Bone-anchored hearing aids: Percutaneous versus transcutaneous attachments - a health economics comparison in paediatric patients

INTRODUCTION

Bone anchored hearing aids (BAHA) are a useful support when conventional hearing aids are not suitable. The two types of attachment of the aid are onto a percutaneous abutment or a transcutaneous magnet. Anecdotally, the abutment requires more care, revision procedures and causes more infections than magnet-based devices.

METHODS

A multicentre, retrospective review was conducted of all patients that underwent a BAHA since our programme began, identified through a prospectively maintained database of patients. Patients' charts were audited for outpatient clinic visits, skin complications and revision surgeries. Developmental delay was also recorded. Patients were censored if the hearing aid was removed, replaced or the patient reached 16 years old. Bilateral or reimplanted patients were recorded as separate implants. Statistical analysis was performed using SAS version 9.4.

RESULTS

150 implants were assessed over 126 patients: 115 transcutaneous and 35 percutaneous. Percutaneous patients had significantly more outpatient clinic attendances (Least square mean 4.19 vs. 1.39 p = 0.00), skin complications (mean 4.82 v 0.11 p = 0.00) and theatre visits (mean 2.8 vs. 1.03 p = 0.00) compared to transcutaneous patients. 77 implants were in patients that had developmental delay; having same made no significant difference to above outcomes.

CONCLUSION

There is a significant difference in healthcare burden between percutaneous and transcutaneous systems in a paediatric population. The increased cost of the percutaneous implant to the healthcare system and inconvenience to the patient is cause to consider a transcutaneous system in the first instance.

Dermatologic adverse effect of subcutaneous furosemide administration in a cat

Background

Furosemide is a mainstay of treatment in congestive heart failure (CHF) and is widely prescribed to dogs and cats by several formulations, including the subcutaneous one. In canine and human medicine, dermatologic adverse effects of subcutaneous furosemide (SF) have been documented; conversely, no prior case has been published describing skin reactions to this therapeutic protocol in cats. In this report, we describe, for the first time in feline medicine, a suspected dermatologic adverse effect after SF in a cat.

Case Description

A 2-year-old domestic shorthair cat was presented for CHF associated with lung edema and pleural effusion. Echocardiography revealed asymmetric left ventricular myocardial thickening and severe left atrial dilation. The cat was hospitalized and initially treated with oxygen, intravenous furosemide, and clopidogrel. After discharge, the route of administration of furosemide was switched from intravenous to oral. Within the following 2 weeks, the cat experienced two relapses of lung edema despite the progressive increase of the furosemide dose, the addition of spironolactone and adherence to the therapeutic protocol by the owners. The dose of furosemide was further increased and its route of administration at home was switched from oral to parental. As the owner was not able to administrate intramuscular injections, SF was prescribed. This allowed the prevention of further episodes of lung edema. However, although the cat had never presented skin problems before, multiple well-defined circular, crusted ulcerative cutaneous lesions associated with alopecia developed at the sites of furosemide injections 2 weeks later. After ruling out several differential diagnoses for these lesions, a rare side effect of furosemide, not yet described in cats but already known in canine and human medicine, was strongly suspected as the possible cause. Therefore, the ongoing injectable formulation of furosemide was interrupted and substituted with an alternative brand, maintaining the same dose and route of administration. Thanks to this change, the dermal ulcerations disappeared within 1 month. Subsequently, the cat experienced neither further skin problems nor a recurrence of lung edema.

Conclusion

Although SF is sometimes prescribed in small animal practice, it should be noticed that this may lead to dermatologic adverse reactions in the cat.

[Lichenoid drug eruption with unfavorable evolution. Difficulties in diagnosis]

We report the case of a woman who started with a lichenoid eruption, unfavorable evolution, for which a drug reaction was suspected. The final diagnosis was paraneoplastic pemphigus. Multidisciplinary care and evaluation by an Allergist is important in patients with severe skin reactions, suspected of drug reactions, due to the difficulty in establishing the diagnosis.

Hypersensitivity reactions to metals in spine surgery

Hypersensitivity to orthopedic devices is a rare condition with an underestimated incidence due to the lack of diagnostic guideline and ambiguous clinical manifestations. Although hypersensitivity to metal is common, a few cases of hypersensitivity reactions have been reported after spinal instrumentation. Spinal fusion and stabilization require a wide range of devices such as screws, wires, bands, and artificial disk replacement devices. Spinal instrumented surgeries are different from total joint arthroplasty in several aspects such as degree and pattern of motion, loading environment, and adjacent tissues with distinct characteristics. The interval for hypersensitivity reactions to occur after spinal metallic implantation is usually weeks to months. The present review covers the topic of hypersensitivity reactions that have been reported after spinal surgeries with the focus on cutaneous presentations.

A two-stage genome-wide association study to identify novel genetic loci associated with acute radiotherapy toxicity in nasopharyngeal carcinoma

Background

Genetic variants associated with acute side effects of radiotherapy in nasopharyngeal carcinoma (NPC) remain largely unknown.

Methods

We performed a two-stage genome-wide association analysis including a total of 1084 patients, where 319 individuals in the discovery stage were genotyped for 688,783 SNPs using whole genome-wide screening microarray. Significant variants were then validated in an independent cohort of 765 patients using the MassARRAY system. Gene mapping, linkage disequilibrium, genome-wide association analysis, and polygenic risk score were conducted or calculated using FUMA, LDBlockShow, PLINK, and PRSice software programs, respectively.

Results

Five SNPs (rs6711678, rs4848597, rs4848598, rs2091255, and rs584547) showed statistical significance after validation. Radiotherapy toxicity was more serious in mutant minor allele carriers of all five SNPs. Stratified analysis further indicated that rs6711678, rs4848597, rs4848598, and rs2091255 correlated with skin toxicity in patients of EBV positive, late stage (III and IV), receiving both concurrent chemoradiotherapy and induction/adjuvant chemotherapy, and with OR values ranging from 1.92 to 2.66. For rs584547, high occurrence of dysphagia was found in A allele carriers in both the discovery (P = 1.27 × 10^− 6, OR = 1.55) and validation (P = 0.002, OR = 4.20) cohorts. Furthermore, prediction models integrating both genetic and clinical factors for skin reaction and dysphagia were established. The area under curve (AUC) value of receiver operating characteristic (ROC) curves were 0.657 (skin reaction) and 0.788 (dysphagia).

Conclusions

Rs6711678, rs4848597, rs4848598, and rs2091255 on chromosome 2q14.2 and rs584547 were found to be novel risk loci for skin toxicity and dysphagia in NPC patients receiving radiotherapy.

Trial registration

Chinese Clinical Trial Register (registration number: ChiCTR-OPC-14005257 and CTXY-140007-2).

Supplementary Information

The online version contains supplementary material available at 10.1186/s12943-022-01631-8.

Evaluation of the skin phototoxicity of systemically administered pharmaceuticals in Sprague-Dawley rats

In vivo phototoxicity testing is important for predicting drug-induced phototoxicity in humans. Currently, there is no internationally validated in vivo test method for the photosafety evaluation of pharmaceuticals. In this study, we evaluated the phototoxicity of systemically administered drugs using SD rats. We first determined the appropriate ultraviolet A (UVA) dose using 8-methoxypsoralen, a well-known phototoxic drug. Compared to lower and higher UVA doses, we found that a UVA dose of 10 J/cm² allowed for the detection of phototoxic responses in both a dose- and time-dependent manner. We next performed a phototoxicity study using seven pharmaceutical drugs which included known phototoxic and non-phototoxic drugs using a UVA dose of 10 J/cm². In order to improve the accuracy of our assessment, we evaluated both gross skin findings as well as histopathological findings. Using gross skin findings alone resulted in an accuracy of 85.7% which could be increased to 100% accuracy when the gross skin findings were combined with histopathological findings. This study suggests that the inclusion of histopathological findings increases the accuracy of the phototoxicity evaluation of systemically administered drugs in SD rats. In conclusion, we found that for studying drug-induced phytotoxicity, a 10 J/cm² UVA dose serves as the optimal radiation dose, and that the inclusion of histopathological findings increases the accuracy of the phototoxicity evaluation of the drugs.

Evaluation of skin reactions during proton beam radiotherapy - Patient-reported versus clinician-reported

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Radiotherapy is used in the treatment for primary brain tumours.

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Radiotherapy causes acute and late toxicities where skin reactions are most common.

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The potential for misreporting of toxicity in specific cases may be significant.

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Oncologist-reported and patient-reported outcomes of skin reactions are crucial.

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A combination of PROs and oncologists’ assessments is most accurate.

Background

Skin reaction is a common side-effect of radiotherapy and often only assessed as clinician-reported outcome (CRO). The aim was to examine and compare patient-reported outcome (PRO) of skin reactions with CRO for signs of acute skin reactions for patients with primary brain tumour receiving proton beam radiotherapy (PBT). A further aim was to explore patients’ experiences of the skin reactions.

Methods

Acute skin reactions were assessed one week after start of treatment, mid-treatment and end of treatment among 253 patients with primary brain tumour who underwent PBT. PRO skin reactions were assessed with the RSAS and CRO according to the RTOG scale. Fleiss’ kappa was performed to measure the inter-rater agreement of the assessments of skin reactions.

Results

The results showed a discrepancy between PRO and CRO acute skin reactions. Radiation dose was associated with increased skin reactions, but no correlations were seen for age, gender, education, occupation, other treatment or smoking. There was a poor agreement between patients and clinicians (κ = −0.016) one week after the start of PBT, poor (κ = −0.045) to (κ = 0.396) moderate agreement at mid treatment and poor (κ = −0.010) to (κ = 0.296) moderate agreement at end of treatment. Generally, patients’ symptom distress toward skin reactions was low at all time points.

Conclusion

The poor agreement between PRO and CRO shows that the patient needs to be involved in assessments of skin reactions for a more complete understanding of skin reactions due to PBT. This may also improve patient experience regarding involvement in their own care.

Evaluation of skin phototoxicity of transdermally administered pharmaceuticals in Sprague-Dawley rats

Some drugs cause phototoxicity in humans when exposed to light, thus there is a need for an in vivo phototoxicity test to evaluate them. However, an in vivo phototoxicity test method to evaluate this has not been established. This study aimed to establish an in vivo phototoxicity test method for transdermally administered drugs. For this, we evaluated the phototoxicity using Sprague-Dawley (SD) rats for transdermal administered drugs and we studied the appropriate UVA dose using 8-methoxypsalen, which is a well-known phototoxic drug. We found that a UVA dose of 15 J/cm2 was dose and time dependent response compared to other UVA doses. We performed the Minimum Erythema Dose (MED) test because UVB can cause skin irritation by itself and selected 0.01 J/cm2 as an appropriate dose of UVB. Using the selected UVA and UVB doses, we performed a phototoxicity study of 6 pharmaceutical drugs, which included phototoxic and non-phototoxic drugs. As a result of the phototoxicity test, 100% accuracy was obtained when compared with previous studies. In addition, we performed histopathology to confirm the new findings. We found that histopathology can be used as an additional indicator of phototoxicity test for transdermally administered drugs.

Prospective practice survey of management of cetuximab-related skin reactions

Purpose

Evidence-based guidelines on how to prevent or treat cetuximab-related skin reactions are lacking and multiple care and management strategies are used. The main purpose of the present study is to gain information about the different skincare products being used against skin reactions in metastatic colorectal cancer (mCRC) and recurrent/metastatic (R/M) or locally advanced (LA) squamous cell cancer of the head and neck (SCCHN) patients treated with cetuximab.

Methods

An open-label, prospective observational study conducted in the Netherlands. The occurrence of skin reactions and the care and management options taken were documented for 16 weeks, starting from the first administration of cetuximab.

Results

A total of 103 patients were included in 7 hospitals. 38 patients (37%) developed a grade ≥ 2 skin reaction. Eighty-six patients could be analysed for the primary endpoint (73.3% males, mean age 62.4 years, n = 44 LA SCCHN, n = 16 R/M SCCHN, n = 26 mCRC). The most frequently used skin products at some point during the observation period were moisturizing products (70%), systemic antibiotics (64%), topical antibiotics (58%), lipid-regenerating (28%) and other topical products (28%). The overall use of products gradually increased from baseline to week 6–10, reducing by week 16. Hospital protocols were the primary reason (> 50%) for choice of the skincare products and medications.

Conclusion

A variety of skin care products and antibiotics were commonly used. Only few patients developed severe cutaneous reactions. For patients, the occurrence of skin reactions did not influence their willingness to continue cetuximab therapy.

An audit of radiation-induced skin reactions in the inframammary fold; does breast size impact on the severity of the reaction?

INTRODUCTION

Skin toxicity is a clinically significant side effect of external beam radiation; moist desquamation is particularly prevalent for breast patients, mainly in the axilla and inframammary fold (IMF). The aim of this audit was to assess if there is a correlation between patient breast size and the presence and extent of radiotherapy skin reaction in the IMF.

METHODS

Between 22/12/2017 and 31/05/2018 forty patients undergoing standard whole breast radiotherapy using 3D planned medial and lateral tangential fields had their skin reaction recorded weekly, whilst on treatment, using the Radiotherapy Oncology Group (RTOG) scoring system. Skin reactions were also documented at three and eight weeks post radiotherapy. A measurement of the patients IMF length and bra size were also noted. Statistical analysis was carried out using IBMÒ SPSS Statistics 24.

RESULTS

Six patients presented with grade ≥2 during week three of radiotherapy. The mean IMF length of six patients with adverse reactions 6.1 cm (±3.6 cm). As the length of the IMF increases, severity of skin reactions also increases; a positive correlation was identified between the two at both week three of radiotherapy and three weeks post radiotherapy (r = 0.401, n = 34, p = 0.05 and r = 0.671, n = 29, p = 0.00 respectively). Only one patient displayed grade 2 at eight weeks post radiotherapy (IMF length 7.5 cm).

CONCLUSION

The findings from this study would suggest that larger breasted patients do present earlier, and with more severe radiation-induced skin reactions.

IMPLICATIONS FOR PRACTICE

Changes to skin care practice could be considered for patients with larger breasts. This could be in the form of more frequent check-ups during treatment or proactive side effect management rather than reactive management.

A systematic review and Meta-analysis on the association between Hand-Foot Syndrome (HFS) and Cancer Chemotherapy Efficacy

Hand-foot syndrome (HFS) is a common skin toxicity of traditional chemotherapies. Some studies showed that HFS has an association with progression-free survival (PFS) and the overall survival (OS). So far, there is not available any systematic literature reviews or meta-analysis aimed to assess the associations between HFS, PFS and OS. For this reason, this study aims to quantitatively summarize, critically review, and interpret the recent literature related to the associations between HFS and efficacy of chemotherapy in terms of PFS and OS. Queries shaped by PICOM framework, a systematic search of three electronic databases (PubMed, Scopus, and Science Direct) was carried out for the period between January 2010 and December 2017. Quantitative data pooling was based on the calculation of Hazard Ratio (HR) with 95% Confidence Interval (95% CI) for the OS and PFS associated to the presence of HFS, through the data of original publications. Five papers were included in this systematic review for the quantitative data pooling. Patients with HFS showed improved PFS (HR = 0.532 [0.431-0.656]; p = 0.000) and improved OS (HR = 0.522 [0.427-0.638]; p = 0.000). HFS causes a reduction of compliance with oncology treatments. Healthcare providers should use this result as a trigger to foster patients' coping and the one of their family caregivers, enhancing their adherence to cancer treatments.

Association Between Skin Reaction and Clinical Benefit in Patients Treated with Anti-Programmed Cell Death 1 Monotherapy for Advanced Non-Small Cell Lung Cancer

BACKGROUND

Anti-programmed cell death 1 antibody is a standard therapy for advanced non-small cell lung cancer (NSCLC). However, immune-related adverse events (irAEs), such as skin reactions, are frequently observed. Although skin reactions are associated with clinical efficacy in melanoma, this association in advanced NSCLC and predictors of irAEs remain unclear. Accordingly, this study identified potential correlations of skin reactions with clinical efficacy and clinical predictors of development of skin reactions.

SUBJECTS, MATERIALS, AND METHODS

We retrospectively surveyed patients with advanced NSCLC who received nivolumab or pembrolizumab monotherapy at Sendai Kousei Hospital (n = 155) during January 2016 to April 2018. Treatment efficacy was evaluated in patients with and without skin reactions, and associated predictive markers were determined. A 6-week landmark analysis was conducted to assess the clinical benefit of early skin reactions.

RESULTS

Skin reactions were observed in 51 patients with a median time to onset of 6.4 weeks. The overall response rate (ORR) was significantly higher in patients with skin reactions (57% vs. 19%, p < .001). Median progression-free survival (PFS) durations of 12.9 and 3.5 months and overall survival durations of not reached and 11.4 months were observed in patients with and without skin reactions, respectively. In the 6-week landmark analysis, the ORR was significantly higher in patients with skin reactions, and skin reactions were significantly associated with increased PFS. A multivariate analysis identified pre-existing rheumatoid factor (RF) as an independent predictor of skin reactions.

CONCLUSION

Skin reactions appeared beneficial in patients treated with nivolumab/pembrolizumab for advanced NSCLC and could be predicted by pre-existing RF. Further large-scale validations studies are warranted.

IMPLICATIONS FOR PRACTICE

This single-institutional medical record review that included 155 patients with advanced non-small cell lung cancer who were treated with nivolumab or pembrolizumab monotherapy revealed that overall response rate and progression-free survival were significantly better in patients with skin reactions. Pre-existing rheumatoid factor was an independent predictor of skin reactions.

Eslicarbazepine acetate as a therapeutic option in a patient with carbamazepine-induced rash and HLA-A*31:01

Eslicarbazepine acetate (ESL) is an anticonvulsant drug approved for the treatment of focal epilepsies, and related to oxcarbazepine and carbamazepine (CBZ), which are also derivatives of the dibenzazepine family. ESL is contraindicated in patients with hypersensitivity reactions to CBZ.We report a patient with frontal lobe epilepsy responding to treatment with ESL without any serious adverse effects after developing a severe skin rash following treatment with CBZ. HLA testing revealed an HLA-A*31:01 haplotype, that increases the risk of CBZ-induced cutaneous reactions.This case study shows that, in clinical practice, ESL may be considered in a patient with the HLA-A*31:01 haplotype and a hypersensitivity reaction to CBZ.

Risk of cutaneous adverse events with febuxostat treatment in patients with skin reaction to allopurinol. A retrospective, hospital-based study of 101 patients with consecutive allopurinol and febuxostat treatment

OBJECTIVE

To investigate the cutaneous tolerance of febuxostat in gouty patients with skin intolerance to allopurinol.

METHODS

We identified all gouty patients who had sequentially received allopurinol and febuxostat in the rheumatology departments of 4 university hospitals in France and collected data from hospital files using a predefined protocol. Patients who had not visited the prescribing physician during at least 2 months after febuxostat prescription were excluded. The odds ratio (OR) for skin reaction to febuxostat in patients with a cutaneous reaction to allopurinol versus no reaction was calculated. For estimating the 95% confidence interval (95% CI), we used the usual Wald method and a bootstrap method.

RESULTS

In total, 113 gouty patients had sequentially received allopurinol and febuxostat; 12 did not visit the prescribing physician after febuxostat prescription and were excluded. Among 101 patients (86 males, mean age 61±13.9 years), 2/22 (9.1%) with a history of cutaneous reactions to allopurinol showed skin reactions to febuxostat. Two of 79 patients (2.5%) without a skin reaction to allopurinol showed skin intolerance to febuxostat. The ORs were not statistically significant with the usual Wald method (3.85 [95% CI 0.51-29.04]) or bootstrap method (3.86 [95% CI 0.80-18.74]).

CONCLUSION

The risk of skin reaction with febuxostat seems moderately increased in patients with a history of cutaneous adverse events with allopurinol. This moderate increase does not support the cross-reactivity of the two drugs.

Intensity modulated radiotherapy with simultaneous integrated boost vs. conventional radiotherapy with sequential boost for breast cancer - A preliminary result

PURPOSE

This study was aimed to assess the acute dermatological adverse effect from two distinct RT techniques for breast cancer patients. We compared intensity-modulated radiotherapy with simultaneous integrated boost (IMRT-SIB) and conventional radiotherapy followed by sequential boost (CRT-SB).

METHODS

The study population was composed of 126 consecutive female breast cancer patients treated with breast conserving surgery. Sixty-six patients received IMRT-SIB to 2 dose levels simultaneously. They received 50.4 Gy at 1.8 Gy per fraction to the whole breast and 60.2 Gy at 2.15 Gy per fraction to the tumor bed by integral boost. Sixty patients in the CRT-SB group received 50 Gy in 25 fractions to the whole breast followed by a boost irradiation to tumor bed in 5-7 fractions to a total dose of 60-64 Gy. Acute skin toxicities were documented in agreement with the Common Terminology Criteria for Adverse Events version 3 (CTCAE v.3.0).

RESULTS

Ninety-eight patients had grade 1 radiation dermatitis while 14 patients had grade 2. Among those with grade 2, there were 3 patients in IMRT-SIB group (4.5%) while 11 in CRT-SB group (18.3%). (P = 0.048) There was no patient with higher than grade 2 toxicity. Three year local control was 99.2%, 3-year disease free survival was 97.5% and 3-year overall survival was 99.2%.

CONCLUSIONS

A significant reduction in the severity of acute radiation dermatitis from IMRT-SIB comparing with CRT-SB is demonstrated.

Loading of osseointegrated implants for bone conduction hearing at 3 weeks: 3-year stability, survival, and tolerability

The objective of this study was to ascertain the long-term safety of loading osseointegrated implants for bone conduction hearing 3 weeks post-surgery. Thirty consecutive adult patients were implanted with the Baha BI300 (Cochlear Bone Anchored Solutions) in our tertiary referral center. Implants were loaded with the sound processor 3 weeks post-surgery. Follow-up examinations were performed at 10 days; 3, 4, 6, 8, and 12 weeks; 6 months; and 1, 2, and 3 years after implant surgery. At each follow-up visit, implant stability quotient (ISQ) values were recorded by means of resonance frequency analysis, and soft tissue status was evaluated according to Holgers’ classification. ISQ trends, implant survival, and soft tissue reactions were compared to a population of 52 patients with the same type of implants loaded from 6 weeks post-surgery as part of another study. Subjective benefit was measured by means of the Glasgow Benefit Inventory (GBI). After an initial dip in ISQ at 10 days after implantation, a gradually increasing trend in ISQ was found until 6 months in both populations, after which ISQ values remained above baseline values. Implant survival was 97 % in the study population and 96 % in the comparison population. Clinically relevant soft tissue reactions were found in 0.9 % (study population) and 1.7 % (comparison population) of all visits. Patients reported subjective benefit; the mean GBI score was 22.8. In conclusion, loading these implants at 3 weeks post-surgery is safe based on the current study, as long-term results show high ISQ values and good implant survival and tolerability.

Phase II trial of epidermal growth factor ointment for patients with Erlotinib-related skin effects

PURPOSE

The efficacy of erlotinib, the epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor, has been demonstrated in patients with non-small cell lung cancer (NSCLC) and pancreatic cancer (PC). In the present study, we evaluated the effect of epidermal growth factor (EGF) ointment on erlotinib-related skin effects (ERSEs).

METHODS

This was an open-label, non-comparative, multicenter, phase II trial. The patients included those diagnosed with NSCLC or PC who were treated with erlotinib. The effectiveness of the ointment was defined as follows: (1) grade 2, 3, or 4 ERSEs downgraded to ≤ grade 1 or (2) grade 3 or 4 ERSEs downgraded to grade 2 and persisted for at least 2 weeks.

RESULTS

Fifty-two patients from seven institutes in Korea were enrolled with informed consent. The final assessment included 46 patients (30 males, 16 females). According to the definition of effectiveness, the EGF ointment was effective in 36 (69.2%) intention to treat patients. There were no statistically significant differences in the effectiveness of the EGF ointment by gender (p = 0.465), age (p = 0.547), tumor type (p = 0.085), erlotinib dosage (p = 0.117), and number of prior chemotherapy sessions (p = 0.547). The grading for the average National Cancer Institute's Common Terminology Criteria for Adverse Events (NCI-CTCAE) rating of rash/acne and itching improved from 2.02 ± 0.83 to 1.13 ± 0.89 and 1.52 ± 0.84 to 0.67 ± 0.90, respectively (p < 0.001). The most common reason for discontinuing the study was progression of cancer (37%).

CONCLUSIONS

Based on the results, the EGF ointment is effective for ERSEs, regardless of gender, age, type of tumor, and dosage of erlotinib. The EGF ointment evenly improved all kinds of symptoms of ERSEs.

CLINICAL TRIAL REGISTRATION NO

ClinicalTrials.gov identifier: NCT01593995.

Necrotizing skin lesion and radial nerve palsy in a patient treated with glatiramer acetate

Glatiramer acetate (GA) is an approved and well tolerated drug for the treatment of relapsing-remitting multiple sclerosis. We report a case of a 52 year-old man with psoriasis and relapsing-remitting multiple sclerosis who developed, after 21 months of GA treatment, an injection-site cutaneous necrosis that involved both subcutaneous and muscular tissue with massive edema, followed, 3 days later, by radial nerve palsy. After few days another similar lesion appeared in another injection-site. We hypothesize that cutaneous necrosis could be due to a local dis-immune reaction and, probably, psoriasis could have played an important role in its pathogenesis.

Significant dermatological side effects of intravenous immunoglobulin

Intravenous immunoglobulin (IVIg) is an essential treatment for many neurological, immunological and haematological conditions. However, the severity of its rare adverse effects is often underrecognised. We report a series of 15 patients receiving IVIg for neurological and immunological disorders who developed severe skin reactions. Despite pre-medication, nearly all patients ceased IVIg due to the severity of the adverse response. Interestingly, the majority of patients were male and two-thirds were receiving treatment for chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) or another inflammatory or demyelinating neuropathy. This marked propensity for male patients with CIDP to develop significant dermatological reactions following IVIg administration has not previously been described. Mechanisms involving the underlying autoimmunity inherent to this condition may play a role.

Antiepileptic drug-related adverse reactions and factors influencing these reactions

OBJECTIVE

According to the basic role of drug side effects in selection of an appropriate drug, patient compliance and the quality of life in epileptic patients, and forasmuch as new drugs with unknown side effect have been introduced, necessity of this research is explained. This study was conducted to evaluate the incidence and clinical characteristics of anti epileptic drug (AED) related adverse reactions in children.

MATERIAL & METHODS

In this descriptive study, children less than 14 years old with AED side effects referred to the Children's Medical Center and Mofid Childeren's Hospital (Tehran, Iran) were evaluated during 2010-2012. The informations were: sex, age, incriminating drug, type of drug side effect, incubation period, history of drug usage, and patient and family allergy history. Exclusive criterions were age more than 14 years old and reactions due to reasons other than AEDs.

RESULTS

A total of 70 patients with AED reaction were enrolled in this study. They included 26 (37%) females and 44 (63%) males. The maximum rate of incidence was seen at age less than 5 years old. All the patients had cutaneous eruptions that the most common cutaneous drug eruption was maculopapular rash. The most common culprit was phenobarbital (70%) and the least common was lamotrigine (1.4%).

CONCLUSION

In this study, we found higher rates of drug rash in patients treated with aromatic AEDs and lower rates with non-aromatic AEDs. Various endogenous and environmental factors may influence the propensity to develop these reactions.