Sorafenib-induced Facial Acneiform Eruption.

Sorafenib is a multikinase inhibitor that is used to treat hepatocellular carcinoma by inhibiting tumor cell growth and angiogenesis. Cutaneous adverse events of sorafenib are commonly reported, with alopecia and hand-foot skin reactions most frequently encountered. Acneiform eruptions represent rare adverse events that have only been reported at high doses of sorafenib. We present a patient who started low dose sorafenib for hepatocellular carcinoma and subsequently developed a fulminant facial acneiform eruption in the absence of other cutaneous adverse events. Treatment included topical clindamycin and tretinoin with some improvement. Facial acneiform eruption represents a rare consequence of sorafenib that has not previously been described at low doses. Additionally, acneiform papules in the absence of other cutaneous adverse events is unusual. The cutaneous mechanism is not well understood but may be related to indirect epidermal growth factor receptor inhibition or direct cytotoxic effects on eccrine glands. Topical treatment produces only minimal improvement in patients who continue sorafenib therapy. Discontinuation of the drug is usually unwarranted except in special circumstances.

A double-blind randomized placebo-controlled pilot study comparing topical immunomodulating agents and corticosteroids for treatment of experimentally induced nickel contact dermatitis.

BACKGROUND: Although topical glucocorticoids are effective for most inflammatory skin disorders, their use is limited by local and systemic side effects. Tacrolimus and pimecrolimus are immunomodulators that provide clinicians with steroid-sparing options in the long-term topical treatment of allergic contact dermatitis. OBJECTIVE: To obtain pilot data regarding the relative efficacies of pimecrolimus 1% cream, tacrolimus 0.1% ointment, clobetasol propionate 0.05% ointment, and triamcinolone acetonide 0.1% ointment, as compared to control preparations (Vanicream and petrolatum), for treatment of experimentally induced nickel contact dermatitis. METHODS: Twenty-one volunteers with positive patch test reactions to nickel sulfate 5% at six sites (three on each arm) applied each study medication to one nickel site, respectively, twice daily for 14 days. Study medications were prepared in identical syringes, and the site of application was randomly assigned by a computer-generated randomization schedule. Assessments were performed at 3, 7, 10, and 14 days after randomization. RESULTS: Most reactions were coded as resolved or as almost resolved by day 14 regardless of treatment. Although most pairwise comparisons were not statistically significant, a clear trend was observed for sites treated with active drug to do better than control sites. CONCLUSION: Possible explanations for these results include contamination by neighboring medication sites, timing of assessments, and lack of repeated nickel applications.

Allergenicity and cross-reactivity of coconut oil derivatives: A double-blind randomized controlled pilot study.

BACKGROUND: Counseling of patients with cocamidopropyl betaine (CAPB) allergy is difficult because the cross-reactivity of CAPB with other coconut-derived surfactants, coconut oil, and coconut fatty acids is largely unknown. OBJECTIVE: To provide pilot data regarding the cross-reactivity and allergenicity of surfactants derived from coconut oil. METHODS: A randomized double-blind controlled pilot study of 10 control patients and 12 patients previously found to be allergic to CAPB. Eleven coconut-derived surfactants, as well as coconut oil and lauric acid, were applied in random order according to standardized patch-test procedures with readings at 48 and 92 hours. The primary outcome measure was the frequency of positive patch-test reactions to each allergen. RESULTS: Only 3 of the 12 patients with previous reactions to CAPB reacted on retesting, and all of these reactions were doubtful. Fifty-nine percent of the study patients had reactions to triethanolamine polyethylene glycol-3 (TEA-PEG-3) cocamide sulfate as compared to none of the controls (p = .005). CONCLUSIONS: Reactions to CAPB were only 25% reproducible. These results substantiate previous experience that doubtful and mild reactions to CAPB may represent irritant reactions as opposed to true allergic reactions. TEA-PEG-3 cocamide sulfate was the only agent that had a statistically significant higher rate of reactions in the study group as compared to the control group.

Optimizing reproducibility for clinical studies involving patch testing and application of topical preparations.

BACKGROUND: The reproducibility and consistency of patch-test techniques can be problematic, making controlled clinical trials of patch testing difficult. OBJECTIVE: To measure the accuracy and reproducibility of applying controlled quantities of petrolatum onto Finn Chambers. METHODS: Four dermatology nurses applied a total of 240 samples of white petrolatum, using three syringe sizes and types. Three different amounts of white petrolatum (0.02 mL, 0.05 mL, and the "usual" amount) were expressed onto previously weighed Finn Chambers, using three different syringe sizes (5 mL, 1 mL, and 0.5 mL), five times each on two separate days. RESULTS: The average weights of 0.05 mL of petrolatum expressed with each type of syringe (5 mL: 0.04252 g; 1 mL: 0.04084 g; and 0.5 mL: 0.04139 g) were not significantly different from each other in pairwise comparisons (p > .36) or from the "gold standard" expected value (0.04138 g, p > .72). The average weights of 0.02 mL of petrolatum expressed with two types of syringes (5 mL: 0.02138 g; 0.5 mL: 0.01778 g) were significantly different from each other (p = .0012), but neither differed significantly from the expected value (0.01655 g, p > .08). The variance due to the effect modifications of nurse, day, and interaction of nurse and day was statistically significant for measurements made with the 5 mL syringe but not for measurements made with the 1 mL or 0.5 mL syringe. CONCLUSION: The average amounts of petrolatum extruded from smaller syringes (0.5 mL and 1 mL) were less variable and more reproducible than those extruded from a 5 mL syringe.