Efficacy and safety of 250 mg versus 500 mg oral terbinafine in the treatment of tinea corporis and cruris: A randomised, assessor-blinded comparative study

Background Though higher doses of terbinafine are often prescribed to treat dermatophyte infections, it is unknown if such doses are more effective than the conventional dose because comparative data are unavailable. Aim To compare the efficacy and safety of a once-daily dose of oral terbinafine 250 mg with 500 mg along with topical clotrimazole in the treatment of tinea infections. Methods A randomised, assessor-blinded, comparative study was carried out. Each group of subjects were administered either 250 mg or 500 mg oral terbinafine once daily for four weeks, along with topical clotrimazole. Clinical improvement was assessed after two weeks and again after four weeks from treatment initiation. Result A total of 60 patients with tinea corporis and cruris were randomised into two groups receiving either 250 mg (group A) or 500 mg (group B) oral terbinafine, along with clotrimazole cream in both groups. Baseline clinical parameters such as lesional activity (papules, vesicles and pustules), degree of erythema, scaling and severity of itching were comparable between both treatment arms. At the first and second follow-ups, no significant differences were found in the clinical parameters between the two groups. At the end of two weeks 13.8% of group A and 14.3% of group B and after 4 weeks 25.9% of group A and 33.3% of group B participants became KOH negative (P = 1.00 and 0.76, respectively). No significant difference in culture negativity was reported at the end of therapy (four weeks) between the two treatment arms (P = 0.78). Overall cure rates were 20% and 33.3% in the two treatment arms respectively at the end of the study (P = 0.82). Conclusion Oral terbinafine 250 mg daily yielded a poor cure rate in tinea cruris and corporis after 4 weeks of treatment and an increased dose of 500 mg did not have any additional benefit.

Safety of important dermatological drugs (retinoids, immune suppressants, anti androgens and thalidomide) in reproductively active males with respect to pregnancy outcome: A brief review of literature

Paternally transmitted damage to offspring is recognized as a complex issue. Each parent contributes 23 chromosomes to a child; hence, it is necessary to know the effects of both maternal and paternal pre-and peri-conceptional exposure to drugs on pregnancy outcome. While there are many studies on the effects of maternal drug exposure on pregnancy outcome, literature on paternal exposure is scarce. Of late however, paternal exposure has been receiving increasing attention. We present a brief review on the safety of commonly used drugs in dermatology, focused on retinoids, immune suppressants, anti androgens and thalidomide.

Epidermolysis bullosa pruriginosa affecting 3 successive generations

A 24-year-old man presented with multiple mildly itchy flesh-colored papules and plaques on both legs for the past decade. The lesions were preceded by transient vesicles that contained clear fluid. The papules and plaques used to develop on sites where vesicles had healed. Many family members in three generations had similar lesions (Figure 1). On examination, multiple discrete flesh-colored papules and plaques were found on both lower extremities, extending from the feet up to the knees (Figures 2 and 3). A few of the plaques were excoriated. No vesicles or bullae were noted, and the skin in between the lesions appeared normal. The nail of left great toe was discolored and dystrophic. The rest of the mucocutaneous examination was unremarkable. Bullous lichen planus, Neckam's disease, lichenoid amyloidosis, and epidermolysis bullosa pruriginosa (EBP) were considered as differential diagnoses. Histopathology from the plaque showed a subepidermal cleft with no inflammatory cells. The epidermis was acanthotic at places, and the dermis appeared normal (Figure 4a and 4b). Based on clinical presentation and histopathology, a diagnosis of EBP was made.

Zinc and skin: a brief summary

Zinc is an essential trace element that is an integral component of many metallo-enzymes in the body and thus serves many biological functions. The clinical presentation of zinc deficiency varies and depends on serum zinc level. Whereas a significantly low serum zinc level results in clinical features similar to acrodermatitis enteropathica, mild hypozincemia presents with a less characteristic appearance; hence it may be underdiagnosed. Recognition of various cutaneous lesions is required for suspecting and identifying cases of zinc deficiency. Although many laboratory tests are useful, therapeutic response in suspected cases remains the gold standard of diagnosis. Serum zinc estimation alone is not very reliable because disease activity may not necessarily correlate with serum zinc level. Zinc supplementation results in a rapid response and the skin lesions heal without permanent sequelae. However, pigmentary alterations may persist longer. Predisposing factors should be identified and corrected. This brief review summarizes the identification and management of clinical zinc deficiency.

Granulosis rubra nasi: a rare condition treated successfully with topical tacrolimus

A 20 years-old girl presented with multiple asymptomatic reddish vesicles on face for four years. It used to get worse in summer and was associated with localized hyperhidrosis. The lesions were notable for disappearance on diascopy. Histopathology from the vesicle showed mononuclear cell infiltration in the upper dermis, especially around eccrine sweat apparatus, along with dilatation of superficial capillaries and lymphatics. Based on clinical presentation and histopathology, diagnosis of Granulosis rubra nasi (GRN) was made. GRN usually resolves at puberty; however, rarely it may persist in adulthood. We here report a case of GRN having lesions persisting in adulthood. Moreover, she showed excellent response to topical tacrolimus, a finding not observed in literature.

Development and implementation of an appropriateness guideline for use of CT in cases of suspected intraabdominal abscess

RATIONALE AND OBJECTIVES

The purpose of this study was to develop an evidence-based guideline for use of computed tomography (CT) in the evaluation of suspected abdominal abscess. The goal of the guidelines was to decrease the absolute number of CT examinations performed for suspected abdominal abscess and to increase the rate of positive CT examinations while not missing clinically relevant abscesses.

MATERIALS AND METHODS

A multidisciplinary team developed an evidence-based guideline regarding use of CT to evaluate for suspected abscess. A control group consisted of patients scanned for suspected abscess during a 6-month period. The intervention group consisted of patients scanned in the 6 months after guideline implementation. Focal fluid collections depicted on CT scans were reviewed for both patient groups to determine if these collections were abscesses. The number and proportion of abscesses in each group were then compared.

RESULTS

During the control period, 263 CT examinations for suspected abscess were performed, 75 of which (28.5%; 90% confidence interval [CI], 24%, 33%) depicted focal fluid and 25 of which (9.5%; 90% CI, 7%, 12%) depicted abscess. During the intervention period, 238 CT examinations were performed, 54 of which (22.7%; 90% CI, 18%, 27%) depicted fluid and 41 of which (17.2%; 90% CI, 13%, 21%) depicted abscess.

CONCLUSION

A guideline was successful at decreasing the number of CT examinations and increasing the proportion of positive CT results for abdominal abscess. As with other inpatient utilization interventions, each practice must assess the cost-benefit trade-off of guideline implementation in complex clinical situations.

Evaluation of bone contusions with fat-saturated fast spin-echo proton-density magnetic resonance imaging

OBJECTIVE

To evaluate the efficacy of fast spin-echo proton-density magnetic resonance imaging (MRI) with fat saturation sequences in the evaluation of bone contusions at the knee.

METHODS

Analysis of 46 consecutive knee MRI examinations performed on patients referred from a sports medicine clinic after knee trauma. All examinations included coronal fast spin-echo proton-density fat saturation, fast spin-echo proton-density and fast spin-echo T2-weighted sequences. All 3 coronal sequences were blindly reviewed independently of each other by 3 experienced musculoskeletal radiologists to identify and grade bone contusions.

RESULTS

Thirty-five bone contusions were identified in 24 patients. All bone contusions were identified on fast spin-echo proton-density fat saturation sequences, which was significantly greater than the percentage identified on either fast spin-echo T2-weighted sequences (21/35, 60%, p < 0.001) or fast spin-echo proton-density sequences (10/35, 29%, p < 0.001). Fourteen (40%) of the contusions were identified only on the fast spin-echo proton-density fat saturation sequences. The average grade of contusion for all 35 examinations was also significantly higher on the fast spin-echo proton-density fat saturation sequences than on the fast spin-echo proton-density and fast spin-echo T2-weighted sequences (p < 0.05).

CONCLUSION

Fast spin-echo proton-density fat saturation sequences are more sensitive in the detection of bone contusions than fast spin-echo proton-density and fast spin-echo T2-weighted sequences. Assessment of other structures in the knee with fast spin-echo proton-density fat saturation MRI provides good spatial resolution and adequate T2-weighted information. It may have advantages over the more heavily T2-weighted fast spin-echo T2 fat saturation and inversion recovery sequences.

Clinical consequences of misinterpretations of neuroradiologic CT scans by on-call radiology residents

BACKGROUND AND PURPOSE

Studies have looked at the accuracy of radiologic interpretations by radiology residents as compared with staff radiologists with regard to emergency room plain films, emergency room body CT scans, and trauma head CT scans; however, to our knowledge, no study has evaluated on-call resident interpretations of all types of neuroradiologic CT scans. Both as a part of our departmental quality control program and to address concerns of clinical services about misinterpretation of neuroradiologic CT scans by on-call radiology residents, we evaluated the frequency of incorrect preliminary interpretations of neuroradiologic CT scans by on-call radiology residents and the effect of such misinterpretations on clinical management and patient outcome.

METHODS

As determined by the staff neuroradiologist the next day, all potentially clinically significant changes to preliminary reports of emergency neuroradiologic CT scans rendered by on-call radiology residents were recorded over a 9-month period. A panel of neuroradiologists reviewed and graded all the changed cases by consensus. An emergency department staff physician reviewed medical records of all submitted cases to determine clinical consequences of the misinterpretations.

RESULTS

Significant misinterpretations were made in 21 (0.9%) of 2388 cases during the study period. There was a significant change in patient management in 12 of the cases, with a potentially serious change in patient outcome in two cases (0.08%).

CONCLUSION

On-call radiology residents have a low rate of significant misinterpretations of neuroradiologic CT scans, and the potential to affect patient outcome is rare.