A three-week double-blind randomized study was carried out to compare the effect of Diprosone cream 0.05% with Synalar cream 0.01%. Forty patients suffering from psoriasis and other steroid responsive dermatoses were included in the study. The disease status was carefully monitored throughout the period of the study and parameters were measured to determine the efficacy, onset of action, tolerance and cosmetic acceptability of the two preparations under study. It was concluded that both preparations were efficacious in the treatment of psoriasis and other steroid responsive dermatoses, and that there was no statistically significant difference between the two preparations in the parameters evaluated, other than in the treatment of psoriasis when the parameter of scaling was measured.
Side effects were recorded in two patients receiving Synalar, and one receiving Diprosone, during this study.
The differences between topical corticosteroids are based mainly on their potency, safety and patient acceptability. The aim of this study was to evaluate a mild- to mid-potent topical corticosteroid, desonide 0.05%, on these three parameters in an Australian cohort of patients with facial seborrhoeic or atopic dermatitis. Eighty-one adult patients were randomized to receive desonide 0.05% lotion or its vehicle, applied twice daily for 3 weeks under double-blind conditions. In the active treatment group, 88% of patients had their skin condition cleared or almost cleared and only two patients experienced cutaneous adverse events (rash and pruritus). The acceptability of the lotion was high; 95% of patients stated they would use this topical corticosteroid again. These data support the short-term use of desonide 0.05% lotion as a suitable agent for the short-term treatment of facial dermatitis.
In a randomised double-blind vehicle controlled trial of 0.05% tretinoin cream in the treatment of photodamaged skin, the histological results of paired biopsies from 28 individuals who applied tretinoin for 26 weeks are compared with 28 paired biopsies from a control group applying vehicle alone. There was a significant increase in epidermal thickness in the tretinoin-treated group (P.001). Epidermal atrophy was reversed in ten patients applying tretinoin cream.
Baseline biopsies obtained from participants in Melbourne, Victoria (38° latitude) showed significantly less elastosis than those in Sydney (34° latitude) and Newcastle in N.S.W., although the two groups did not show significant differences in age or sex, and the differences could not be correlated with skin type. Tretinoin cream had no effect on the degree of solar elastosis after 26 weeks application. Tretinoin cream appears effective in reversing epidermal atrophy and clinically diminishes fine wrinkling, mottled hyperpigmentation and skin roughness. Tretinoin cream may not offer a solution to the gross solar damage seen in the Australian population who have marked solar elastosis as a principal, clinical and histologie finding. However it is possible that dermal repair and reversal of solar elastosis may require topical application of tretinoin cream for a longer period than the six months used in this trial.
Tuberous sclerosis complex (TSC) is an autosomal dominant genodermatosis characterised by the development of hamartomatous tumours in multiple organs including the brain, skin, kidneys, heart and lungs. Facial angiofibromas are the most visible and unsightly of the cutaneous manifestations of TSC, often resulting in stigmatisation for both the affected individuals and their families. Current treatments include vascular laser, ablative lasers and other destructive techniques such as shave excision and electrodessication. For the best outcome these treatments have to be repeated throughout childhood and teenage years, necessitating multiple general anaesthetics. We report a pilot study of topical rapamycin in four children with TSC and facial angiofibromas. Two patients were trialled on 0.1% rapamycin in petrolatum and the other two patients with 0.1% rapamycin solution (Rapamune) applied topically. Both preparations were rapidly and equally effective, however the 0.1% in petrolatum was much better tolerated. Younger patients with smaller angiofibromas had the best response with near complete clearance. Both preparations were more cost effective than pulsed dye laser under general anaesthesia. Although larger studies are needed, this treatment shows a potential to be a first-line management for facial angiofibromas in TSC and appears safe to start in early childhood.
A case of molluscum contagiosum arising on the face and neck of a woman using topical tacrolimus over a period of 6 weeks for the treatment of atopic dermatitis is presented. Of particular note, these lesions remained confined to areas treated with tacrolimus and did not extend to adjacent regions treated with topical corticosteroids.
Erythropoietic protoporphyria is a rare photodermatosis for which treatment options are limited. The present report describes the clinical features of a patient with erythropoietic protoporphyria and liver function test abnormalities associated with treatment with beta-carotene. Subsequent treatment with narrow-band UVB phototherapy resulted in marked subjective improvement in photosensitivity, which was confirmed by abolition of demonstrated abnormalities on monochromator phototesting. The therapeutic options for photosensitivity in erythropoietic protoporphyria are reviewed and discussed.
To characterise the trends in dermatophyte isolation from specimens sourced from metropolitan Melbourne over a 48-year time period.
Analysis of submitted specimens from three time periods.
Trends identified include: an increasing mean age of the patients; increased numbers of onychomycosis isolates; a significant age difference among patients with Trichophyton interdigitale isolates compared with patients who had other dermatophyte species; and an increasing number of previously rarely isolated imported dermatophytes.
Significant shifts are occurring in dermatophyte epidemiology.
The diagnoses of 1,000 personal cases in a private dermatological specialist practice in South Australia over six months are recorded and analysed. Skin aging and malignancy accounted for 26.3%, constitutional eczema for 12.6 %, infections 11.4%, psoriasis 11.3% and adverse effects from chemicals and drugs, used either externally or internally, 9.8%. Clinical data is readily recorded in dermatological practice and clinical epidemiology could be valuable in assessing what steps in preventive medicine might be taken.
The compound 1,2-benzisothiazolin-3-one (BIT) is the active ingredient in Proxel GXL a commonly used preservative in many industries. The present case report identifies the carpet industry as an additional source of occupational allergic contact dermatitis to BIT.
beta-1,3-D-glucans are yeast-derived carbohydrate polymers which have been shown to be potent immunoresponse modulators which promote the regression of certain tumours. To date there is no published data concerning the efficacy of topical beta-1,3-D-glucan in the treatment of solar keratoses. This randomized double-blind prospective pilot study of 20 patients was performed to investigate the efficacy and skin tolerance of beta-1,3-D-glucan gel versus placebo in the treatment of solar keratoses. The results of this study showed no significant benefit in using beta-1,3-D-glucan gel over placebo in reducing counts of solar keratoses. No adverse effects were reported by any patient at any stage of the trial.
Printers are exposed to a wide variety of irritants and sensitizers. Allergy developing from a single exposure to any compound is rare. We report two cases of workers in the printing industry who developed allergic contact dermatitis to 1,6-hexanediol diacrylate (HDDA) within a short period of exposure. The first developed within weeks of exposure to a plastic sheet primed with HDDA. The second developed after a single accidental exposure.
A 43-year-old woman presented with a history of dermatitis in a somewhat linear pattern under her breasts, across her back and around her waist. This dermatitis occurred after wearing a new blue dress with a blue lining. Patch testing showed an allergy to disperse blue 106 dye and also to her dress lining. However, she was not positive to p-phenylene-diamine, a dye in the standard patch test series. We recommend that any patient even slightly suspected of having an allergy to a textile dye should be tested with disperse blue, in addition to the standard series.
We undertook a clinical and histopathological analysis of patients presenting with Meyerson's naevi. Eleven patients with the characteristic histological features of a Meyerson's naevus were identified over a 5-year period. Diagnostic criteria included epidermal spongiosis and a dermal inflammatory infiltrate associated with a banal junctional or compound naevus. Cases were excluded if naevus cells showed moderate to severe atypia or regression. Patients were contacted by phone and interviewed regarding their lesions. The most common clinical appearance was a solitary, pruritic, erythematous eruption encircling a pre-existing pigmented naevus. The trunk and proximal upper extremities were preferentially affected. Only one clinician listed Meyerson's naevus in the clinical differential diagnosis. All cases demonstrated a pigmented junctional or compound naevus with epidermal spongiosis, parakeratosis and a perivascular lymphohistiocytic inflammatory infiltrate with scattered eosinophils. The inflammatory infiltrate consisted almost exclusively of CD3+ lymphocytes, the majority of which were CD4+. However, a substantial number were CD8+. In all patients, the lesions cleared with excision or spontaneously, without recurrence or progression to melanoma. The aetiology of this entity remains unclear and most clinicians are unlikely to be familiar with it.
Sebaceous adenitis, an idiopathic inflammation of the sebaceous gland, is a condition that is well described in animals but has been reported only thrice previously in humans. We present a series of 11 cases of sebaceous adenitis that presented as tender nodular lesions clinically similar to hidradenitis suppurativa, but was confined to the labia minora. All cases responded to tetracyclines and anti-androgen therapy.
Imidazolidinyl urea is a preservative used commonly in cosmetics. Although there have been few reports of contact sensitivity, it does seem to be an important contact allergen. Sensitivity should be considered in any woman with dermatitis of the face.
Since 1965 13 cases of chromoblastomycosis have been seen at the Royal Brisbane Hospital. These cases have been reviewed. All were men who presented with localized, chronic, verrucous and cicatrizing plaques on the distal of the distal part of the upper limb. Fungal culture demonstrated the presence of Cladosporium carrionii in 8 of 10 cases and was negative in the remainder. No evidence of spread following invasive techniques was found. Treatments employed included oral potassium iodide, surgery, cryotherapy, and oval 5-fluorocytosine.
One hundred and thirty-one small cell melanomas were reviewed with respect to clinical data submitted with each specimen and the histological pattern of each tumour. Of the small cell melanomas, 80% developed in individuals over the age of 50 years. There was a 2:1 male predominance with 58% of the tumours in men occurring on the back. All but one melanoma showed a lentiginous intraepidermal pattern. The dermal component was characterized by cords and nests of hyperchromatic melanocytes associated with interstitial fibrosis. Small cell melanomas may be recognized as thin lesions and are commonly located in chronic sun-damaged skin of elderly individuals. They may represent a special naevoid variant of lentigo maligna melanoma.
A total of 131 new cases of mycosis fungoides and Sézary syndrome were diagnosed clinically and histopathologically at our centre over a 5-year period. There were 87 males and 44 females with a mean age of 36.3 years (range 3-87 years) and no racial predilection. Of the 62 patients (47.3%) with classical mycosis fungoides, the majority were male (male : female = 4.2:1). There was one patient with Sézary syndrome. Patients aged older than 50 years were more likely to present with a longer duration of symptoms and advanced disease. In contrast to classical mycosis fungoides, the 47 patients diagnosed with hypopigmented mycosis fungoides had early stage disease, were younger, and no gender predilection was noted. The mean duration of follow up was 19.7 months (range 0.2-54.8 months). Complete remission was achieved in 24.7% and 53.8% of patients followed up at 1 and 3 years, respectively, using skin-directed and systemic treatment modalities appropriate for the stage of disease. There were five patients with progressive disease and three patients with advanced disease who died from disease-related complications. The most significant prognostic factors for 1-year and 3-year outcomes were the patient's duration of symptoms and stage of disease at presentation.
Haemangiomas of infancy are the commonest benign tumour in childhood, with the majority being a localized subtype, only requiring therapy in specific locations. The segmental subtype, however, confers a higher complication rate, an association with the PHACE syndrome and poorer prognosis. This retrospective case series of 14 infants with segmental haemangiomas aimed to further define the variety of clinical presentations, complication rates, and response to treatment in this subset of patients. We found in our series that 71% of infants with segmental haemangiomas develop at least one complication related to the lesion. Systemic corticosteroids prevented the further growth as well as reduced the pain and ulceration of the segmental haemangiomas in all of those treated. Early recognition and early treatment to arrest the growth of segmental haemangiomas will reduce morbidity and complications associated with these haemangiomas. Corticosteroid use, however, needs to be considered against the high incidence of side-effects such as secondary hypertension (40%), cushingoid features (40%) and growth suppression (67%). In our experience, these infants benefit from multidisciplinary team involvement for the assessment of associated syndromes, and to follow up and avoid complications associated with systemic therapy.
Epidermolysis bullosa simplex (EBS) is a blistering disorder affecting the basal layer of the epidermis usually inherited in an autosomal dominant fashion. Most cases are caused by mutations in the genes encoding keratin 5 (K5) and keratin 14 (K14) and are characterized by cytolysis within the basal layer of the epidermis. We report a patient manifesting the Dowling-Meara variant of EBS in whom we characterized a cytosine to thymine transition at codon 125 (R125C) in K14. This missense mutation is located at the amino terminus of the helical rod domain of the keratin 14 molecule, resulting in defective pairing with K5, thereby disrupting keratin tonofibril integrity.
The objective of this study was to assess the efficacy and tolerability of combination therapy for molluscum contagiosum (MC) with topical cantharidin and imiquimod 5%. A prospective case series of 16 paediatric patients with a mean age of 4.8 years had cantharidin applied to lesions by a dermatologist, followed by home treatment with imiquimod 5% cream nightly for an average of 5 weeks. This regimen resulted in >90% of lesions clearing in 12 patients, with half of these being totally clear. Two patients had 80-90% of lesions resolve. Two patients had 30-50% clearance of lesions at the end of the treatment period. One patient found the cantharidin reaction too strong. The mean number of imiquimod 250 mg sachets used was 4.25. In conclusion, this study suggests that combination therapy using cantharidin and imiquimod for treatment of MC in children is effective and well tolerated.
We report an epidemic of sporotrichosis in a south-east Queensland rural community. Sporotrichosis is a fungal infection due to the organism Sporothrix schenckii, typically presenting with cutaneous lesions. Sixteen cases of cutaneous sporotrichosis were seen over a 9 month period in the Darling Downs region of Queensland. All patients had had contact with a batch of mouldy hay presumed to be contaminated by Sporothrix schenckii. Nine of 16 patients were male; the youngest patient was aged 11 and the oldest was 67 years of age. Lymphocutaneous sporotrichosis was seen in 50% of patients; the rest demonstrated the fixed cutaneous form. No cases of disseminated cutaneous or systemic sporotrichosis were seen. One case demonstrated lymphangitis related to sporotrichosis. No apparent difference in the duration to diagnosis was demonstrated to exist between lymphocutaneous or fixed cutaneous types.
The clinical features and outcomes of 17 patients with Stevens-Johnson syndrome (SJS) or toxic epidermal necrolysis (TEN) were retrospectively reviewed. There were 11 males and six females with an average age of 61.5 years. Ten patients with SJS (seven males, three females) and seven patients with TEN (four males, three females) were identified. Antibiotics, mainly beta-lactams, were the most common cause of SJS/TEN in this series. The mean skin loss in TEN was 45.7% total body surface area in contrast to the lesser skin loss (< 10%) observed in three patients with SJS. Complications included septicaemia, pneumonia and multi-organ failure, mainly in the TEN group. Two patients died from TEN-related complications and one patient with SJS died from unrelated causes. Ocular involvement and skin pigmentary changes represented the most significant long-term sequelae.
This is a retrospective review of the case files and clinical photographs of 173 children diagnosed with cutaneous mastocytosis by a dermatologist in an exclusively paediatric practice. Of the 98 males and 75 females, 51% had mastocytomas, 47% had urticaria pigmentosa and three patients had diffuse cutaneous mastocytosis. Of these cases, 87% first appeared prior to or at 6 months of age. Flushing occurred in 26% of urticaria pigmentosa cases, 29% of mastocytomas and 100% of diffuse cutaneous mastocytosis. Blistering was noted in 23% of urticaria pigmentosa, 31% of mastocytomas and 100% of diffuse cases. Neither symptom was noted in 59% of urticaria pigmentosa and 49% of mastocytomas. There were three cases with a positive family history. The finding of a palmar mastocytoma has only once been previously reported. Illustrated descriptions of our cases are provided.
Western Australia has only two superficial radiotherapy units, one of which is located at Fremantle Hospital, and run by the radiation oncologists of Perth Radiation Oncology Centre. A 3-year retrospective review was undertaken of all patients who underwent treatment at this unit from 1999 to 2001. Patients were identified from the unit's log book, and data was collected from their files. For malignant skin conditions, 369 lesions were treated in 259 patients over the study period. The patients' median age was 76 years. A wide variety of conditions were treated, but the most common diagnoses were basal cell carcinoma (237 lesions) and squamous cell carcinoma (92 lesions), most commonly located in the head region. The most frequently used treatment schedule was 36 Gy in six fractions over a 3-week period. Where radiotherapy was administered as primary treatment, the diagnoses had been biopsy-proven in only 53% of cases. Fifty-four patients underwent treatment of benign skin disease over the study period; most commonly keloid scars (41 patients) followed by warts (six patients). We conclude that superficial radiotherapy has a distinct role in dermatology, particularly for skin carcinomas around the nose and eyes, which cannot presently be superseded by electron beam therapy.
Isotretinoin has revolutionized the management of acne vulgaris. However, concerns continue regarding the adverse effect profile of isotretinoin. This study aims to review the adverse effects experienced by patients started on isotretinoin by a single dermatologist.
Retrospective chart review of 1743 patients started on isotretinoin for various dermatological conditions over a 6-year period. Details of the dose of isotretinoin used, concomitant medications, adverse effects and outcome were recorded.
One-fifth (18.5%) of patients reported no adverse effects during the study period. Cheilitis was the most commonly reported adverse effect, affecting 78% of users, followed by eczema and tiredness, seen in 12% each. However, these were clearly dose-dependent, as the group treated with doses of isotretinoin under 0.25 mg/kg/day only reported cheilitis in 47%, eczema in 7% and tiredness in 5%, compared with 96%, 16% and 18%, respectively, in those treated with more than 0.75 mg/gm/day. Twenty-four patients (1.4%) stopped isotretinoin because of adverse effects; a further three patients complained of severe adverse effects on at least one occasion, but continued taking the medication. The adverse effect(s) that led to patients stopping isotretinoin were cheilitis (22 patients), mood change (13), tiredness (12), eczema (6) and pregnancy (2). There were no reported instances of suicidal ideation or attempted suicide.
Other than the two oral contraceptive failures, there were no serious adverse events recorded during this review period. Isotretinoin is a very effective medication with a low adverse-effect profile when used at lower doses.
We report on our experience with sunscreen allergy between 1992 and 1999 and also review the international literature on sunscreen allergy. There were a total of 21 allergic reactions to sunscreen chemicals observed in 19 patients over the 8 years. There were nine positive photopatch reactions to oxybenzone, eight to butyl methoxy dibenzoylmethane, three to methoxycinnamate and one to benzophenone. No positive reactions were observed to para aminobenzoic acid. Six patients also had positive patch tests to components of the sunscreen base. In our experience, sunscreen chemicals are the most common cause of photoallergic contact dermatitis.
The incidence of neurological abnormalities in patients with sebaceous naevi may not be as high as has been previously accepted. One hundred and ninety-six patients with epidermal naevi of the sebaceous type were examined for clinical neurological abnormalities. Ninety-three per cent of these patients were neurologically normal on examination. Extensive naevi were present in 21% (3/14) of patients with neurological abnormalities and in 5% (9/182) of those without. A centrofacial location of the naevus was found in 21% (3/14) of patients with abnormalities and in 2% (4/182) of neurologically normal patients. A surprising finding was the low yield of abnormalities from neuroimaging in the patients with clinical neurological abnormalities. Imaging was performed in eight of the 14 and was normal in six patients. Despite the lower than expected rate of associated abnormalities and the low yield of abnormal findings from imaging, it is strongly recommended that all patients with sebaceous naevi have a detailed neurological assessment and that imaging be performed on all those in whom clinical abnormalities are demonstrated, as well as on those patients with large naevi involving the centrofacial area.
Indigenous diseases included leprosy (with infection of two members of the same family in two cases), mycetoma caused by Streptomyces madurae, gangosa in an Aboriginal woman from Derby, cercarial dermatitis from Wagin, Kununurra and Derby, tick bite granuloma of the penis and vaginal myiasis. Imported diseases comprised Cordylobia anthropophaga from Malawi, calabar swelling (three cases from West Africa), with a nematode longevity of 14 yr in one patient, and cutaneous leishmaniasis, with an incubation period of 3 1/2 yr, from Italy.
Within the broad criteria of the current private practice fee-for-service medical system, the present paper attempts to produce definitive concepts for dermatological training posts and numbers within Australia. The suggested dermatologist: population ratio of 1:80,000, adopted as a guideline in 1973, was based upon our own experience, together with comparative figures from other countries with similar economic systems and standards. Experience since that time suggests that this recommended ratio may already need upward revision.
The present pattern of full-time training, usually undertaken in the first five years after graduation, can result in inordinate difficulties for females – a steadily increasing proportion of medical graduates. Together with the possible reduction in governmental funding of training posts, there would seem to be an urgent need for introducing flexibility into the current training programme including the acceptable alternatives of a greater component of accredited overseas training and the establishment of part-time and shared training posts.
A retrospective study was undertaken of 192 cases of culture proven tinea capitis occurring between 1979 and 1988 in a predominantly white population of children in New South Wales (NSW). The aim of the study was to identify whether Trichophyton tonsurans was increasing in importance in the causation of this condition in Australia as it was in many other parts of the world. The results of our study were compared with those of earlier Australian studies. Our study demonstrated that Trichophyton tonsurans is now equal in importance to Microsporum canis which was previously the strongly predominant organism.
Melanoma has become a major public health problem worldwide and its incidence in individuals of Caucasian origin continues to rise. The objective was to determine historical changes in thickness, melanoma proportions and anatomical site of presentation over a 25-year period in our Department.
This was a historical retrospective study (January 1985 to December 2009). Only patients born and living in Italy were considered. The following parameters were evaluated: age, gender, year of diagnosis, site of primitive lesion (head, back, chest, anterior and posterior upper limbs, anterior and posterior lower limb, and acral sites) and Breslow thickness of the lesion.
In the 25-year period, 993 cases of melanoma were diagnosed. The total number of cases per year tripled between 1985-1989 and 1995-1999 and more than doubled between 1995-1999 and 2005-2009. Our results also revealed that thicker melanomas were more frequent in elderly patients and on parts of the body that cannot be readily self-inspected.
The importance of observation of the posterior parts of the body is stressed, since not only did most melanomas arise in these sites but the diagnosis of lesions in these sites is often delayed.