Crusted scabies and multiple dosages of ivermectin.

We present the case of a bone marrow transplant patient who was diagnosed with crusted scabies but did not respond to the usual approach with topical permethrin and ivermectin. The Centers for Disease Control and Prevention were contacted and suggested a 7-dose regimen of ivermectin. The patient started to improve remarkably after the third dose, and the skin eruption was resolved after 7 doses. This case supports the use of a more prolonged course of oral ivermectin for crusted scabies in those who fail the conventional approach.

Azathioprine in dermatology: the past, the present, and the future.

For several decades, dermatologists have utilized azathioprine to treat numerous debilitating skin diseases. This synthetic purine analog is derived from 6-mercaptopurine. It is thought to act by disrupting nucleic acid synthesis and has recently been found to interfere with T-cell activation. The most recognized uses of azathioprine in dermatology are for immunobullous diseases, generalized eczematous disorders, and photodermatoses. In this comprehensive review, the authors present recent advancements in the understanding of azathioprine and address aspects not covered in prior reviews. They (1) summarize the history of azathioprine; (2) discuss metabolism, integrating information from recent publications; (3) review the mechanism of action with attention paid to the activities of azathioprine not mediated by its 6-mercaptopurine metabolites and review new data about inhibition by azathioprine of the CD28 signal transduction pathway; (4) thoroughly examine thiopurine s-methyltransferase genetics, its clinical relevance, and interethnic variations; (5) review prior uses of azathioprine in the field of dermatology and grade the level of evidence; (6) discuss the use of azathioprine in pregnancy and pediatrics; review (7) key drug interactions and (8) adverse effects; (9) suggest a dosing and monitoring approach different from prior recommendations; and (10) explore the future of azathioprine, focusing on laboratory considerations and therapeutic application.

Eosinophilic folliculitis in HIV-infected women: case series and review.

BACKGROUND AND OBJECTIVE: Dermatologic conditions are often presenting signs of HIV infection and may be the sole cause of morbidity in patients who have otherwise stable HIV disease. Eosinophilic folliculitis is a pruritic, follicular eruption that typically manifests late in the course of HIV infection. Most published reports of eosinophilic folliculitis have been in HIV-infected men. In those reports, a characteristic truncal distribution was present, with involvement of the head, neck, and upper extremities commonly seen as well. The objective of this study was to better characterize the presentation of eosinophilic folliculitis in women. METHODS: We conducted a retrospective chart review of six HIV-seropositive women with eosinophilic folliculitis previously seen in our dermatology clinics. We also reviewed the literature for cases of eosinophilic folliculitis in women and for clinical and therapeutic aspects of the condition, particularly in women. RESULTS: In our case series, we found that eosinophilic folliculitis in women may predominantly affect the face and mimic acne excoriée. A review of the literature of HIV-associated eosinophilic folliculitis in women supports these findings. Regarding treatment, many therapies are available, but none is uniformly effective. CONCLUSION: Given the dramatic rise in the incidence of HIV infection in women, who now represent nearly 50% of adults living worldwide with HIV/AIDS, a heightened awareness of HIV-related dermatoses in women is essential. HIV-associated eosinophilic folliculitis should be considered in the differential diagnosis of chronic, pruritic, papular facial eruptions in females.

Tacrolimus ointment is safe and effective in the treatment of atopic dermatitis: results in 8000 patients.

OBJECTIVE: We sought to evaluate the safety and efficacy of tacrolimus ointment in a large cohort of adult and pediatric patients with atopic dermatitis (AD). METHODS: A cohort of 3964 adult and 3959 pediatric patients with AD were enrolled in this open-label noncomparative study. Patients applied tacrolimus 0.03% or 0.1% ointment twice daily to the affected areas. Efficacy and safety assessments included percentage of body surface area affected and incidence of adverse events, respectively. RESULTS: A total of 7923 patients were evaluated; 95.5% had severe or moderate AD at baseline. There was a 52% decrease from baseline in the mean percentage of body surface area affected at month 1 and a 91% decrease at month 18. Two of the most common adverse events, skin burning and pruritus, were generally mild, transient in nature, and decreased in prevalence as AD improved. Severity and frequency of other common adverse events were consistent with expected rates in the general population. CONCLUSION: Tacrolimus ointment monotherapy in almost 8000 pediatric and adult patients led to continuous improvement in AD and revealed no change in the safety profile reported in previous clinical trials.

A catalog of dermatology utilities: a measure of the burden of skin diseases.

Utilities are measures of quality of life that reflect the strength of individuals' preferences or values for a particular health outcome. As such, utilities represent a measure of disease burden. The aim of this article is to introduce the concept of utilities to the dermatology community and to present a catalog of dermatology utilities obtained from direct patient interviews. Our data are based on 236 total subjects from Grady Hospital (Atlanta, GA), Stanford Medical Center (Palo Alto, CA), and Parkland Hospital (Dallas, TX). The mean time trade-off utilities ranged from 0.640 for blistering disorders to 1.000 for alopecia, cosmetic, and urticaria. The mean utility across all diagnoses was 0.943. We present utilities for 17 diagnostic categories and discuss the underlying reasons for the significant disease burden that these utilities represent. We also present these dermatology categories relative to noncutaneous diseases to place the cutaneous utilities in perspective and to compare the burden of disease. We have demonstrated that skin diseases have considerable burden of disease and provided a preliminary repository of utility data for future researchers and policy makers.

Subcutaneously administered efalizumab (anti-CD11a) improves signs and symptoms of moderate to severe plaque psoriasis.

BACKGROUND: Phase I and Phase II studies in patients with moderate to severe plaque psoriasis demonstrated that intravenous (IV) efalizumab improved clinical signs and symptoms and was well tolerated. OBJECTIVE: To determine if subcutaneous (SC) delivery of efalizumab improves chronic plaque psoriasis and demonstrates an acceptable safety profile. METHODS: This was a Phase I, open-label, single- and multiple-dose, escalating-dose study. Subjects received a single dose of efalizumab (0.3 mg/kg/wk SC) or escalating multiple doses of efalizumab (0.50-2.0 mg/kg/wk SC). Effectiveness was assessed using the Psoriasis Area and Severity Index (PASI), target lesion assessment, and Physician's Global Assessment (PGA). Safety was assessed by evaluating adverse events, clinical laboratory test results, physical examination results, immunologic responses, and vital signs. RESULTS: PASI score, target lesion assessment, and PGA showed improvement of approximately 40%-60% in signs and symptoms of plaque psoriasis by day 56. Mean PASI scores were still declining at the end of the eight-week dosing period, suggesting that longer duration of treatment would be more effective. By day 91, mean PASI scores were 16.2 vs. 14.6 at day 56 in the 0.5-1.0-mg/kg/wk group and 11.7 vs. 10.1 in the 1.0-2.0-mg/kg/wk group. This demonstrates that, on average, patients maintained their treatment benefit during the 42-day followup period. Overall, there were considerably fewer adverse events than in previous IV studies. These consisted principally of mild to moderate headache, pain, and rhinitis. No allergic reactions were observed. Antibodies to efalizumab were observed in only one subject (2%) and did not have any clinical relevance. CONCLUSION: The SC administration of eight weekly doses of efalizumab improves signs and symptoms of psoriasis. The treatment was safe and very well tolerated. In comparison to previously published results with IV efalizumab, SC administration of efalizumab improves overall safety and tolerability, with the additional advantage of greater convenience.

Advances in the management of psoriasis: monoclonal antibody therapies.

Psoriasis is a common skin disorder characterized by erythematous, scaling plaques. Until recently, therapies for this disease have been aimed at reducing keratinocyte proliferation. We have learned that psoriasis is not primarily a disorder of keratinocyte hyperproliferation, but is an inflammatory disease. This knowledge, especially our current understanding of the role of activated T cells in psoriasis, has led to new therapeutic options and new areas of research. Immunosuppressive agents such as cyclosporine have proven very useful in the treatment of psoriasis, but their use is limited by toxicity. Monoclonal antibodies directed against key components of the inflammatory process have been studied in an attempt to produce safer, more selective immunosuppressive agents. This review summarizes much of the available literature describing the use of monoclonal antibodies in the treatment of psoriasis.

Sporotrichoid cutaneous Mycobacterium avium complex infection.

Mycobacterium avium complex, a common opportunistic pathogen among patients with AIDS, usually manifests as disseminated disease involving the lung, lymph nodes, and gastrointestinal tract. Primary cutaneous infections with M avium complex are extremely rare, and most cutaneous lesions are caused by dissemination. Cutaneous manifestations thus far reported include scaling plaques, crusted ulcers, ecthyma-like lesions, verrucous ulcers, inflammatory nodules, panniculitis, pustular lesions, and draining sinuses. Localized skin involvement resembling sporotrichosis is unusual and to our knowledge has been reported only once in the English-language literature. We describe an additional case of primary cutaneous M avium complex infection manifesting as sporotrichosis-like lesions on a patient with AIDS.

Squamous cell carcinoma of the legs in African Americans.

BACKGROUND: Squamous cell carcinoma (SCC) is the most common skin cancer in African Americans, but its incidence is low. Although incompletely described in the literature, an increased incidence of SCC in sun-protected areas in black patients has been reported. OBJECTIVE: This study was conducted to better define the incidence, characteristics, and cutaneous markers of SCC occurring on the legs in African Americans. METHODS: We did a 5-year retrospective chart review of patients diagnosed with SCC in the dermatology clinic of an inner city hospital in the southern United States. RESULTS: A total of 35 African Americans had biopsy-proven SCC during the study period. Sixteen patients had lesions on the legs; all of them were elderly African-American women, and most showed atypical lesional and perilesional features. CONCLUSION: SCC is not rare on the legs of elderly African-American women. It can present with atypical features, and physicians must be alert to this possibility. Accompanying cutaneous changes may assist in its diagnosis.