Severe reaction to 5% imiquimod cream with excellent clinical and cosmetic outcomes.

Imiquimod, an immune response modifier approved for the treatment of external genital warts, actinic keratoses, and superficial basal cell carcinoma, can induce a severe local inflammatory response. This phenomenon can accompany inappropriately overzealous, as well as entirely conventional, drug utilization. Despite strikingly brisk reactions, the 9 patients reported herein ultimately experienced excellent cosmetic and clinical outcomes. We report this series to alert clinicians of the good prognosis for a satisfactory outcome even when faced with extreme imiquimod cream-induced inflammation.

Diagnosis, staging, and monitoring of cutaneous T-cell lymphoma.

Cutaneous T-cell lymphoma includes mycosis fungoides and its leukemic variant, the Sézary syndrome. This review discusses the clinical, histopathologic, immunophenotypic and immunogenotypic features of cutaneous T-cell lymphoma as they apply to the diagnosis, staging and monitoring of this disease.

Clotrimazole/betamethasone diproprionate: a review of costs and complications in the treatment of common cutaneous fungal infections.

The use of antifungal/corticosteroid combinations as topical therapy for dermatophytoses has been criticized as being less effective, more expensive, and the cause of more adverse cutaneous reactions than antifungal monotherapy. The combination of clotrimazole and betamethasone diproprionate (Lotrisone) is a mix of an azole antifungal and a high-potency corticosteroid, and is one of the most widely prescribed of these combinations. Our objective was to describe the beneficial and deleterious effects of Lotrisone in the treatment of common cutaneous fungal infections and its relative cost-effectiveness. We did a literature review documenting clinical trial data and adverse reactions to Lotrisone and collected a cost analysis of topical antifungal prescribing data over a 2-month period from a large midwestern staff-model health maintenance organization (HMO). Lotrisone is approved by the U.S. Food and Drug Administration (FDA) for the treatment of tinea pedis, tinea cruris, and tinea corporis in adults and children more than 12 years of age. Treatment is limited to 2 weeks in the groin area and 4 weeks on the feet. The most concerning adverse effects of Lotrisone were reported in children and included treatment failure, striae distensae, hirsuitism, and growth retardation. This combination was also reported to have decreased efficacy in clearing candidal and Trichophyton infections as compared to single-agent antifungals. Lotrisone was considerably more expensive than clotrimazole alone and was found to account for more than 50% of topical antifungal expenditures as prescribed by primary care physicians, but only 7% of topical antifungals prescribed by dermatologists. We found that Lotrisone was shown to have the potential to induce many steroid-related side effects and to be less cost effective than antifungal monotherapy. This combination should be used judiciously in the treatment of cutaneous fungal infections and may not be appropriate for use in children.

Clinicopathologic characterization of squamous-cell carcinoma arising from pilonidal disease in association with condylomata acuminatum in HIV-infected patients: report of two cases.

Pilonidal disease is a common acquired condition believed to arise from penetration of short hairs into the subcutaneous tissue that induces a cyst or sinus formation. Malignant degeneration is rare and is typically seen only after decades of antecedent disease presence. Condylomata acuminatum in association with pilonidal disease have been described in two prior case reports, however, the coexistence of condyloma with pilonidal disease complicated by malignant degeneration has not been previously reported. Condylomata have known potential for malignant degeneration and are correlated with human papilloma virus infection, with certain serotypes of higher oncogenic potential. Coinfection with human immunodeficiency virus and human papilloma virus is associated with higher rates of anal neoplasia. We report two cases of human immunodeficiency virus-infected patients with the constellation of pilonidal disease, condylomata acuminatum, and subsequent malignant degeneration into squamous-cell carcinoma. In contrast to other case reports in the literature, these two patients had considerably shorter antecedent periods of pilonidal disease before malignant degeneration was detected. Both cases also had intractable courses. We conclude that the existence of condylomata acuminatum and pilonidal disease in an immunocompromised patient may represent a more ominous condition than solitary pilonidal disease. Therefore, careful inspection of the pilonidal area in human immunodeficiency virus-infected patients presenting with condylomata is important and earlier intervention should be considered. Moreover, further evaluation of the prevalence of squamous-cell carcinoma arising from pilonidal disease complicated by condylomata, particularly in the immunosuppressed, is warranted.

Men assigned to ethylene oxide production or other ethylene oxide related chemical manufacturing: a mortality study.

A retrospective cohort study was conducted to examine the mortality experience of 2174 men employed between 1940 and 1978 by a large chemical company and who had been assigned to a chemical production department that used or produced ethylene oxide (EO). Comparisons were made with the general United States population, the regional population, and with a group of 26,965 unexposed men from the same plants. Comparisons with general United States death rates showed fewer deaths than expected in the EO group due to all causes and for total cancers. There was no statistically significant excess of deaths due to any cause. Seven deaths each due to leukaemia and pancreatic cancer were observed with 3.0 and 4.1 deaths expected. Among the subcohort of men who worked where both average and peak exposure levels were probably highest, however, one death due to pancreatic cancer (0.9 expected) and no deaths due to leukaemia were observed. Four of the seven who died from leukaemia and six of the seven who died from pancreatic cancer had been assigned to the chlorohydrin department where the potential for exposure to EO is judged to have been low. The relative risk of death due to each disease was strongly related to duration of assignments to that department. When men who worked in the chlorohydrin department were excluded, there was no evidence for an association of exposure to EO with pancreatic cancer or leukaemia. Together with the failure to show independent EO associations, the chlorohydrin department results suggest that leukaemia and pancreatic cancer may have been associated primarily with production of ethylene chlorohydrin or propylene chlorohydrin, or both. These results emphasise the importance of examining additional concurrent/asynchronous exposures among human populations exposed to EO.

Assessment of exposure to chemicals in a complex work environment.

Exposure information was evaluated for two large chemical manufacturing facilities and a research and development center in support of occupational health studies of employees assigned to these facilities. Methodology and rationale underlying the exposure categorization are provided, and descriptive exposure statistics are presented for a sample of 774 employees. Analysis of work patterns and exposure profiles revealed that 1) employee transfers among various production work areas did not follow a predictable pattern, 2) over 41% of the chemicals identified were present in multiple work areas, and 3) individuals exposed to one chemical of toxicologic interest were also likely to be exposed to other similarly toxic materials. The use of both work area and chemical-specific exposure measures is recommended, as each may be helpful in addressing etiologic questions regarding complex work environments.

Lymphatic and hematopoietic tissue cancer in a chemical manufacturing environment.

Nested case-control studies of non-Hodgkin's lymphoma (52 cases), multiple myeloma (20 cases), nonlymphocytic leukemia (39 cases), and lymphocytic leukemia (18 cases) were conducted within a cohort of employed men from two chemical manufacturing facilities and a research and development center. Exposure odds ratios were examined in relation to 111 work areas, 21 specific chemicals, and 52 chemical activity groups. Associations were observed for a maintenance and construction subgroup (non-Hodgkin's lymphoma) and a chlorohydrin production unit (nonlymphocytic leukemia). The odds ratio for the association of "foremen and others" with non-Hodgkin's lymphoma was 3.2 (CI95 = 1.47-7.2) based on 11 cases. A duration-response trend was observed for the chlorohydrin unit with three of four cases assigned 5+ years to that unit. An association between non-Hodgkin's lymphoma and assignment to strong acid alcohol production units (OR = 8.3; CI95 = 2.3-30.7) was not supported by a duration-response trend. Two highly correlated chemical groups, antioxidants (five cases) and nitriles (four cases), were over-represented among multiple myeloma cases. A duration effect was observed. However, examination of work histories did not reveal common jobs or departments among these cases.

Pigmentosis tubae, a new entity: light and electron microscopic study.

The authors noted an unusual finding in the fallopian tubes of a 31-year-old woman who had received external and internal whole pelvis radiotherapy for squamous cell carcinoma of the cervix. Aggregates of macrophages containing pigment, identified in a subepithelial location, were reminiscent of melanosis coli, which is caused by abuse of anthracene-containing laxatives. Electron microscopic examination of the pigment revealed cytoplasmic material with the appearance of lipofuscin, identical to the pigment described in cases of colonic melanosis. After a careful study of possible etiologic agents, it was concluded that the pigment most likely resulted from cellular damage caused by radiotherapy. The authors are not aware of any other reported case of this entity, which will be called pigmentosis tubae.