Lithium therapy associated with hidradenitis suppurativa: case report and a review of the dermatologic side effects of lithium

A Rare Phenomenon of Lithium-Associated Acne Inversa: A Case Series and Literature Review

Lithium use has been associated with dermatological issues, including psoriasis, folliculitis, and acneiform outbreaks. The lithium dosage and the therapeutic range of serum lithium levels are closely correlated with the frequency of cutaneous adverse effects. Lithium-induced acne inversa is a less well-known adverse effect, causing significant morbidity. Acne inversa (hidradenitis suppurativa) is a chronic inflammatory illness of the skin seen in the folds of the skin and face and distinguished by the presence of painful nodules and fistulas, as well as a propensity for tissue fibrosis. We report two cases of bipolar affective disorder who received long-term lithium treatment and experienced acne inversa during treatment, which subsided once the lithium was withdrawn.

Hidradenitis Suppurativa

Background:

Hidradenitis suppurativa is a clinically defined disease that causes considerable morbidity for patients. The results of recent studies, which have increased the understanding of this disease, are reviewed.

Objective:

The epidemiology, risk factors, pathogenesis, and treatment of this disease are summarized to help clinicians with practical patient management.

Conclusion:

Hidradenitis suppurativa remains a clinical challenge to patients and physicians alike. Physicians should be familiar with the impact this disease has on the patient and with the range of treatments available. Use of simple incisions as treatment is strongly discouraged. Additional pathogenic as well as therapeutic studies are necessary.

Hidradenitis Suppurativa in 64 Female Patients: Retrospective Study Comparing Oral Antibiotics and Antiandrogen Therapy

Background:

Hidradenitis suppurativa (HS) is a recurrent disease confined to apocrine gland-bearing areas causing painful, deep-seated lesions and draining sinus tracts. Uniformly effective therapy is lacking. Improvements in current medical management strategies are needed.

Objective:

We sought to determine the success rate for a variety of treatments in our female HS patients and whether androgen-related tests can predict a response to antiandrogen therapy. As HS has been linked to a hyperandrogen state, we sought to determine if it is also associated with polycystic ovary syndrome (PCOS).

Methods:

A retrospective chart review was performed examining hormonal profiles and the response to a variety of treatments in female patients with HS.

Results:

Sixty-four female HS patients were identified (mean age 33 years). Antiandrogen therapy was superior to oral antibiotic therapy (55% vs 26%) based on a two-sample, two-sided, t-test statistic (p < .04). The prevalence of PCOS among our study patients in whom androgen markers were available was 8 of 21 (38.1%), and even if taken over all study patients, not necessarily investigated for PCOS, the prevalence was 8 of 64 (12.5%). This reflects a greater than expected prevalence among all women (10%).

Conclusion:

As a proof-of-concept study, despite limitations inherent in a retrospective chart review, there is sufficient signal to suggest that a hormonal manipulation approach to therapy should be considered in all women presenting with HS. Female patients presenting with HS should prompt investigations for underlying PCOS and insulin resistance.

A review of cutaneous drug eruptions

Cutaneous drug eruptions can range from an asymptomatic rash to a life-threatening emergency. Because of the high frequency, morbidity, and potential mortality associated with drug eruptions, patients with possible drug reactions should promptly be recognized, worked up, and treated. Drug reactions are common in the elderly population due to age-related alterations in metabolism, excretion of medications, and polypharmacy. This review discusses the epidemiology, pathogenesis, clinical presentation, diagnosis, and management of drug eruptions that providers commonly encounter in the care of the geriatric population. An algorithm for an approach to patients with a suspected drug eruption is presented.

Relevant issues in pharmacotherapy of psycho-cutaneous disorders

Psychiatric disorders frequently co-occur with dermatological conditions and psychotropic agents may be indicated in treating the underlying psychiatric symptoms. Use of psychotropics can be associated with significant cutaneous adverse effects as well as drug interactions with pharmacological agents used in treatment of the dermatological conditions. Knowledge of indication, contraindication, side effects, and interactions of psycho-tropics is essential for the practicing dermatologist in managing psycho-dermatological conditions. This review aims at discussing relevant issues in pharmacological management of psycho-cutaneous disorders.

Hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a chronic, inflammatory, scarring condition involving the intertriginous skin of the axillary, inguinal, inframammary, genital, and perineal areas of the body. It is also referred to as acne inversa and Verneuil disease. Follicular occlusion is the primary event in HS. It is now accepted that the first pathogenetic change is in the pilosebaceous follicular ducts, like acne, and so there has been a move to rename this disorder acne inversa. Despite the legitimate argument that hidradenitis suppurativa is a misnomer, the term has become generally accepted.

Hidradenitis suppurativa: successful treatment using carbon dioxide laser excision and marsupialization

BACKGROUND

Hidradenitis suppurativa (HS) is a disease associated with significant patient morbidity and less-than-ideal therapies.

OBJECTIVES

To determine the long- and short-term benefits of carbon dioxide (CO(2)) laser excision and marsupialization in the management of persisent lesions of HS.

METHODS

Patients with long-standing lesions of HS were treated using a CO(2) laser to excise inflammatory and draining masses.

RESULTS

One hundred eighty-five areas were treated in 61 patients using the CO(2) laser excision and marsupialization technique in 154 sessions. Local anesthesia was used for all but three sessions. Healing occurred primarily through secondary intention. In follow-up from 1 to 19 years, acceptable to excellent qualities of healing occurred. Recurrence within the treated area occurred in two of 185 sites treated.

CONCLUSION

CO(2) laser excision and marsupialization appears to be an effective therapy for management of persisent or late-stage HS. There was good patient comfort during and after treatment, lower costs than with inpatient modalities, good healing, and minimal risk of recurrence within the treated areas.

Hidradenitis suppurativa

Hidradenitis suppurativa is a chronic disease characterized by recurrent, painful, deep-seated, rounded nodules and abscesses of apocrine gland-bearing skin. Subsequent suppuration, sinus tracts and hypertrophic scarring are its main features. Onset is usually after puberty, although it is most common during the third decade and may persist in old age. The disease tends to be chronic and may develop to subcutaneous extension leading to indurations, sinus, and fistula having a profound impact on the quality of life. The prevalence is 1% in several studies. Axillary and inguinal involvement is more common in females; peri-anal and buttocks localizations are prevalent in males. The exact aetiology remains unknown. The primary event is a follicular occlusion with secondary inflammation, infection and destruction of the pilo-sebaceo-apocrine apparatus and extension to the adjacent sub-cutaneous tissue. Infection is common. Smoking may be a triggering factor. Obesity aggravates the discomfort. Differential diagnostic includes Crohn's disease, nodular acne and furonculosis. The main complications are arthropathy, carcinoma. Treatment depends upon the stage of the disease. Early nodular lesions may be treated by antibiotics for acute stage; long-term antibiotics, zinc salts may be useful as maintenance treatment; anti-TNF drugs have been used in severe cases; systemic steroids, estrogens, anti-androgens, retinoids have been used as options with limited success. Surgical treatment includes incision with or without drainage for limited abscesses; limited excisions are used for locally recurring draining sinuses. Total wide excision and healing with secondary intention or flaps and grafts is the only curative procedure in case of advanced disease.

Acne and systemic disease

Acne is the most common disease of the skin. It affects 85% of teenagers, 42.5% of men, and 50.9% of women between the ages of 20 and 30 years.96,97 The role of hormones, particularly as a trigger of sebum production and sebaceous growth and differentiation, is well known. Excess production of hormones, specifically androgens, GH, IGF-1, insulin, CRH, and glucocorticoids, is associated with increased rates of acne development. Acne may be a feature in many endocrine disorders, including polycystic ovary disease, Cushing syndrome, CAH, androgen-secreting tumors, and acromegaly. Other nonendocrine diseases associated with acne include Apert syndrome, SAPHO syndrome, Behçet syndrome and PAPA syndrome. Acne medicamentosa is the development of acne vulgaris or an acneiform eruption with the use of certain medications. These medications include testosterone, progesterone,steroids, lithium, phenytoin, isoniazid, vitamins B2, B6, and B12, halogens, and epidermal growth factor inhibitors. Management of acne medicamentosa includes standard acne therapy. Discontinuation of the offending drug may be necessary in recalcitrant cases. Basic therapeutic interventions for acne include topical therapy, systemic antibiotics,hormonal agents, isotretinoin, and physical treatments. Generally, the severity of acne lesions determines the type of acne regimen necessary. The emergence of drug-resistant P acnes and adverse side effects are current limitations to effective acne management.

The effects of subchronic lithium administration in male Wistar mice on some biochemical parameters

Lithium salts are efficiently used for treatment of psychiatric disorders. However, prolonged treatment frequently involves adverse side effects. In this study, effects of lithium carbonate administration on some biochemical parameters were studied in male mice. Lithium carbonate (20, 40, or 80 mg/kg body weight corresponding to 3.77, 7.54, or 15.08 mg Li element/kg body weight, respectively) was injected daily for 14 or 28 days. The following parameters were recorded: drinking water consumption, body weight, lithium and testosterone serum concentrations, activities of catalase (CAT), superoxide-dismutase (SOD), and glutathione-peroxidase (GPX), and level of lipid peroxidation (expressed as TBARS) in liver was performed. Lithium treatment, especially at the highest dose for 28 days, was found to induce weight gain and polydipsia and a significant decrease of plasma testosterone level. Lipid peroxidation level and activities of SOD and GPX were increased in liver, which suggests a perturbation of the antioxidative status. Our results indicate that subchronic exposure to lithium, which induces weight gain and polydipsia under our experimental conditions, also damages the male reproductive system and triggers an oxidative stress in the liver.

The effects of subchronic lithium administration in male Wistar mice on some biochemical parameters

Lithium salts are efficiently used for treatment of psychiatric disorders. However, prolonged treatment frequently involves adverse side-effects. In the present work, effects of lithium carbonate administration on some biochemical parameters were studied in male mice. Lithium carbonate (20, 40 or 80 mg/kg body weight, corresponding to 3.77, 7.54 or 15.08 mg Li element/kg body weight, respectively) was injected daily for 14 or 28 days. The following parameters were recorded: water consumption, body weight, lithium and testosterone serum concentrations, activities of catalase (CAT), superoxide-dismutase (SOD) and glutathione-peroxidase (GPX) and level of lipid peroxidation (expressed as TBARS) in liver was performed. Lithium treatment, especially at the highest dose for 28 days, was found to induce weight gain, polydipsia and a significant decrease of plasma testosterone level. Lipid peroxidation level and activities of SOD and GPX were increased in liver which suggests a perturbation of the antioxidative status. Our results indicate that subchronic exposure to lithium, which induces weight gain and polydipsia under our experimental conditions, also damages the male reproductive system and triggers an oxidative stress in the liver.

Hidradenitis suppurativa: a comprehensive review

Hidradenitis suppurativa, also known as acne inversa, is a chronic, often debilitating disease primarily affecting the axillae, perineum, and inframammary regions. Prevalence rates of up to 4% have been estimated. Our understanding of the disease has changed over time. It is now considered a disease of follicular occlusion rather than an inflammatory or infectious process of the apocrine glands. Clinically, the disease often presents with tender subcutaneous nodules beginning around puberty. The nodules may spontaneously rupture or coalesce, forming painful, deep dermal abscesses. Eventually, fibrosis and the formation of extensive sinus tracts may result. The location of the lesions may lead to social embarrassment and the failure to seek medical treatment. Therapies in the past have consisted of long-term antibiotics, antiandrogens, and surgery. New treatments like tumor necrosis factor-alfa inhibitors have given clinicians more options against this difficult disease.

Psychodermatology: a guide to understanding common psychocutaneous disorders

OBJECTIVE

This review focuses on classification and description of and current treatment recommendations for psychocutaneous disorders. Medication side effects of both psychotropic and dermatologic drugs are also considered.

DATA SOURCES

A search of the literature from 1951 to 2004 was performed using the MEDLINE search engine. English-language articles were identified using the following search terms: skin and psyche, psychiatry and dermatology, mind and skin, psychocutaneous, and stress and skin.

DATA SYNTHESIS

The psychotropic agents most frequently used in patients with psychocutaneous disorders are those that target anxiety, depression, and psychosis. Psychiatric side effects of dermatologic drugs can be significant but can occur less frequently than the cutaneous side effects of psychiatric medications. In a majority of patients presenting to dermatologists, effective management of skin conditions requires consideration of associated psychosocial factors. For some dermatologic conditions, there are specific demographic and personality features that commonly associate with disease onset or exacerbation.

CONCLUSIONS

More than just a cosmetic disfigurement, dermatologic disorders are associated with a variety of psychopathologic problems that can affect the patient, his or her family, and society together. Increased understanding of biopsychosocial approaches and liaison among primary care physicians, psychiatrists, and dermatologists could be very useful and highly beneficial.

Lithium-induced lung toxicity in rats: the effect of caffeic acid phenethyl ester (CAPE)

AIMS

We aimed to evaluate the effects of caffeic acid phenethyl ester (CAPE) on lithium (Li)-induced lung toxicity.

METHODS

Twenty-two adult male Wistar albino rats weighing between 280 and 300 g were used. The rats were randomly divided into three groups: control, Li and Li+CAPE groups. Li and CAPE were co-administered intraperitoneally twice daily for 4 weeks. Control rats were given 0.9% NaCl during the same period. All the rats were allowed to feed ad libitum until midnight after they had received the proposed treatment.

RESULTS

In the Li group, peribronchial and intraparenchymal lymphocyte and macrophage infiltration were observed. Atypical type II pneumocytes, alveolar destruction and emphysematous changes were also detected. Lymphocyte and macrophage infiltration was significantly decreased in the Li+CAPE group compared with the Li group. Alveolar destruction, emphysematous changes and intraparenchymal mononuclear cell infiltration were also recovered to a level close to the control group. Malondialdehyde (MDA) levels were increased in the Li group compared with the control group. CAPE administration decreased the MDA levels in the Li+CAPE group.

CONCLUSIONS

CAPE was found to associate with histopathological changes recovery in the lungs and oxidative stress due to Li treatment.

Lithium

The mode of action of the cation lithium is not well known. It is at present used as a topical drug in dermatology. Lithium inhibits many enzymes: Na/K ATPase, adenylcyclase, enzymes of the prostaglandines E1 synthesis, inositol-1-phosphatase. It is active on neutrophils et T lymphocytes, explaining in part its anti-inflammatory activity. It has a dose-dependent action on levures. It has possibly a direct inhibitory activity on DNA synthesis of herpes viruses. Lithium has a good local safety. Percutaneous penetration is weak and plasma concentrations are very much lower than that observed after oral intake. Lithium has been studied in seborrhoeic dermatitis. Its efficacy was primarily observed in psychotic patients. An assay with oral lithium did not confirmed the first observations. Topical lithium was found more efficient. Topical lithium succinate associated with zinc sulfate and lithium gluconate had a greater efficacy than placebo. Comparison with topical ketoconazole showed a non inferiority of lithium gluconate. Oral lithium also showed a reduction of symptoms' duration of herpes simplex. Cutaneous side-effects of oral lithium are frequent and numerous. Some of them may be explained by a lithium pharmacological cell activity (such as psoriasis). Teratogenicity is observed in mice and rats. Drug interactions are not expected after topical application. Irritants side effects are mainly observed after topical application; they are moderate and transitory. Lithium gluconate treatment of seborrhoeic dermatitis is a bid application during at least 8 weeks. It may be used in renal insufficiency. It is not recommended in the first trimester of pregnancy.

Subchronic supplementation of lithium carbonate induces reproductive system toxicity in male rat

Lithium is frequently used as an effective drug for the treatment of several psychiatric disorders in human. This alkali element and its salt, at its higher doses, may lead to various side effects or has several toxic effects after prolonged therapeutic use. To test this hypothesis, the present study was designed to investigate the adverse effect of subchronic exposure of lithium carbonate on reproductive organs of male rat. Rats were exposed to lithium carbonate at doses of 500, 800, 1100 mg/kg of diet for 90 days. The weight of reproductive organs, histology of testis, epididymis, seminal vesicle, prostate, testicular interstitial fluid volume (IFV), testosterone level, sperm morphology and fertility index were analyzed. Treatment with higher doses of lithium carbonate (i.e. 800, 1100 mg/kg diet) significantly reduced testes, epididymis and accessory sex organs weights, whereas, lower dose (500 mg/kg diet) did not show any untoward effect. Similarly, the sperm number from cauda epididymis and daily sperm production was significantly decreased with higher doses of lithium carbonate. The serum testosterone levels and IFVs were also reduced significantly. Seminal vesicle and prostate secretions were completely blocked and spermatozoa were not seen in the lumen of epididymis and vas deference. Histological studies have revealed that lithium carbonate (1100 mg/kg) caused degeneration of spermatogenic cells and vacuolization of sertoli cells cytoplasm in the testis. The sperm transit rate and production of abnormal spermatozoa were significantly (P<0.01) increased. When the lithium carbonate-treated males were mated with normal cyclic females, the fertility index declined to 50% even after 30 days of withdrawal of lithium carbonate treatment. These results clearly suggest that subchronic exposure of lithium carbonate promote reproductive system toxicity and reduces fertility of male rats.

Acne inversa (alias hidradenitis suppurativa)

Acne inversa is a recurrent, suppurative disease manifested by abscesses, fistulas, and scarring. Once considered to be a disease of the apocrine glands, it is actually a defect of follicular epithelium. Thus, the term hidradenitis suppurativa is a misnomer and should be abandoned. In cases of familial acne inversa, the pattern of transmission and number of affected individuals are consistent with autosomal dominant inheritance. Aetiological factors such as hyperandrogenism, obesity, smoking and chemical irritants are not consistently associated with the affection. Bacterial involvement is not a primary event in acne inversa, but is secondary to the disease process. Potential complications include dermal contraction, local or systemic infection due to the spread of microorganisms, systemic amyloidosis, arthropathy, and squamous cell carcinoma. As spontaneous resolution is rare and progressive disability is the rule, early definitive surgical intervention is advisable. The surgical procedure of choice in most cases is wide local excision and healing by secondary intention. Pharmacotherapeutic drugs, including synthetic retinoids and antiandrogens, do not prevent progression of the disease.

A control study of the cutaneous side effects of chronic lithium therapy

BACKGROUND

To assess the nature and prevalence of skin disorders among psychiatric patients on chronic lithium therapy and to compare them with patients on other psychotropic medications.

METHOD

51 patients on lithium and 57 patients on other psychotropics were recruited. Dermatological assessment included a semi-structured questionnaire and clinical examination of the subjects by two dermatologists who were blind to the psychiatric diagnosis and treatment. Secondary cutaneous reaction was defined as skin eruption that developed or deteriorated after commencement of psychiatric medication.

RESULTS

Lithium treated patients developed significantly more secondary cutaneous reactions than the control group. This applied particularly to acne and psoriasis. Male patients on lithium were more likely to be affected than female patients.

CONCLUSION

Lithium aggravates or triggers cutaneous conditions that are characterized by the pathological findings of neutrophilic infiltration. Since these cutaneous problem can be distressing to patients and may affect medication compliance, there should be heightened attention to skin problems in patients receiving lithium treatment.

Subcutaneous fistulectomy in bridging hidradenitis suppurativa

BACKGROUND

The treatment of chronic lesions in hidradenitis suppurativa remains a challenge. For some clinical types surgical management is an excellent alternative.

OBJECTIVE

This study evaluates an alternative surgical approach for the treatment of hidradenitis suppurativa of specific bridging lesions by subcutaneous resection of the tubular fibrotic tissue.

METHODS

Periorificial fusiform skin incisions were made around the orifices parallel to the axillary or inguinal folds and the subcutaneous tubular fibrotic tissue was removed en bloc before skin suturing.

RESULTS

The outcome was evaluated as satisfactory due to lower morbidity, minimizing the excised skin areas, prevention of bridles or adherences, shorter incisions, no healing difficulties, and less dehiscence or wound exposure.

CONCLUSION

The subcutaneous fistulectomy is a surgical option in bridging hidradenitis suppurativa.

Alopecia due to psychotropic medications

OBJECTIVE

To review the literature and describe the incidence and nature of psychotropic drug-related alopecia to assist clinicians in their therapeutic decisions when this adverse event occurs.

DATA SOURCES

A MEDLINE search (December 1966-March 1998), using each drug name and the keywords alopecia or hair loss, was conducted. A database from the Clarke Institute of Psychiatry in Toronto was also searched. Additional English-language articles were identified through the bibliography of the reviewed literature. Certain pharmaceutical companies were also consulted.

STUDY SELECTION

All published case reports and review articles were considered for study evaluation.

DATA EXTRACTION

When possible, details regarding psychotropic drug therapy, development of alopecia, and clinical outcomes were collected for each case.

DATA SYNTHESIS

Hair loss from the scalp, eyebrows, and pubic area was identified as a possible, yet uncommon, adverse effect of most psychotropic medications. There are few effective management options for alopecia; however, resolution was achieved on discontinuation of the offending drug in almost all of the cases reported. Alopecia was perceived to be an undesirable effect by most patients, often resulting in poor compliance and hence therapeutic failures.

CONCLUSIONS

Due to the self-limiting nature of mild to moderate hair loss with psychotropic medications, clinicians should consider continuing therapy if there is a good clinical response and the patient agrees with this decision. If severe alopecia occurs, it is recommended to discontinue the medication and pursue therapy with another agent. This is to ensure positive therapeutic outcomes and improved patient compliance.

Hidradenitis suppurativa, Dowling Degos disease and perianal squamous cell carcinoma

A patient with hidradenitis suppurativa (HS) is described in association with Dowling Degos disease and perianal squamous cell carcinomas. As the initial treatment for HS failed to give any satisfactory relief he sought no further medical help for the subsequent 40 years. This patient illustrates the management difficulties in HS and the need for regular surveillance to exclude the development of anogenital squamous cell carcinoma. Previous reports of hidradenitis suppurativa in association with Dowling Degos disease are reviewed and the aetiology is discussed.

Lithium-induced follicular hyperkeratosis

A wide range of cutaneous reactions have been described in association with lithium therapy. Follicular eruptions have been noted briefly, but are not well documented in the dermatological literature. We report a 68-year-old man who developed a florid erythematous follicular eruption on the extensor surfaces of the limbs, with macular truncal erythema 6 months after commencing lithium therapy. His blood lithium levels were within the therapeutic range and there was no clinical evidence of lithium toxicity. Histology of lesional skin showed perifollicular inflammation and follicular plugging. The eruption improved on drug withdrawal. The cutaneous reactions to lithium and possible pathogenic mechanisms are discussed.