Treatment of multiple miliary osteoma cutis of the face with local application of tretinoin (all- trans retinoic acid): a case report and review of the literature

BACKGROUND

Multiple miliary osteoma cutis of the face represents primary extra-skeletal bone formation that arises within the skin of the face.

METHODS

A 60-year-old woman with multiple miliary osteoma cutis of the face was treated by application of 0.05% tretinoin (all-trans-retinoic acid) cream nightly.

RESULTS

After 3 months of therapy there were fewer papules and a decrease in size of remaining lesions. In a literature search, it was found that local application of tretinoin was successful and achieved a decrease in the number of papules over the face in all patients with multiple miliary osteoma cutis of the face; however, the length of time to achieve response varied from a few weeks to 6 months.

CONCLUSION

It is suggested that local application of tretinoin cream should be considered in the therapy of multiple miliary osteoma cutis of the face, particularly when the lesions are small and superficial.

Nonattendance in a dermatology clinic--a large sample analysis

BACKGROUND

Previous studies have described factors determining non-attendance at dermatology appointments in small sample sizes.

OBJECTIVE

To perform an analysis of factors associated with non-attendance in a dermatology clinic in a larger sample.

METHODS

Factors determining non-attendance were examined in 52 604 consecutive first-time visits to a dermatology clinic over a period of 44 months.

RESULTS

Non-attendance proportion was 27.6%. Among children, non-attendance was associated with waiting for an appointment < 7 days [odds ratio (OR), 1.44], Bedouin sector (OR, 1.30), rural Jewish sector (OR, 0.45) and the treating physician. Among adults, non-attendance was associated with female gender (OR, 1.08), age < 55 years (OR, 1.65), waiting time for an appointment < 7 days (OR, 1.44), timing of the appointment between 1 and 4 pm (OR, 1.13), Bedouin sector (OR, 1.63), rural Jewish sector (OR, 0.46) and the treating physician.

CONCLUSION

Non-attendance is common among Bedouins, adult female patients and young adults and is more likely as waiting times become longer. Strategies to reduce non-attendance are needed.

Psoriasis and diabetes: a population-based cross-sectional study

BACKGROUND

Previous reports have shown an association between psoriasis and the metabolic syndrome, but there are only a few studies on the association between psoriasis and diabetes.

OBJECTIVES

To study the association between psoriasis and diabetes.

METHODS

A cross-sectional study was performed utilizing the database of Clalit Health Services (CHS). Patients who were diagnosed with psoriasis were compared with CHS enrolees without psoriasis regarding the prevalence of diabetes. Patients with diabetes were identified using the CHS chronic diseases registry. Chi-squared tests were used to compare categorical parameters. Logistic regression models were used for multivariate analyses.

RESULTS

The study included 16 851 patients with psoriasis and 74 987 subjects without psoriasis (control patients). The proportion of diabetes was significantly higher in patients above 35 years (P < 0.05). The age-adjusted proportion of diabetes was significantly higher in psoriasis patients as compared to the control group [odds ratio (OR), 1.38, P < 0.05] and was similar in men and women (OR, 1.32, 1.45, respectively). A multivariate logistic regression model showed that psoriasis was significantly associated with diabetes, independently of age and gender (OR, 1.58, P < 0.001).

CONCLUSIONS

Our study supports previous reports of an association between psoriasis and diabetes. Dermatologists taking care of patients with psoriasis should be aware of this association and advise the patients to reduce additional risk factors such as smoking, hypertension or dyslipidemia.

Association between psoriasis and the metabolic syndrome. A cross-sectional study

BACKGROUND

Previous reports have shown an association between inflammatory diseases such as systemic lupus erythematosus or rheumatoid arthritis and the metabolic syndrome. Recent data demonstrate that psoriasis is an inflammatory disease, suggesting that psoriasis may be one of the components of the metabolic syndrome.

OBJECTIVE

To assess the association between psoriasis and the metabolic syndrome.

METHODS

A cross-sectional study was performed utilizing the database of the Clalit Health Services. Case patients were defined as patients with a diagnosis of psoriasis vulgaris. Controls were randomly selected from the list of Clalit Health Services enrollees. The proportions of components of the metabolic syndrome (ischemic heart disease, hypertension, diabetes, obesity and dyslipidemia) were compared between case and control patients by univariate analyses. chi(2) tests were used to compare categorical parameters between the groups. Logistic and linear regression models served to measure the association between psoriasis and the metabolic syndrome.

RESULTS

The study included 16,851 patients with psoriasis and 48,681 controls. In the case group, there were 8,449 men (50.1%) and 8,402 women (49.9%), with a mean age of 42.7 years (SD = 20.3, range = 2-111). Diabetes mellitus was present in 13.8% of the patients with psoriasis as compared to 7.3% of the controls (p < 0.001). Hypertension occurred in 27.5% of the patients with psoriasis and in 14.4% of the controls (p < 0.001). Obesity was present in 8.4% of the patients with psoriasis as opposed to 3.6% of the controls (p < 0.001). Ischemic heart disease was observed in 14.2% of the patients with psoriasis as compared to 7.1% of the controls (p < 0.001). Multivariate models adjusting for age, gender and smoking status of the patients demonstrated that psoriasis was associated with the metabolic syndrome (OR = 1.3, 95% CI = 1.1-1.4), ischemic heart disease (OR = 1.1, 95% CI = 1.0-1.2), diabetes mellitus (OR = 1.2, 95% CI = 1.0-1.3), hypertension (OR = 1.3, 95% CI = 1.2-1.5) and obesity (OR = 1.7, 95% CI = 1.5-1.9).

LIMITATIONS

The study is designed as a case-control study, thus an association alone was proven and not causality.

CONCLUSION

Our findings demonstrate a possible association between psoriasis and the metabolic syndrome. Appropriate treatment of the metabolic syndrome may be an important part of the management of patients with psoriasis.

Nonattendance of adult otolaryngology patients for scheduled appointments

Background: Nonattendance for appointments is an impediment to otolaryngology patient care worldwide. In a previous study of children attending an otolaryngology clinic, we observed that attendance was determined by the waiting time for an appointment and the timing of the appointment within the day. However, the factors that affect nonattendance in adults have not been well studied.

Objective: We aimed to investigate factors associated with nonattendance in adults visiting an otolaryngology clinic.

Methods: Nonattendance was observed for a period of one year in adult patients visiting an ambulatory otolaryngology clinic. The following parameters were also noted: age, gender, treating physician, waiting time and timing of the appointment. The chi-square test was used to analyse differences between categorical variables. The t-test was used to analyse differences between continuous variables. Logistic regression was used for multivariate analyses.

Results: The study assessed 8071 visits to the otolaryngology clinic. The overall proportion of nonattendance was 27.7 per cent. A multivariate logistic regression model demonstrated that nonattendance was significantly associated with the following factors: female gender, younger age, long waiting time for an appointment, timing of the appointment within the day and the treating physician.

Conclusion: In adult otolaryngology patients, nonattendance was associated with patient-related factors and healthcare systems related factors alike. It is suggested that managed overbooking could be carefully introduced into otolaryngology patient scheduling.

Prevalence and risk factors for tinea pedis in Israeli soldiers

BACKGROUND

Tinea pedis is a common infection in soldiers. However, prevalence and risk factors for tinea pedis in soldiers were investigated in only a few studies.

OBJECTIVES

To investigate the prevalence and risk factors for tinea pedis in Israeli soldiers.

METHODS

A cross-sectional study including interviews, clinical skin examination and mycological tests was performed in Israeli soldiers. The presence of tinea pedis was assessed using the Athlete's Foot Severity Index (AFSI), a scoring system that was developed in order to evaluate the presence and severity of tinea pedis. In soldiers with clinical evidence of tinea pedis (AFSI > 1), scrapings were taken for direct microscopic examination (20% KOH preparation) and fungal culture. Statistical analyses were performed using chi-square or Fisher's exact test for dichotomous variables (as needed), or t-tests for continuous variables. Logistic regression was used for multivariate analyses of dichotomous variables.

RESULTS

Two hundred and twenty-three soldiers were included in the study: 205 men (91.9%) and 18 women (8.1%). Mean age was 19.6 years (SD 1.0 year). Clinical point prevalence was 60.1%. Mycological point prevalence was 27.3%. Further analyses were performed using the clinical point prevalence. Univariate analyses demonstrated that the prevalence of tinea pedis varied with the setting of military training (basic training: 70.3%, advanced infantry training: 81.5%, armor commander training: 56.4% and armor officer training: 34.8%) and was associated with male gender, frequency of sock changes and the length of military service. A multivariate analysis demonstrated that tinea pedis was associated with the setting of the military training (OR 1.6, 95% CI 1.2-2.1) and male gender (OR 4.3, 95% CI 1.4-13.8); however, there was no association with hygiene measures (e.g. frequency of changing socks or sleeping with socks) or the length of military service.

CONCLUSION

Tinea pedis is highly prevalent in Israeli soldiers. Association of tinea pedis with the setting of military training suggests that contagious spread may be an important risk factor. We suggest that environmental interventions should be planned to in order to decrease the morbidity of tinea pedis among soldiers.

An independent comparison of terbinafine and itraconazole in the treatment of toenail onychomycosis

BACKGROUND

Previously, sponsored publications have shown that either terbinafine or itraconazole (pulse regimen) are effective for patients with toenail onychomycosis. However, independent comparative studies are lacking.

OBJECTIVES

To objectively compare treatment with terbinafine and itraconazole in patients with toenail onychomycosis.

METHODS

The effectiveness of terbinafine (250 mg/day 3 months) versus itraconazole pulse regimen (400 mg/day for the first week of each month, for three cycles) was retrospectively evaluated in patients with toenail onychomycosis using mycological tests and subjective outcome measures. Statistical analyses were performed using one-way analyses of variance (ANOVA) for continuous variables and Fisher exact tests for categorical variables.

RESULTS

Included in the study were 117 patients (74 patients treated by terbinafine and 43 patients treated with itraconazole). Patients were examined at an average period of 20 months after the end of therapy. Mycological cure was observed in 70.6% and 62.8% of the patients who were treated by terbinafine or itraconazole, respectively (not statistically significant). Mean visual analogue scale assessment of treatment outcome was 79.9 mm (SD 24.7 mm) and 65.2 mm (SD 34.6 mm) for patients treated by terbinafine or itraconazole, respectively (p=0.008). When the results were stratified according to age and gender, it was observed that the advantage of terbinafine versus itraconazole retained statistical significance only for patients who were 55 years old and above, or females.

CONCLUSIONS

Mycological cure proportions were not statistically significant between patients treated by terbinafine or itraconazole for toenail onychomycosis. However, better subjective outcome measures indicated an advantage for terbinafine over itraconazole, noticeable in females and patients 55 years old and above.

AFSS: athlete's foot severity score. A proposal and validation

We developed a simple scoring system to evaluate the severity of tinea pedis (Athlete's foot severity score, AFSS). The AFSS consists of a clinical evaluation, using a three-point scale, of erythema and scaling in the plantar and interdigital spaces of the feet, and counts of interdigital spaces involved. Each foot is evaluated separately. The validity of the AFSS was assessed in 224 soldiers of the Israel Defense Force using mycological cultures as the main outcome measure and subjective assessment of pruritus as the secondary outcome measure. Mycological examinations were performed in 106 patients who had clinical evidence of tinea pedis. AFSS was significantly associated with culture results (P<0.0001), as well as with the presence of pruritus (P=0.002), and pruritus scores (P=0.025). We conclude the AFSS is valid for the clinical evaluation of tinea pedis severity in military settings. The application of AFSS to civilian morbidity should be subjected to further evaluation. AFSS: Schweregrad-Beurteilung des Athletenfusses. Ein Vorschlag

Cherry angiomas associated with exposure to bromides

Cherry angiomas are the most common vascular proliferation; however, little is known about the pathogenesis and etiology of these lesions. We present two laboratory technicians who were exposed to brominated compounds for prolonged periods and who developed multiple cherry angiomas on the trunk and extremities. We suggest that the association between exposure to bromides and cherry angiomas should be investigated by a controlled study.

Relapse of cutaneous leishmaniasis in a patient with an infected subcutaneous rheumatoid nodule

Cutaneous leishmaniasis is a protozoal infection generally considered to be limited to the skin. In Israel, the disease is common in geographically defined areas and is caused predominantly by Leishmania major. Sporotrichoid subcutaneous spread has been reported but is uncommon. We describe a patient with rheumatoid arthritis, treated with methotrexate and prednisone, in whom numerous rheumatoid nodules concomitant with cutaneous leishmaniasis were found, mimicking sporotrichoid spread of the disease. In a rheumatoid nodule that was examined by electron microscopy, Leishmania parasites were found at intracellular and extracellular locations. This observation supports the hypothesis that cutaneous leishmaniasis parasites persist after clinical cure of the disease and may re-emerge as a result of immunosuppression.

Coding medical information: classification versus nomenclature and implications to the Israeli medical system

The efficient retrieval of medical information is essential for all functional aspects of a health system. Such retrieval is possible only by coding data (as it is produced or after it is produced) and entering it into a data-base. The completeness and accuracy of retrieved information depend, therefore, on the coding system employed. The main coding system that is in use in Israel is the ICD-9: International Classification of Diseases and its clinical modification (ICD-9-CM). Using such a statistical classification system for coding has met the basic needs for statistical and administrative purposes, but causes distortion and loss of information. With the recent growth and availability of information technology, more detailed data can be coded and processed than was possible before. A detailed nomenclature system such as SNOMED (the Systematized Nomenclature Of Human and Veterinary Medicine) can be used as a coding system that enables a more comprehensive and flexible medical information data base. This article discusses some aspects of coding medical information and suggests that a national revision of medical coding systems be considered as the computerized-patient-record is further developed and implemented.

Chronic radiodermatitis following cardiac catheterization

BACKGROUND

Fluoroscopy and cineradiography used during coronary angiography expose patients to some of the highest doses of ionizing radiation in diagnostic radiology. The possibility of radiation-induced damage has been discussed by several authors in the past. However, to the best of our knowledge, chronic radiation dermatitis caused by exposure to x-rays during cardiac catheterization has not been described.

OBSERVATIONS

We describe 4 patients in whom chronic radiodermatitis developed following multiple cardiac catheterizations and coronary angioplasties. The cumulative radiation doses to which these patients were exposed were retrospectively calculated to be a mean of 24.6 Gy per patient, with a range of 11.4 to 34.9 Gy.

CONCLUSIONS

Chronic radiodermatitis is a threat in patients undergoing multiple cardiac catheterizations and angioplasties. In susceptible patients, radiation doses as small as 11.4 Gy, which can sometimes be emitted during 1 or 2 procedures, are potentially harmful. Awareness and protective measures against this long-term side effect of cardiac catheterization should be encouraged.

Knuckle pads--a forgotten skin condition: report of a case and review of the literature

A 12-year-old boy presented with knuckle pads, palmar keratoderma, and hand eczema. Since Morginson's description of knuckle pads associated with other dermatoses almost forty years ago, little attention has been given to this disorder. We describe a case and review some of the clinical aspects of this disorder.

Induction of autocrine epidermal growth factor receptor ligands in human keratinocytes by insulin/insulin-like growth factor-1

Autocrine activation of the epidermal growth factor (EGF) receptor on keratinocytes has been recognized as an important growth regulatory mechanism involved in epithelial homeostasis, and, possibly, hyperproliferative diseases. Insulin-like growth factor (IGF)-1 and insulin have been shown to be paracrine keratinocyte mitogens that bind to the type I IGF receptor which is expressed on actively proliferating keratinocytes in situ. In this report, we demonstrate that IGF-1/insulin induced production of keratinocyte-derived autocrine growth factors that bind to the EGF receptor. Increased steady-state mRNA levels for transforming growth factor alpha (TGF-alpha) and for amphiregulin (AR) were observed upon incubation of keratinocytes with mitogenic concentrations of IGF-1. IGF-1 also induced production and secretion of TGF-alpha and AR proteins as detected by immunoassays. An EGF receptor antagonistic monoclonal antibody abolished the mitogenic effect of IGF-1 on cultured keratinocytes. These results suggest that stimulation of keratinocyte growth of IGF-1 requires activation of an EGF receptor-mediated autocrine loop.

Treatment of vulvar lichen sclerosus in the elderly: an update

Lichen sclerosus et atrophicus is a disorder of the skin that can occur anywhere on the body and in all age groups but mainly affects middle-aged and elderly women in the vulvoperineal area. It consists of ivory or pink papules or macules that eventually coalesce into thin, gray, parchment-like areas. Clinically, the main symptoms are severe and intractable itching and vaginal soreness with dyspareunia. Although it has been described to be associated with an increased risk for epithelial malignancy this, in fact, very rarely occurs. The exact nature of LSA is still unknown. The accumulation of evidence does little to clarify its pathogenesis and etiology. The different reports indicate at least three general possibilities; autoimmune, metabolic, and more recently infectious etiology. The coexistence of such diverse findings in one disease entity may indicate one of the two; either we are facing a group of very similar conditions, which will be separated in the future into several closely related clinical entities, each with its own etiology, or that all findings represent a complex multi-step single pathogenetic mechanism. The latter possibility seems more probable because it has previously been suggested that B. burgdorferi, a recent prime suspect in the pathogenesis of LSA, may induce both metabolic and autoimmune abnormalities in the course of infection. New therapeutic options and attitudes emerge that dramatically improved the conservative treatment of this disease (Table 5).(ABSTRACT TRUNCATED AT 250 WORDS)

Unusually extensive disease caused by Leishmania major parasites

Simple cutaneous leishmaniasis (CL), which is endemic in several areas of Israel, is usually caused by Leishmania major. CL, which is caused by replication of parasites within dermal macrophages, is self-limited and almost always confined to the skin. We recently encountered two cases of CL in which skin defenses were breached and lesions appeared in subcutaneous locations. In one case, abnormal cell-mediated immune function was detected. The purpose of this article is to present these data and to comment on the immunological aspects of leishmaniasis.

Specific cutaneous infiltrates in chronic myelogenous leukemia

Specific leukemic infiltration of the skin is possible in all types of leukemia, and occurs most commonly in monocytic leukemias. We report the case of a 76-year-old woman with chronic myelogenous leukemia who showed specific cutaneous lesions one month before she died. In the absence of other signs of accelerated disease or blast crisis, cutaneous lesions should be considered an ominous sign in chronic myelogenous leukemia.

Full skin thickness burns caused by contact with the pavement in a heat-stroke victim

A 70-year-old woman, with a previous history of heat-stroke, suffered another heat-stroke on a hot summer day (air temperature 43 degrees C (109 degrees F)). She presented the rare complication of a heat-stroke plus deep burns sustained while lying unconscious on the pavement. In addition to age, obesity, previous illness, incidental fever, drugs, dehydration and physical effort, a previous history of heat-stroke is probably an important risk factor for a second heat-stroke. Burns from contact with the pavement are uncommon but possible, especially if the patient is obese, immobile and poorly insulated.