Intermittent vs. continuous 1-year cyclosporin use in chronic plaque psoriasis.

OBJECTIVE: To comparatively assess the impact of intermittent and continuous cyclosporine (CyA) administration in chronic plaque psoriasis. METHODS: A two-step procedure was followed for the 51 patients who were randomly assigned in the study. CyA in doses 2.5 mg kg(-1) day(-1) escalated up to 5 mg kg(-1) day(-1) for efficacy reasons, were given to all patients during the initial 12-week step. Only patients who achieved a minimum 50% reduction of baseline PASI could enter the 2nd step, which lasted for nine additional months. Subjects on the intermittent schedule stopped all therapy to receive other 12-week course(s) if and when they relapsed. Patients on the continuous schedule continued CyA therapy at the lowest, individualized, effective dose. RESULTS: 78% of all patients achieved a PASI-75, with subjects on continuous treatment manifesting greater improvement (92% vs 62%, P= 0.008). The decrease of DLQI was 89%, without any difference between the two schedules (P= 0.214). The median effective and maintenance doses were 3 (2.5-3.8) and 1.8 (0.7-3) mg kg(-1) day(-1), respectively for intermittent and continuous schedules. A significant correlation was observed between the clinical parameters and DLQI change at 1 year, for both groups of patients. Dose modifications for safety reasons were necessary in 5 patients, but no treatment discontinuation was required. Patients on the continuous regimen received 139% of the mean cumulative annual CyA dose of Intermittent therapy. CONCLUSION: The significantly higher annual cumulative dose required for the continuous CyA regimen compared to intermittent, leads to the suggestion that the first modality may offer higher physical improvement but must remain an option for those patients who do not respond or are uncooperative with intermittent CyA use.

Tinea capitis in adults during 1981-95 in northern Greece.

The mycological laboratory of our Hospital examined 31,073 patients between 1981 and 1995. Sex, age, the residence of patients, the clinical type of tinea and contacts with other persons and animals were investigated. All the patients were also examined under Wood's light. Tinea capitis was diagnosed in 35 adults. Trichophyton violaceum was the commonest aetiological agent (54.5%), especially in elderly women. The other anthropophilic fungi were T. rubrum (8.5%), T. schoenleinii (5.7%) and T. tonsurans (2.8%). The zoophilic fungi Microsporum canis (14.3%), T. terrucosum (8.5%) and T. mentagrophytes (5.7%) were also isolated.

Value of routine diagnostic criteria of bullous pemphigoid.

BACKGROUND AND DESIGN: The clinical, histologic, and direct (DIF) and indirect (IIF) immunofluorescence findings are used in a critical, although arbitrary, manner in the routine diagnostic process of bullous pemphigoid (BP). Our purpose was to estimate their relative value. In the present retrospective study, a follow-up of at least 18 months was used as a prerequisite for the final diagnosis of BP (63 patients) and controls (n=159). RESULTS: The clinical, histologic, DIF, and IIF diagnostic criteria of BP were found to vary independently of each other. Positive DIF was the most sensitive (90.5%) typical for BP histology and positive IIF were the most specific (99%). Immunopathologic tests were the most valuable, especially in the atypical varieties of BP. Nearly 25% of patients in this group would have been misdiagnosed if IF tests had not been performed. Atypical cases (40%) seemed to represent a clinical continuum over the whole spectrum of the disease. Patients with exclusively immunoglobulin G (IgG) and C3 basal membrane zone (BMZ) deposits were significantly more often seropositive than the rest of the DIF-positive cases; however, the class of BMZ immunoreactants varied according to the site of biopsy. C3 was almost invariably deposited at the BMZ of DIF-positive patients. When Igs were also present, they were only exceptionally (5% of cases) of greater fluorescence intensity than C3. CONCLUSIONS: The combination of clinical data plus one positive immunopathologic test provide the best combination of sensitivity and specificity (98%), and seem to be most appropriate in defining patient populations for study purposes. The relationship between the classes of immunoreactants should be better evaluated with reference to the site of skin biopsy. It may be suggested, however, that the likelihood of BP existence is very low when in vivo C3 is absent or of lower intensity of fluorescence than the concomitant Ig(s).

Plasmapheresis in toxic epidermal necrolysis.

BACKGROUND: The treatment of toxic epidermal necrolysis (TEN) is usually based on the removal of the offending drug(s), fluid replacement, nutritional support, and local management. The mortality and morbidity, however, remain high and the death rate may be reduced to 10% only in special centers that use biologic dressings. Plasma exchange (PE) was proven efficacious in small series of patients and of no particular value in others. METHODS: Seven patients suffering from severe TEN covering 30%-80% of body surface area and having two or four mucous membranes involved, were included in this open study. Malignancy (Hodgkin's disease, brain tumor) and a variety of medicaments (carbamazepine, allopurinol, diphenylhydantoin, cefaclor, amoxicyllin with clavullanic acid) were considered as causally implicated. One to four PEs of 2.5 L were given on alternate days in six patients and on a daily basis in the seventh. RESULTS: All patients recovered successfully from their disease. No new lesions appeared after the first PE in four patients. Neither adverse reactions from this therapy nor sequelae from TEN were observed after a long follow-up lasting up to 8 years. CONCLUSIONS: Although PE is expensive and requires easy venous access to be performed, it could be listed in the first line of TEN therapy. The method is safe and efficacious, providing prompt relief from pain and rapid cessation of necrolysis. The alternate day PEs are considered preferable to the everyday regimen.

Cutaneous alternariosis in an immunocompromised patient.

A case of cutaneous alternariosis in a 68-year-old male farmer is presented. The patient had been treated with prednisone and azathioprine for thrombocytopenic purpura, and two months later he noted multiple ulcerated and slightly infiltrated granulomatous lesions on exposed areas. The diagnosis was confirmed by results of direct examination, culture of biopsy material, and histologic examination. A concurrent herpetic infection healed without sequelae. The protracted course of our patient's condition and a review of the literature suggest the tapering or stopping of steroids as the first step in the successful and permanent treatment of cutaneous alternariosis.

The treatment of pemphigus vulgaris. Experience with 48 patients seen over an 11-year period.

We present a retrospective analysis of 48 patients with pemphigus vulgaris (PV) who were seen between 1978 and 1988. They were divided into three treatment groups: 25 (group A) received 40-100 mg of oral prednisone daily; eight (group B) received > 100 mg of prednisone daily; 15 (group C) received 40 mg of oral prednisone every other day and azathioprine 100 mg daily. A second immunosuppressive agent was subsequently added to the treatment regimen of three patients in group A and eight patients in group B. By 1989, 10% of the patients had been able to discontinue all therapy, and were in complete remission. Sixty-five per cent of patients were on maintenance therapy, but in clinical remission. Twenty-five per cent of the patients had died [eight in group A (31%) and four in group B (50%)] either as a consequence of the disease or its treatment. None of the patients in group C had died. Most of the deaths occurred during the first 2-3 months of therapy. Morbidity and mortality were related to the severity of the disease, to the maximum dose of prednisone required to induce remission, and to the presence of other diseases. Patients needing a total of 5 g or more of prednisone to induce a remission during the acute stage had a high mortality rate.

Steroid-pulse therapy in pemphigus vulgaris long term follow-up.

BACKGROUND: Patients with pemphigus vulgaris may occasionally present the highly active, widespread form of the disease, and/or maybe resistant to conventional oral steroid therapy, and/or manifest significant side effects from the prolonged use of high oral prednisone dosage. Our purpose was to evaluate the efficacy of steroid "pulse" therapy (PT) in these patients. METHODS: Eight patients were given alternate-day, one hour, infusions of 8, 9, or 10 mg/kg methylprednisolone Na succinate. Oral prednisone and a second immunosuppressive agent were simultaneously administered; these were rapidly decreased when control of the disease was achieved. RESULTS: All patients initially responded well to therapy. The disease recurred in four patients after 3, 4, 9, and 16 months of remission, respectively. Three of these patients were treated again with PT and went into remission. None of the patients who received cyclophosphamide had a recurrence. One patient died of cardiac arrest, 12 days after PT. On a follow-up of 59 +/- 25 months since the last relapse, patients continue in remission. CONCLUSIONS: Pulse therapy is recommended as an adjunct to the total management plan of severely affected patients with pemphigus vulgaris. The addition of cyclophosphamide may prevent the disease from recurring. Alternate-day small-quantity bolus infusions over 16-20 days, may be equally effective as the administration of 15 mg/kg/daily for 3-5 days. The risk of cardiac arrest exists even with this, less aggressive form of PT therapy. A medical history of supraventricular arrhythmias may be considered a risk factor.