Cutaneous manifestations of sexually transmitted diseases

Sexually transmitted diseases remain a prevalent problem in the United States and throughout the world, despite efforts in prevention and education. This review highlights the cutaneous manifestations of the following sexually transmitted diseases: syphilis, chancroid, lymphogranuloma venereum, granuloma inguinale, genital herpes, genital warts, scabies, and pediculosis pubis. Emphasis is placed on the clinical findings, diagnostic methodology, and recommended treatment for each disease.

Once-daily tazarotene gel versus twice-daily fluocinonide cream in the treatment of plaque psoriasis

BACKGROUND

A new class of topical receptor-selective acetylenic retinoids, the first of which is tazarotene, has been developed.

OBJECTIVE

Our purpose was to compare the safety, efficacy, and duration of therapeutic effect of 12 weeks of once-daily tazarotene 0.1% and 0.05% gel with that of twice-daily fluocinonide 0.05% cream in the treatment of patients with plaque psoriasis.

METHODS

Three hundred forty-eight patients with plaque psoriasis were enrolled and 275 patients completed a multicenter, investigator-masked, randomized, parallel-group clinical trial.

RESULTS

Both tazarotene gels were as effective as fluocinonide in reducing plaque elevation after 1 week of treatment, and tazarotene 0.1% gel was similar to fluocinonide in reducing scaling of trunk/limb lesions at all study weeks except week 4. Tazarotene 0. 1% gel was similar to fluocinonide in reducing scaling of knee/elbow lesions at weeks 8 and 12. Fluocinonide had a significantly greater effect on erythema than tazarotene at weeks 2 through 8. However, treatments were not significantly different at week 12, and tazarotene demonstrated significantly better maintenance of therapeutic effect after cessation of therapy.

CONCLUSION

Tazarotene 0.1% and 0.05% gels were safe and effective in the treatment of mild-to-moderate plaque psoriasis.

Anti-inflammatory activity of antifungal preparations

BACKGROUND

Although steroid/antifungal combination medications are used extensively, they are associated with potential disadvantages. Antifungal preparations possessing inherent anti-inflammatory activity, leading to rapid symptomatic relief while providing mycologic cure, would be very useful.

OBJECTIVE

Our purpose was to investigate the anti-inflammatory activity of proprietary antifungal preparations in an in vivo, human experimental model.

METHODS

Using a double-blind, controlled protocol, we assessed the comparative ability of antifungal preparations to suppress the expected delayed erythema response following in vivo human exposure to ultraviolet B (UVB) irradiation generated by a solar stimulator.

RESULTS

Currently available allylamine preparations and ciclopirox olamine proved to be the most anti-inflammatory, while ketoconazole was intermediate in anti-inflammatory activity under these experimental conditions. These agents were superior to oxiconazole, econazole, and 2.5% hydrocortisone.

CONCLUSIONS

Some antifungal preparations possess inherent anti-inflammatory activity, although the exact mechanism remains uncertain.

Itraconazole therapy is effective for pedal onychomycosis caused by some nondermatophyte molds and in mixed infection with dermatophytes and molds: a multicenter study with 36 patients

BACKGROUND

Onychomycosis of the toenail caused by nondermatophyte molds alone or in combination with dermatophytes is difficult to eradicate with standard antifungal therapy.

OBJECTIVE

Our purpose was to determine the effectiveness of itraconazole in the treatment of toenail onychomycosis caused by molds alone or in combination with dermatophytes.

METHODS

We treated 36 patients with this drug given as continuous dosing (100 or 200 mg/ day) for 6 to 20 weeks or as a 1-week pulse dosing (200 mg twice daily for 1 week per month) for two to four pulses.

RESULTS

Patients with toenail onychomycosis with the following organisms were treated: Aspergillus spp. (eight patients), Fusarium spp. (four patients), Scopulariopsis brevicaulis (23 patients), and Alternaria spp. (one patient). Nineteen patients had onychomycosis with a mixed origin. At follow-up, 12 months after therapy was initiated, clinical and mycologic cure was achieved in 15 of 17 patients (88%) with onychomycosis caused by a single mold. In patients with mixed infection, a clinical cure was obtained in 16 of 19 patients (84%) and a mycologic cure in 13 of 19 patients (68%).

CONCLUSION

Itraconazole appears to be effective and safe for the treatment of toenail onychomycosis caused by some nondermatophyte molds alone or in combination with dermatophytes.

The Q-switched ND:YAG laser effectively treats tattoos in darkly pigmented skin

BACKGROUND

Laser therapy for removal of cosmetic tattoos has been proven efficacious in lighter skin. Few studies have been reported using the Q-switched neodymium-yttrium-aluminum-garnet (Nd:YAG) laser to treat tattoos in darkly pigmented or type VU skin, however.

OBJECTIVE

To report results using the Q-switched Nd:YAG laser to remove tattoos from type VI skin.

METHODS

Eight darkly pigmented patients had 15 amateur tattoos treated with the Q-switched Nd:YAG laser. Treatments numbered three or four on average and were given at 8-week intervals. Results were rated by the patients and by a panel of four physicians.

RESULTS

Eight of 15 tattoos were rated as 75-95% cleared after therapy. Another five tattoos were 50% cleared. Two tattoos were only 25% cleared, but underwent only two treatments. None of the patients reported any changes in texture of their skin post therapy. Thirteen of 15 tattoos were removed without any change in the color of the involved skin. The other two tattoos were removed with only slight lightening of the skin.

CONCLUSION

When treating patients in whom there is a significant risk for keloid scarring or destruction of natural pigment as a consequence of tattoo removal, the Q-switched Nd:YAG laser appears to be an excellent choice of therapy.

Characterization of CP-122,721; a nonpeptide antagonist of the neurokinin NK1 receptor

CP-122,721 [(+)-(2S,3S)-3-(2-methoxy-5-trifluoromethoxybenzyl)amino-2 -phenylpiperidine] interacts with high affinity (pIC50 = 9.8) at the human NK1 receptor expressed in IM-9 cells. In the presence of CP-122,721, there was a reduction in Bmax of [125I]BH-SP binding with no change in affinity suggesting that CP-122,721 does not interact with the NK1 receptor in competitive manner. In an in vitro functional assay. CP-122,721 blocked SP-induced excitation of locus ceruleus cells in guinea pig brain slices with a IC50 value of 7 nM. In vivo, CP-122,721 potently blocked plasma extravasation in guinea pig lung elicited by aerosolized capsaicin (1 mM) with an ID50 = 0.01 mg/kg, p.o. Orally administered CP-122,721 antagonized Sar9, Met (O2)11-SP-induced locomotor activity in guinea pigs with an ID50 = 0.2 mg/kg suggesting good entry into the central nervous system. In addition, consistent with insurmountable blockade observed in vitro, CP-122,721 (0.01, 0.03 0.3 mg/kg, p.o.) produced a rightward shift in the dose response curve for SP-induced hypotension in the awake dog that was accompanied by a decrease in the maximal response. Thus, in vitro and in vivo CP-122,721 appears to behave functionally as a non-competitive antagonist producing an insurmountable blockade of the actions of SP.

Cutaneous lesions due to Pleurophoma (Phoma) complex

We report a case of striking and disfiguring facial mycosis due to an organism belonging to the Pleurophoma complex of Coelomycetes. This condition was likely acquired through repeated contact with infected soil and exacerbated by prolonged applications of topical corticosteroid preparations. Antifungal drug susceptibility testing was used to direct a therapeutic choice in this unusual infection.

Persistent viability of the Medlar body

BACKGROUND

The Medlar body represents an adaptive tissue form of the fungi known to cause cutaneous chromomycosis. This study was designed to determine the in vitro viability of Medlar bodies that are found in profusion within lesional epidermis.

METHODS

Epidermal scrapings of three indigenous cases from Texas of chromomycosis due to Fonsecaea pedrosoi were collected and periodically cultured to determine the duration of fungal viability.

RESULTS

The causative organism could be recovered 11, 15, and 18 months, respectively, after epidermal scrapings were obtained from the three patients.

CONCLUSIONS

This simple but important experiment indicates that Medlar bodies are quite hardy. Thus, clinical lesions may appear after long incubation periods subsequent to traumatic implantation of etiologic fungi. The robust adaptability of the tissue form may also account for the difficulty in achieving a "cure" in cases of chromomycosis.

Dog, cat, and human bites: a review

It is estimated that half of all Americans will be bitten by an animal or another human being during their lifetimes. The vast majority of the estimated 2 million annual mammalian bite wounds are minor, and the victims never seek medical attention. Nonetheless, bite wounds account for approximately 1% of all emergency department visits and more than $30 million in annual health care costs. Infection is the most common bite-associated complication; the relative risk is determined by the species of the inflicting animal, bite location, host factors, and local wound care. Most infections caused by mammalian bites are polymicrobial, with mixed aerobic and anaerobic species. The clinical presentation and appropriate treatment of infected bite wounds vary according to the causative organisms. Human bite wounds have long had a bad reputation for severe infection and frequent complication. However, recent data demonstrate that human bites occurring anywhere other than the hand present no more of a risk for infection than any other type of mammalian bite. The increased incidence of serious infections and complications associated with human bites to the hand warrants their consideration and management in three different categories: occlusional/simple, clenched fist injuries, and occlusional bites to the hand. This article reviews dogs, cat, and human bite wounds, risk factors for complications, evaluation components, bacteriology, antimicrobial susceptibility patterns, and recommended treatments. Epidemiology, clinical presentation, and treatment of infections caused by Pasteurella multocida, Capnocytophaga canimorsus, Eikenella corrodens, and rhabdovirus (rabies only) receive particular emphasis.

Evidence that a low-fat diet reduces the occurrence of non-melanoma skin cancer

The effect of a low-fat diet on occurrence of non-melanoma skin cancer was examined in a 2-year dietary intervention trial. A total of 101 skin-cancer patients were randomized either to a control group that consumed, on average, 38% of caloric intake as fat, and in which no changes in dietary habits were introduced, or to a low-fat dietary-intervention group, in which patients were instructed to limit their calories from fat to 20% of total caloric intake. Patients were examined at 4-month intervals by dermatologists blinded to their dietary assignments. Nutrient analyses, conducted at each of the 4-month follow-up visits, indicated that the % calories of fat consumed in the intervention group had been reduced to 21% at 4 months and remained below this level throughout the 2-year period. There were no significant differences in total calories consumed, or in mean body weights, between the control and the intervention groups. Nor were there significant group differences in P/S ratios until month 24. Numbers of new skin cancers treated at each examination were analyzed in 8-month periods of the 2-year study. Comparisons of skin-cancer occurrences revealed no significant changes in the control group from baseline values. However, cancer occurrence in the low-fat intervention group declined after the first 8-month period and reached statistical significance by the last 8-month period. Patients in this group had significantly fewer cancers in the last 8-month period than did patients in the control group. In addition, there was a significant reduction in the number of patients developing skin cancer in the last 8-month period, as compared with the first 8-month period, within the low-fat intervention group. There were no significant changes in the control group. These data indicate that a low-fat diet can significantly reduce occurrence of a highly prevalent form of cancer.

Histologic patterns of basal cell carcinoma based upon patient immunostatus

BACKGROUND

The biologic behavior of basal cell carcinoma (BCC) seems to be dictated by the histologic subtype. Moreover, BCCs in immunosuppressed patients appear to show a more aggressive biologic behavior.

OBJECTIVE

The purpose of this study was to retrospectively investigate different histologic subtypes of BCC to determine whether a particular subtype would predominate in immunosuppressed patients.

METHODS

The histologic patterns of 112 primary BCCs from 77 immunosuppressed patients and 60 primary BCCs from 46 patients who are endogenously immunocompromised, due to diabetes mellitus and/or chronic renal failure, were examined. The results were compared with 488 primary BCCs of 318 immunocompetent patients.

RESULTS

The nodular subtype was the predominant pattern among all patients. However, a statistical difference was found in the immunosuppressed patients in that there was a lower percentage of nodular pattern (P = .0038), and a higher percentage of infiltrative pattern (P = .0002). The higher frequency of the infiltrative pattern in the immunosuppressed group was particularly prominent among chronic alcoholics.

CONCLUSION

In immunosuppressed patients, the higher frequency of the infiltrative subtype of BCC, particularly among chronic alcoholics, may have a predictive role in the management of these cases.

Treatment of cutaneous leishmaniasis

The World Health Organization estimates that approximately 400,000 new cases of leishmaniasis occur worldwide each year. Cutaneous leishmaniasis is being encountered more frequently in the United States because of increasing travel and immigration from endemic areas. The indications for treatment and recommended treatment regimens reported in the infectious disease and dermatology literature vary widely. We examine both classic and newly developed therapeutic agents and modalities for cutaneous leishmaniasis. Proper therapy depends on species identification. New World leishmaniasis, in general, requires more aggressive therapy; parenteral antimonials are the drugs of choice. Physical modalities may suffice in most cases of Old World leishmaniasis because of its strong tendency toward spontaneous resolution.

Basal cell carcinoma of the scalp resulting in spine metastasis in a black patient

Basal cell carcinoma (BCC), the most common skin cancer in the United States, is locally invasive but has a low risk of metastasis. BCC is rare in black patients but, regardless of racial origin, most BCC occurs on sun-exposed areas. We describe a 67-year-old black man with a large BCC on the hairy scalp, a relatively sun-protected area, that metastasized to the spine. To our knowledge, this is the first description of a black patient with development of metastatic BCC on an otherwise normal scalp.

Evaluation of acetowhitening in Bowen's disease

BACKGROUND

From a clinical standpoint, the lesions of Bowen's disease (squamous cell carcinoma in situ) are generally sharply demarcated. Following excision, however, contiguous extension and/or small foci of Bowen's disease are occasionally found, located outside the clinically apparent margins. Acetowhitening has been suggested as a means of delineating the extent of involvement and identifying subclinical lesions of condyloma acuminata. More recently, acetowhitening has offn similarly reported to be of potential value in the presurgical evaluation of Bowen's disease.

OBJECTIVE

The purpose of this investigation was to further evaluate the use and reliability of acetowhitening both to delineate margins of Bowen's disease and to identify subclinical foci of involvement.

METHODS

Eight patients with histologically confirmed Bowen's disease were studied. Six percent acetic acid was applied to the lesions and the surrounding skin. Histologic examination of acetowhite lesions and adjacent acetowhite skin as well as adjacent, nonwhitened normal appearing skin was performed.

RESULTS

Our results were inconsistent, and included both false positives and false negatives.

CONCLUSIONS

Acetowhitening is unreliable in identification of Bowen's disease. Clinically normal, acetowhite-negative skin adjacent to a lesion of Bowen's disease may be involved.

Effect of a low-fat diet on the incidence of actinic keratosis

BACKGROUND

Actinic keratoses are premalignant lesions and are a sensitive and important manifestation of sun-induced skin damage. Studies in animals have shown that dietary fat influences the incidence of sun-induced skin cancer, but the effect of diet on the incidence of actinic keratosis in humans is not known.

METHODS

We randomly assigned 76 patients with nonmelanoma skin cancer either to continue their usual diet (control group) or to eat a diet with 20 percent of total caloric intake as fat (dietary-intervention group). For 24 months, the patients were examined for the presence of new actinic keratoses by physicians unaware of their assigned diets.

RESULTS

At base line, the mean (+/- SD) percentage of caloric intake as fat was 40 +/- 4 percent in the control group and 39 +/- 3 percent in the dietary-intervention group. After 4 months of dietary therapy the percentage of calories as fat had decreased to 21 percent in the dietary-intervention group, and it remained below this level throughout the 24-month study period. The percentage of calories as fat in the control group did not fall below 36 percent at any time. The cumulative number of new actinic keratoses per patient from months 4 through 24 was 10 +/- 13 in the control group and 3 +/- 7 in the dietary-intervention group (P = 0.001).

CONCLUSIONS

In patients with a history of nonmelanoma skin cancer, a low-fat diet reduces the incidence of actinic keratosis.

Cashew nut dermatitis

The urushiol dermatitis caused by plants of the Anacardiaceae family is the most common cause of acute allergic contact dermatitis. We have reported a case of cashew nut urushiol dermatitis due to ingestion of homemade cashew nut butter contaminated by cashew nut shell oil. With the precautions taken today to avoid contamination of food products with cashew urushiols, it is rare to find a case of cashew nut dermatitis in the United States. We have found no other report of contact dermatitis due to cashew nut butter. Moreover, though hinted at in the literature, there has been no previous detailed report of perianal contact dermatitis due to cashew ingestion. The fact that our patient was ill enough to require treatment with 3 weeks of systemic steroid therapy highlights the potential public health hazard of consumption of improperly prepared cashew products. However, the risk of cashew nut dermatitis today remains small, and this should not discourage cashew lovers from enjoying their treats. A final lesson to be learned from this case is that perianal eruptions may be due to materials deliberately applied to the anogenital region or to ingested antigens that remain sufficiently intact within the feces to affect perianal skin.