Effects of acitretin on the liver.

BACKGROUND: Therapy with aromatic retinoids for psoriasis is associated with abnormal liver function test findings and toxic hepatitis (in 1.5% of patients). OBJECTIVE: Our purpose was to determine the safety of acitretin with respect to liver function, on the basis of biopsy. METHODS: We treated 128 adults (with chronic, stable psoriasis) with oral acitretin (25-75 mg/day) for four 6-month intervals in a prospective, open-label, 2-year multicenter study. Liver biopsies were performed before and after study completion (2 years). RESULTS: Eighty-three available pairs of pretreatment and posttreatment liver biopsies demonstrated no change in 49 patients (59%), improvement in 20 (24%), and worsening in 14 (17%). Of these 14 patients with decrements in biopsy status, most changes were mild. There was no correlation between liver function test abnormalities or cumulative acitretin dose and changes in liver biopsy status. CONCLUSION: Acitretin therapy elicited no biopsy-proven hepatotoxicity in this prospective 2-year study. These findings suggest that periodic liver biopsy may not be necessary with acitretin treatment.

Acitretin combination therapy.

Systemic therapies used in psoriasis such as methotrexate, PUVA, cyclosporine, and acitretin often have side effects that limit their usefulness. Combination therapy, an effective strategy for treating psoriasis, allows use of lower doses of medications to achieve superior therapeutic results with fewer side effects. Acitretin is one of the most popular drugs used in combination with other systemic therapies for psoriasis. Details of the regimens used and results obtained from combining acitretin with PUVA, cyclosporine, and methotrexate are discussed.

Treatment of multiple facial syringomas with the carbon dioxide (CO2) laser.

BACKGROUND: Syringomas are benign tumors of eccrine origin most commonly found in the periorbital area. Previously reported treatments for syringomas include excision, electrodesiccation and curettage, dermabrasion, and carbon dioxide (CO2) laser resurfacing. The ideal treatment of syringomas should be destruction of the tumor with minimal scarring and no recurrence. OBJECTIVE: The objective is to present a treatment method for multiple syringomas without scarring or recurrence. METHOD: Ten patients with multiple periorbital syringomas were treated with a high energy, scanned carbon dioxide laser. Settings of 5 watts, 0.2 second scan time, and 3mm spot size were used. Two passes were performed, but some lesions required four passes. In some cases the entire lower periorbital area was treated. Results were evaluated clinically by both physicians and patients over a span of 1 to 24 months. RESULTS: Elimination of the syringomas was successful in all patients. Each patient remains free of recurrence 1 to 24 months after therapy. Prolonged erythema was the most common side effect, but no scarring was seen. Four out of the ten patients required repeat spot treatments. CONCLUSION: The CO2 laser is a dependable, safe, and nonscarring method for the treatment of periorbital syringomas.

Dermatologic manifestations of gastrointestinal disorders.

Many disorders of the gastrointestinal tract have cutaneous manifestations. Thus, a careful examination of the skin may uncover clues to underlying diseases of the liver, gastrointestinal tract, and pancreas. This article explores the alimentary-cutaneous relationship.

2-Chlorodeoxyadenosine in cutaneous T-cell lymphoproliferative disorders.

The efficacy and toxicity of 2-chlorodeoxyadenosine (2-CdA) in cutaneous T-cell lymphoproliferative disorders was examined. Between February 1991 and April 1996, 25 patients with relapsed or refractory cutaneous T-cell lymphoproliferative disorders (24 mycosis fungoides or Sezary syndrome, one Ki-1+ anaplastic large cell lymphoma) were treated with 2-CdA initially administered by continuous intravenous infusion at a dose of 0.1 mg/kg/d for 7 days (13 patients). The infusion duration was subsequently reduced to 5 days (9 patients) because of prohibitive hematologic toxicity. Three patients were treated at the same daily dose by bolus injection over two hours for 5 days. Cycles were administered at 28 day intervals. Seventeen patients received more than one cycle. An overall response rate of 24% was achieved. Three patients (12%) had a complete response with a median duration of 4.5 months (range, 2.5 to 16). Three (12%) had a partial response with a median duration of 2 months (range, 2 to 4). Nineteen patients (76%) had no response. The most significant toxicities encountered were myelosuppression (64%) and infectious complications (64%). 2-CdA has activity as a single agent in patients with previously treated relapsed T-cell lymphoproliferative disorders.

Recurring structural chromosome abnormalities in peripheral blood lymphocytes of patients with mycosis fungoides/Sézary syndrome.

Cytogenetic analysis was performed on peripheral blood lymphocyte cultures from 19 patients with mycosis fungoides (MF)/Sézary syndrome (SS) stimulated with either phytohemagglutinin, a conventional mitogen, or a combination of interleukin-2 (IL-2) plus IL-7. The use of both PHA-stimulated and IL-2 plus IL-7-stimulated cultures enhanced the ability to identify clonal abnormalities. Clonal abnormalities were observed in 11 patients (53%) including one with monosomy for the sex chromosome as the sole abnormality. Five of the 11 patients with clonal abnormalities had normal peripheral white blood cell counts, indicating detectability of clones in the absence of frankly leukemic disease. The presence of clonal abnormalities correlated with advanced stage disease and a significantly reduced survival duration from the time of cytogenetic studies. Clonal abnormalities involving chromosomes 1 and 8 were observed in six cases. In five cases with aberrations of chromosome 1, loss of material involved the region between 1p22 and 1p36. In an additional case, a reciprocal translocation involving 1p33 was observed. Clonal abnormalities involving chromosomes 10 and 17 were observed in 5 cases, clonal abnormalities involving chromosome 2 in 4 cases, and clonal abnormalities involving chromosomes 4, 5, 6, 9, 13, 15, 19, and 20 in 3 cases. In 2 cases a der(8)t(8;17)(p11;q11) was observed. Regions of the genome that encode T-cell receptors were not involved in abnormalities. The region between 1p22 and 1p36 is identified as a region of the genome that requires detailed analysis toward the identification of potential gene(s) involved in the process of malignant transformation and/or progression in MF/SS.

Chemical peel as a treatment for skin damage from excessive sun exposure.

The increased incidence of melanomas and other skin cancers has caused awareness of various other skin diseases resulting from too much sun exposure. People are more conscious of the appearance of their skin and skin aging, and are interested in treatment. Chemical peel is one of the most popular forms of therapy for certain skin disorders.

Lichenoid changes in mycosis fungoides.

BACKGROUND: The lichenoid tissue reaction (LTR) is present in a variety of dermatoses. Numerous histologic variants of mycosis fungoides (MF) have also been described. OBJECTIVE: Our purpose was to analyze a subset of patients with mycosis fungoides (MF) who had a prominent LTR at the time of presentation. METHODS: Clinical and pathologic features were evaluated in 12 patients with MF and an LTR. RESULTS: The primary complaint was intense pruritus (in 10 of 12 patients). An accelerated course was noted in one half of the patients including four with Sézary syndrome. Four patients died: two with Sézary syndrome and two with extensive patch/plaque MF. Lymphocyte atypia, prominent basal cell layer epidermotropism, and the presence of plasma cells and eosinophils may help to distinguish lichenoid MF from lichen planus. CONCLUSION: A subset of patients with MF present with lichenoid changes. The pathologic features may have a striking resemblance to lichen planus. Our findings suggest that lichenoid changes in MF tend to be associated with intense pruritus and may connote a poor prognosis.

The cutaneous manifestations of gastrointestinal disease.

Specific cutaneous manifestations are found to be associated with gastrointestinal disease. A careful examination of the skin, therefore, may uncover clues to underlying diseases of the gastrointestinal tract, pancreas, and liver. This article explores the alimentary cutaneous relationship.

The place of laser resurfacing within the range of medical and surgical skin resurfacing techniques.

The history of resurfacing procedures used to treat the aging face is reviewed, and the place of laser resurfacing within this context is described. The changing medical reimbursement system and desire by "baby boomers" to maintain a youthful image have driven the technical development of laser resurfacing. Medical management of the skin begins with prevention of photodamage by sunscreens and education about sun protection. The next step in management of the aging face is therapy with alpha-hydroxy acid creams and topical tretinoin. Finally, the resurfacing procedures of chemical peels, dermabrasion, and lasers are the next step. The treatment of the aging face with medical and surgical methods has been enhanced over several decades by new and existing topical agents and surgical treatments. The advent of laser resurfacing in the 1990s occurring with the introduction of the Coherent Ultra-Pulse CO2 (Coherent Laser, Palo Alto, CA) and Sharplan Silk Touch (Sharplan Lasers, Inc, Allendale, NJ) lasers has added new therapeutic options for our patients. The combination of new resurfacing lasers with traditional surgical procedures will probably be the ideal approach to the treatment of the aging face.

Multiple periorbital cutaneous myxomas progressing to scleromyxedema.

Myxomas are rare cutaneous tumors that have been associated with a variety of other abnormalities including atrial myxomas, endocrine abnormalities, and bone malformations. We describe a 38-year-old white man with multiple periorbital myxomas in whom myalgias, fatigue, and more diffuse cutaneous involvement developed. These findings were consistent with scleromyxedema. He also had an associated left subclavian deep venous thrombosis. The patient responded well to therapy with cyclophosphamide.

Phase II trial of 2-chlorodeoxyadenosine for the treatment of cutaneous T-cell lymphoma.

We investigated the efficacy of 2-chlorodeoxyadenosine (2-CdA) therapy in patients with mycosis fungoides (MF) and the Sezary syndrome (SS). Between February 1991 and November 1993, 21 patients with relapsed or refractory MF/SS were treated with 2-CdA. 2-CdA was administered by continuous intravenous infusion at a dose of 0.1 mg/kg/d for 7 days initially (13 patients), but was subsequently reduced to 5 days (nine patients) due to hematologic toxicity. All patients had failed to respond to at least one prior treatment for MF/SS (median number of total prior therapies, five; median number of systemic prior therapies, three) and had an Eastern Cooperative Oncology Group performance status of two or better. Cycles were administered at 28-day intervals. Assessable patients received at least 5 days of 2-CdA. Fourteen patients received more than one cycle of 2-CdA. An overall response rate of 28% was achieved. Three patients (14%) had a complete response with a median duration of 4.5 months (range, 2.5 to 16). Three (14%) had a partial response with a median duration of 2 months (range, 2 to 4). Fifteen patients (72%) had no response. The most significant toxicities encountered were bone marrow suppression (62% of patients) and infectious complications (62% of patients). Thirty-eight percent of patients experienced no toxicity from 2-CdA. 2-CdA has activity as a single agent in patients with previously treated relapsed MF/SS. Studies in less heavily pretreated individuals with 2-CdA alone or in combination will be undertaken.

Allergy to Unna boots in four patients.

We report the cases of four patients seen in our department since 1967 with allergic reactions to preservatives in Unna boots. The first three patients had reactions to parabens and the last had a photoallergic reaction to hexachlorophene. Preservative-free Unna boots were successfully applied to patients with allergy to parabens. A table of some currently available Unna boots, detailing their ingredients, is also presented.

Ultraviolet radiation for treatment of cutaneous T-cell lymphoma.

Cutaneous T-cell lymphoma (CTCL) often begins as limited patches and plaques on the skin that can be effectively treated with ultraviolet radiation. Many long-term remissions and cures have been well documented with the use of ultraviolet radiation alone for stage I CTCL. The side effects of this treatment are minimal.

Treatment of mycosis fungoides with photochemotherapy (PUVA): long-term follow-up.

BACKGROUND: Mycosis fungoides (MF) is a non-Hodgkin's T-cell lymphoma of the skin that often begins as limited patches and plaques with slow progression to systemic involvement. No studies have been published comparing photochemotherapy (PUVA) with other topical therapies in the treatment of early-stage disease. OBJECTIVE: The purpose of the study was to examine our long-term experience using PUVA to treat early-stage MF and to compare its effectiveness and side-effect profile with other previously reported topical therapies. METHODS: Eighty-two patients with MF (83% stage IA or IB) were treated with PUVA. Clinical and histologic features were observed for a period from 2 months to 15 years (median, 43 months). RESULTS: A response was noted in 78 patients (95%) with complete clinical and histologic clearing in 53 patients (65%) for all stages. The mean duration of total complete response to PUVA for all stages was 43 months (3.6 years). The mean survival of our study group for all stages was 8.5 years. Signs of chronic actinic skin damage were found in 10% of patients, including three patients with basal cell carcinomas and three patients with squamous cell carcinomas. In a nonrandomized comparison with previously reported data for other topical therapies, the efficacy and side-effect profile of PUVA compared favorably. CONCLUSION: PUVA is an effective and safe therapy for MF with prolonged disease-free remissions being achieved. Patients with stage I and II MF respond best to PUVA. Palliative therapy with PUVA is useful in more advanced cases of MF.