occur at birth via the maternal genital mucosa. Treatment usually is based on wide exeresis with cryo-application although spontaneous regression is possible.
Post-radiation atypical vascular lesions of the skin display clinical and morphological overlap with well-differentiated angiosarcomas, and correct diagnosis may be difficult.
We studied clinical, histological and immuno-histochemical aspects (CD31, CD34, D2-40 and VEGFR-3) of eight post-radiation atypical vascular lesions comparatively with three post-radiation angiosarcomas.
All patients were female and received radiation therapy for breast carcinoma. On average, atypical vascular lesions occurred 4.3 years after radiation therapy and presented as small papulonodules or erythematous plaques. The clinical course after simple excision was benign. Histologically, they were relatively circumscribed lesions and showed slit-like vessels dissecting dermal collagen in all cases. On average, angiosarcomas occurred 5 years after radiation therapy and presented as more extensive lesions with a more aggressive clinical course. The lesions showed histological overlap with atypical vascular lesions, but were poorly circumscribed, with deeper invasion, cytological atypia and mitosis. Although the immuno-histochemical profiles were similar, expression of VEGFR-3 was greater in two cases of angiosarcoma.
Post-radiation atypical vascular lesions are benign lesions that display clinical, histological and immuno-phenotypic overlap with well-differentiated angiosarcoma, and diagnosis requires good clinicopathological correlation. VEGFR-3 may be useful for differential diagnosis, as well as amplification of the MYC gene.
Pseudoxanthoma elasticum is a congenital dystrophy of the connective tissue. Its clinical expression is cutaneous, ocular and cardiovascular.
The aim of our study was to specify the principle characteristics of this disease and to discuss the interest of various supplementary examinations in its diagnosis and control in a series of 11 patients.
The study included 9 women and 2 men (sex ratio: 4.5). The mean age the onset of the symptoms was of 18 years. In 4 cases there was a family history of the disease. All the patients exhibited yellowish, pigskin, and papular lesions on the sides of the neck. The systematic ophthalmologic examination revealed angioid streaks in 7 cases and a pigskin aspect in 4 cases. The systematic cardiovascular and metabolic explorations revealed no abnormalities specific to pseudoxanthoma elasticum. Two cases of asymptomatic nephrocalcinosis were observed.
In our patients, the disease was probably of autosomal recessive transmission. The predominance of women consulting for the disease would be explained by the esthetic damage. Diagnosis of pseudoxanthoma elasticum is based on clinical, histological and genetic criteria. Supplementary explorations are useful to confirm the diagnosis and also for the search to other, visceral, localizations. Such examinations vary depending on the teams, means and above all the evocative signs.
A retrospective study of 111 patients admitted to the Dermatology department of the Bichat hospital, Paris, between 1981 and 1988 for treatment of erysipelas revealed the following data: 1. Erysipelas was located on the lower limbs in 88.3 p. 100 of the cases and on the face in only 9.8 p. 100. 2. Facilitating and/or aggravating factors were: portal of entry in 75 p. 100 of the cases; impairment of venous and lymphatic circulations (41 p. 100); diabetes mellitus (13.5 p. 100); alcoholism and its socio-economic consequences (29 p. 100); unnecessary prescription of anti-inflammatory agents (11 p. 100). 3. Insufficient consideration was given to the clinical diagnosis: in 7.2 p. 100 of the patients erysipelas was diagnosed either after failure of heparin therapy or because phlebography was normal; some clinical features, notably bullae (30 p. 100) or purpura on the lower limbs (13 p. 100), confused the physicians. Delayed treatment was the main cause of local complications, such as abscess (4 cases) or focal cutaneous necrosis (4 cases). Erysipelas was recurrent in 23.5 p. 100 of the patients. 4. Bacteriological data in this series were insufficient to establish percentages of responsible organisms. However, penicillin G in mean doses of 12 million units per day administered intravenously for 5.5 days, then intramuscularly for 10 days was effective as first-line treatment in 80 p. 100 of the cases. Penicillin therapy may fail in patients with insulin-dependent diabetes or belated treatment with complications. No thromboembolic complication was observed (89 p. 100 of patients with lower limb erysipelas had received anticoagulants). There was only one death due to a severe underlying condition.
Xeroderma pigmentosum is a rare recessive and autosomically transmitted genodermatosis. Its cutaneous manifestations are dominated by skin cancers. This investigation aims at studying the epidemiologic, clinic, histologic, therapeutic and evolutive aspects of the skin tumors during xeroderma pigmentosum.
A retrospective monocentric study was carried out in the Dermatology and Veneorology Department of Ibn Rochd University Hospital of Casablanca, Morocco. It included all the xeroderma pigmentosum admitted to hospital or followed-up from 1990 to 2000. All the dossiers were included. The anatomopathologic study was carried out in all the skin tumor cases.
One hundred and twenty xeroderma pigmentosum were admitted in 10 Years. Fifty-four percent of the cases were females and 46 p. 100 were males. The mean apparition of the first tumor was 7.7 Years. One hundred and fifty-three skin tumors were diagnosed in 96 patients (80 p. 100). These tumors were of basocellular carcinoma type in 32.6 p. 100, of squamous cell carcinoma type in 33.9 p. 100 and of melanoma type in 11 p. 100. Ocular tumors were found in 31 cases (25.8 p. 100) and buccal in 8 cases. Therapeutically, the surgical exeresis of one or many tumors was performed in all cases. Electrocoagulation was associated in 42 p. 100 of the cases and skin graft in 52 p. 100. Cutaneous relapses after surgery were noticed in 55 cases (57.2 p. 100). Twenty-five patients died and 31 were lost to follow-up.
Our series is characterized by a large frequency of mainly cutaneous tumors (80 p. 100) in comparison with the largest review of literature (45 p. 100). These tumors were mainly represented by basocellular and squamous cell carcinoma with onset at an early age (7.7 Years). Our series is also characterized by a large frequency of cutaneous relapses after surgery (51.6 p. 100). Neglecting advice on photoprotection and the lack of regular control visits lead to the proliferation of large size tumors, making therapeutic strategies difficult or even impossible.
To determine the prevalence of the Human Papillomavirus (HPV) in Human Immunodeficiency Virus (HIV) infected men, using clinical examination and molecular hybridization in situ.
From May 1995 to May 1997 we studied the prevalence, clinical and histological characteristics, the types and the evolution of the HPV lesions among 121 HIV-infected men. The HPV DNA was determined by molecular hybridization in situ, using biotinylated probes which recognized HPV types 6/11, 16/18 and 31/33/35 in 79 p. 100 (5/19) of the patients (17 biopsies).
Sixteen per cent (19/121) of the patients are HPV infected: genital warts in 37 p. 100 (7/19), anal warts in 37 p. 100 (7/19), and ano-genital warts in 26 p. 100 (5/19) of the patients. In every case of anal codyloma, intracanalar lesions were found. In 47 p. 100 (9/19) of the cases, histological exam showed an intra-epithelial neoplasia. The HPV types 6/11, 16/18 and 31/33/51 were positive in 53 p. 100 (9/17), 35 p. 100 (6/17) and 35 p. 100 (6/17) biopsies respectively. High-risk types of HPV have been noted in 71 p. 100 (12/17) of the biopsies. The evolution of the clinical lesions was: recovering in 47 p. 100 (9/19) of the patients (after 3 months of treatment), recurrence in 16 p. 100 (3/19) of the anal warts (after 1 to 3 months of treatment), stabilization in 16 p. 100 (3/19) of the genital warts (after 6 months of treatment) and extension in 11 p. 100 (2/19) of the anogenital warts (after 3 months of treatment).
The high prevalence of condyloma and dysplasia emphasizes the importance of the anogenital exam in HIV-positive patients. In case of anal lesions, anuscopy and biopsy are required. We insist on the need to closely follow these patients with HPV lesions in order to adapt treatment. Anal cytology and HPV-DNA detection by Hybrid Capture Assay, should be developed for screening and prevention of the malignant transformation of HPV lesions in this population.
The purpose of this study was to evaluate the epidemiology of tinea capitis in the Bordeaux area (Dermatology Unit of the Hôpital des Enfants, Bordeaux) during a 6-year period (January, 1979 to December, 1984). Dermatophytic infection of the hair was proven by culture in 124 patients, 21 of whom had a negative potassium hydroxide direct examination. Age and sex distribution are shown in figure 1. One case was observed in a 15 days old infant, and 4 cases in adult females (3 young black mothers of affected children, 1 elderly white woman). Table I indicates the geographical origin of the patients and the isolates identified. The incidence of anthropophilic dermatophytes has increased from 13 p. 100 to 50 p. 100 since our previous survey (1975-1978). M. langeronii (29 cases), T. soudanense (19 cases) and T. violaceum (10 cases) were isolated mostly among African immigrants from Western tropical Africa and the Maghreb. However, 4 children of French origin without any history of previous sojourn in endemic areas developed tinea capitis due to M. langeronii; the source of contamination could not be determined. Zoophilic dermatophyte infection was mainly caused by M. canis (50 cases), with cats being the most frequent source of contamination. Family cases were frequent: 64 corresponding to 28 families. This may be due to either interhuman contamination or the presence of a contact pet animal in the family. The discussion is focused on: the shift in dermatophytic isolates from tinea capitis toward anthropophilic species, notably M. langeronii, mainly caused by an increased immigration from West Africa; the relevant clinical and mycological correlations.(ABSTRACT TRUNCATED AT 250 WORDS)
In a series of 86,400 pathological examinations 125 cases of pigmented naevus associated with one or several foci of cutaneous ossification were observed. This association, known as osteonaevus of Nanta, account for 1.4 p. 100 of all pigmented naevi. In our series of examinations, osteonaevus was the most frequent cause (62 p. 100) of the 201 skin ossifications observed, the other causes being keratinizing basal cell epithelioma (7 p. 100) and pilomatricoma (5.5 p. 100). The patients' mean age was 46 years (range: 21-80 years), and 81 p. 100 of them were women. In almost every case the lesions were located on the head. The clinical diagnosis was always pigmented naevus, but it coexisted with inflammatory changes in 8 cases, and an underlying induration could be perceived at palpation in 4 cases. In 123 or ou 125 cases the pigmented naevus was restricted to the dermis, junctional theques being present in only 2 cases. The number of ossified foci varied from 1 in 45 p. 100 of the cases to 2 to 4 in 91 p. 100, and in 1 patient up to 8 foci were visible on the same section plane. The lesions presented as compact balls (135 cases), or lamellated bone (126 cases), or spicules of unorganized bone formations. They varied in size from 0.5 mm for balls to 1.5 mm for elements with a central cavity. In the latter were rudiments of bone marrow with capillary vessels, osteoclasts, adipose cells and cells that could be regarded as having haemopoietic functions. All naevi contained hair follicles.(ABSTRACT TRUNCATED AT 250 WORDS)
Since the description by Toker in 1972, neuroendocrine carcinoma or Merkel cell carcinoma, is a well identified clinical entity although the appropriate treatment is still debated. Wide surgical exeresis is indicated as first line treatment in all cases but the question concerning protocols for adjuvant radiotherapy or chemotherapy remains open. We analyzed retrospectively our series of 13 patients with neuroendocrine carcinoma looking for an association between radiotherapy and surgery.
There were 7 women and 6 men in our study population (age range 43-88 years). Two cancers of the rectum and one prostate cancer were associated. In 6 cases, the tumor was localized on the limbs, in 5 on the face and in 2 on the buttocks. Mean delay to diagnosis was 2.5 months. At diagnosis, only 1 patient had satellite nodes. The pathology examination evidenced intermediary cell type and architecture. Immunohistochemistry tests were positive for NSE, NF, KII and the ultrastructure confirmed the diagnosis. Nine patients were treated with surgical exeresis with wide 1 cm margins and was completed with radiotherapy of the tumoral bed at homogeneous doses of 45 to 60 Gy. Surgery alone was used in 4 patients.
Mean follow-up was 27 months (5-98). Among the 13 operated patients, 11 have survived, 1 died due to the neoplasia and in 1 other from another cause. Local and regional recurrence rate after exercise alone was 50 p. 100 (2/4) with concomitant development of metastasis in both cases. When local or locoregional post-operative radiotherapy was given, local or regional recurrence rate was 33 p. 100 (2/6).
Cutaneous neuroendocrine carcinoma or Merkel cell carcinoma is an uncommon skin tumor. It is difficult to determine the management protocol on the basis of data in the literature. Due to risk of locoregional recurrence, we currently propose post-operative radiotherapy of the tumor bed and drainage nodes in all patients.
15 patients with severe nodulo-cystic acne were treated with 13-cis retinoic acid (Ro 4-3780) for 6 to 12 months. The initial dose was 40 mg/day in all the cases. In 14 out of 15 cases this dose was progressively reduced depending on improvement of the acne lesions and on the occurrence of side effects. In one case the initial dose was later increased to 60 mg/day because of lack of response to the treatment. A 75 p. 100 improvement in the severity of the acne lesions was achieved within 4 to 5 months. Complete disappearance of the lesions was achieved in most of the patients after between 6 and 12 months of treatment. The most frequent clinical side effects were dryness of the lips, cheilitis with rhagades and facial dermatitis. Abnormal increased values of hepatic enzymes and triglycerides were found in some patients.
Hypomelanosis of Ito was first described by Ito in 1952 as incontinentia pigmenti achromians. The consistent feature of the disease is a characteristic cutaneous hypopigmentation area following the lines of Blaschko, but the clinical manifestations are varied and hypomelanosis of Ito is regarded as a neurocutaneous syndrome. Hypomelanosis of Ito is sporadic but is probably a non-specific expression of chromosomal mosaicism; we report a case with four clones.
We report the case of a 26 year-old woman with neurocutaneous hypomelanosis of Ito and Trisomy 13 mosaicism. She also exhibited skeletal and ophthalmologic disorders. Immunohistology revealed a PS100 and Melan A decrease in hypopigmented skin. Cytogenetic study of normal and hypopigmented skin fibroblasts showed mosaicism with four clones.
This is the third case of Trisomy 13 mosaicism associated with hypomelanosis of Ito, although other anomalies on chromosome 13 have been described. Happle published "phylloid" pigmented cases, which are mainly associated with Trisomy 13. This is the first observation of four-clone mosaicism and can be explained by successive mutations during embryogenesis. Anomalies on chromosomes 5,6 and 21 have never been described. The definition of hypomelanosis of Ito is not well established and the disease is presently included in a group of "pigmentary dysplasia" with genetic mosaicism.
The case of a 75 yr old woman suffering since 13 years from a subcorneal pustular dermatosis which showed histologic signs of acantholysis, developed an IgA myeloma. Treatment with melphelan was instituted. The skin lesions responded very well to topical vitamin A acid.