Cefpodoxime proxetil in the treatment of skin and soft tissue infections.

Patients with skin and soft tissue infections were enrolled in a study comparing 2 dosage regimens of orally administered cefpodoxime proxetil; 204 patients with mild to moderate infections received cefpodoxime proxetil 200mg twice daily and 47 patients with severe infections received 400mg twice daily. Both dosage regimens were given for 7 to 14 days. 132 of 142 (93.0%) evaluable patients in the 200mg group and 22 of 29 (75.9%) in the 400mg group were clinically cured post-therapy, the remainder in both groups being classified as improved. The pathogen eradication rate at the end of therapy in the 200mg group was 161 of 165 (97.6%), and 38 of 38 (100%) in the 400mg group. Adverse reactions (drug-related) were reported by 20 (8.0%) patients overall, and there was no apparent relationship between the dosage group and the incidence of adverse reactions. The most commonly reported reactions involved the gastrointestinal tract (diarrhoea) or female genital tract (vaginitis). Cefpodoxime proxetil appears to be a useful and safe agent in the therapy of skin and soft tissue infections.

24-Hour plasma secretin level and pancreatic secretion in dog.

Plasma secretin concentrations were determined and duodenal pH was recorded continuously for a period of 24 hours after ingestion of a meal in 3 dogs with gastric cannula and duodenal cannula and in 4 dogs with pancratic fistulae. The mean plasma secretin concentration increased significantly after a meal and it remained elevated for the first 12-hour period (peak at 30 min). Duodenal pH frequently decreased below 4.5 during the first 12-hour postprandial period, but it remained above 5.0 during the second 12 hours. Pancreatic secretion peaked during the first hour of meal ingestion and remained elevated until the end of 12 hours. The increased plasma secretin level in pancreatic fistula dog during the postprandial period was significantly greater than that of duodenal cannula dog, but the trends of increase in the secretin levels were quite identical. The present study indicates that: (1) plasma secretin concentration increases significantly within 30 min after a meal and remains increased during the first 12-hour period, (2) duodenal pH frequently decreaded below 4.5 during the same 12 hours but more frequently during the first 6 hours, and (3) a significant increase in pancreatic water, HC03- and protein occurred during the same time period.

A randomized vehicle-controlled trial of topical capsaicin in the treatment of postherpetic neuralgia.

A large double-blind, vehicle-controlled study of 143 patients with chronic postherpetic neuralgia (PHN) was performed to evaluate the degree of efficacy of topically applied capsaicin 0.075% cream. In addition, the safety and efficacy of long-term application of topical capsaicin in PHN was assessed by following patients in an open-label study for up to 2 years. In the double-blind phase, 143 patients with PHN of 6 months' duration or longer were enrolled. Since epidemiologic studies of patients who receive no treatment have shown that only 10% to 25% of those with PHN after 1 month will still have pain at 1 year, two separate efficacy analyses were performed: one with all evaluable patients (n = 131) and the other with 93 patients whose PHN lasted for longer than 12 months prior to study startup. All efficacy variables, including the physician's global evaluation of reduction in PHN pain, changes in pain severity on the categoric scale, visual analogue scale for pain severity, visual analogue scale for pain relief, and functional capacity scale, showed significant improvement at nearly all time points throughout the study for both patient groups, based on duration of PHN pain. In contrast, the group receiving vehicle cream remained essentially unchanged. Data from the long-term, open-label phase (up to 2 years, n = 77), which immediately followed the 6-week blinded phase, showed that the clinical benefit in patients treated for a short (6-week) period with topical capsaicin could be maintained or amplified in most patients (86%) during prolonged therapy. There were no serious adverse effects observed or reported throughout the trial; in fact, the only side effect associated with capsaicin treatment was the burning or stinging at local sites of application (in 9% of patients) during exposures of up to 2 years (long-term phase). On the basis of these data, we conclude that capsaicin 0.075% cream is a safe and effective treatment for the pain of postherpetic neuralgia and should be considered for initial management of patients with this condition.

The antipruritic effect of 5% doxepin cream in patients with eczematous dermatitis. Doxepin Study Group.

BACKGROUND AND DESIGN: Eczematous dermatitis is commonly characterized by intense pruritus. Current treatment modalities for this condition, regardless of its cause, are primarily directed at blunting the cutaneous inflammatory response and thereby providing relief of pruritus. To expand on our previous findings in atopic dermatitis, the present multicenter double-blind trial was conducted to evaluate the safety and antipruritic efficacy of 5% doxepin hydrochloride cream in patients with lichen simplex chronicus (n = 136), nummular eczema (n = 87), or contact dermatitis (n = 86). A total of 309 patients with moderate to severe pruritus were randomly assigned to apply either doxepin cream (n = 154) or vehicle cream (n = 155) to eczematous areas four times per day for a period of 7 days. Efficacy was assessed using a pruritus severity rating scale, a Physician's Global Evaluation for pruritus relief, and a Visual Analogue Scale for pruritus relief. RESULTS: Twenty-four hours after initiation of treatment, and continuing throughout the remainder of the study, patients treated with doxepin cream experienced significantly greater pruritus relief than did vehicle-treated patients as determined by all efficacy parameters (P < .002). Sixty percent of doxepin-treated patients experienced pruritus relief within 24 hours. The response rate increased to 84% by conclusion of the study. As judged by significant changes (P < or = .05) occurring in at least one assessment of efficacy, doxepin cream provided pruritus relief in all forms of eczematous dermatitis that were examined. The study medication was well tolerated. The two most common adverse effects, stinging at the site of application and drowsiness, were usually transient and mild to moderate in severity. CONCLUSION: Topical application of doxepin provides significant antipruritic activity with a favorable safety profile, suggesting a role for doxepin cream in the symptomatic treatment of pruritus associated with eczematous dermatitis.

Epithelioid sarcoma. Report of a case.

Epithelioid sarcoma is familiar to orthopedic surgeons but not to dermatologists. Because this malignant neoplasm presents as a subcutaneous mass, often with overlying epidermal changes, the patient may be seen by a dermatologist for evaluation. The differential diagnosis often includes nodular fasciitis and tenosynovitis. The histopathologic interpretation of the biopsy specimen may be difficult, so it is helpful for the physician to suspect and consider epithelioid sarcoma in the differential diagnosis given to the pathologist. Early, accurate diagnosis can be achieved and can thus spare the patient significant morbidity or even death.

Human absorption of crude coal tar products.

Five normal adult volunteers without cutaneous disease applied 2% crude coal tar to the skin for eight-hour periods on two consecutive days. Blood extracts subjected to gas chromatography and mass spectrometry yielded evidence of absorption in all five volunteers. Phenanthrene, anthracene, pyrene, and fluoranthene, found in four of our volunteers, have been shown to be tumor initiators or cocarcinogens.

Topical metronidazole maintains remissions of rosacea.

BACKGROUND: Rosacea is a chronic skin disease that requires long-term therapy. Oral antibiotics and topical metronidazole successfully treat rosacea. Because long-term use of systemic antibiotics carries risks for systemic complications and adverse reactions, topical treatments are preferred. OBJECTIVE: To determine if the use of topical metronidazole gel (Metrogel) could prevent relapse of moderate to severe rosacea. DESIGN: A combination of oral tetracycline and topical metronidazole gel was used to treat 113 subjects with rosacea (open portion of the study). Successfully treated subjects (n = 88) entered a randomized, double-blind, placebo-controlled study applying either 0.75% topical metronidazole gel (active agent) or topical metronidazole vehicle gel (placebo) twice daily (blinded portion of the study). SETTING: Subjects were enrolled at 6 separate sites in large cities at sites associated with major medical centers. SUBJECTS: One hundred thirteen subjects with at least 6 inflammatory papules and pustules, moderate to severe facial erythema and telangiectasia entered the open phase of the study. Eighty-eight subjects responded to treatment with systemic tetracycline and topical metronidazole gel as measured by at least a 70% reduction in the number of inflammatory lesions. These subjects were randomized to receive 1 of 2 treatments: either 0.75% metronidazole gel or placebo gel. INTERVENTIONS: Subjects were evaluated monthly for up to 6 months to determine relapse rates. MAIN OUTCOME MEASURES: Inflammatory papules and pustules were counted at each visit. Relapse was determined by the appearance of a clinically significant increase in the number of papules and pustules. Prominence of telangiectases and dryness (roughness and scaling) were also observed. RESULTS: In the open phase, treatment with tetracycline and metronidazole gel eliminated all papules and pustules in 67 subjects (59%). The faces of 104 subjects (92%) displayed fewer papules and pustules after treatment, and 82 subjects (73%) exhibited less erythema. In the randomized double-blind phase, the use of topical metronidazole significantly prolonged the disease-free interval and minimized recurrence compared with subjects treated with the vehicle. Eighteen (42%) of 43 subjects applying the vehicle experienced relapse, compared with 9 (23%) of 39 subjects applying metronidazole gel (P<.05). The metronidazole group had fewer papules and/or pustules after 6 months of treatment (P<.01). Relapse of erythema also occurred less often in subjects treated with metronidazole (74% vs 55%). CONCLUSION: In a majority of subjects studied, continued treatment with metronidazole gel alone maintains remission of moderate to severe rosacea induced by treatment with oral tetracycline and topical metronidazole gel.

Immunophenotyping as a diagnostic tool to differentiate lichen planus from chronic graft-versus-host disease: diagnostic observations on two patients.

BACKGROUND: Lichen planus (LP) and the lichenoid variant of chronic graft-versus-host disease (cGVHD) can present with similar clinical and histological findings. The distinction, although difficult, is important both prognostically and therapeutically. The mechanism and effector cell phenotypes have also shown to differ between the 2 entities. While the lichenoid infiltrate of LP is predominantly T lymphocytes helper/inducer cell phenotype, the suppressor/cytotoxic subset appears to play a major role in cGVHD. The aim of this study is to determine whether the immunophenotypic character of the lichenoid infiltrate can aid in distinguishing the 2 entities. METHODS: Biopsies were obtained from 2 patients with lichenoid papules and a history of transplantation. Light microscopy revealed lichenoid inflammation in both cases characterized by a band-like lymphohistiocytic infiltrate at the dermal-epidermal junction. Immunochemistry was performed on fresh tissue using a panel of monoclonal antibodies including anti-CD1a, CD3, CD4, CD8, CD16, CD20, CD28, and CD68. Results were quantitated using computer-assisted image analysis. RESULTS: We found that in both cases the majority of cells stained with pan T cell marker CD3+. One case demonstrated predominantly CD4+ T cells and increased numbers of CD1a positive Langerhans cells, while the lymphokine natural killer cell activity (LAK) markers anti-CD16 and anti-CD28 were largely nonreactive. Conversely, the second case contained predominately CD8+ lymphocytes and very few CD1a positive Langerhans cells with abundant LAK cell anti-CD16 and anti-CD28 reactivity. CONCLUSIONS: Based on these findings, the former was classified as lichen planus and the latter as lichenoid cGVHD. The diagnoses are substantiated with clinical history and follow-up information. We conclude that immunophenotypic characteristics of the infiltrate can be a useful tool in differentiating lichenoid cGVHD from lichen planus.

Dermatologic diseases of eastern Africa.

The countries of eastern Africa are deprived of the most basic of care for their skin disease. Diagnostic tools and treatment modalities that are commonplace in developed countries are at a bare minimum in these third world nations. In addition, there is a dearth of trained dermatologic specialists, especially in the arid areas of Kenya and Tanzania. The International Foundation for Dermatology was founded in 1987 in an attempt to address this vacuity in medical care. During the last 6 years, they have launched a campaign concentrated on the activation of Regional Training Centers in Africa, where students will enter a 2-year training program and graduate with the title of "Dermatology Officer" possessing those skills required to treat 80% of common skin diseases. It is hoped that this will lead to an increased awareness of skin pathology in general and the specific need for trained specialists in underserved areas. However, a lack of health care specialists is only part of the problem. Better nutrition, clean water, and the education of tribal communities are impending future goals, difficult to attain in a nation burdened with economic and political strife.

Deep fungal infections in the tropics.

Although tropical deep fungal infections are uncommonly identified in North America, these disorders are a diagnostic and therapeutic challenge to the clinician. Presented in this article is information on the management of patients suffering from mycetoma, chromomycosis, African histoplasmosis, or keloidal blastomycosis.

Myiasis.

Myiasis is not an uncommon parasitic infestation in the tropics and subtropics, and with the increase in international travel, cases also are encountered outside the endemic regions in both Europe and North America. This article reviews the ecology, classification, pathophysiology, pathology, and treatment of myiasis.

Superficial fungal infections in the tropics.

Cutaneous dermatophyte infections are limited to the superficial layers of the epidermis. Tropical and subtropical regions of the world provide warm and humid climates and therefore a favorable environment for organisms causing superficial dermatophyte infections. This article deals with cutaneous dermatophyte infections, with particular emphasis on those occurring in tropical regions of the world. History, causative organisms, diagnosis, and treatment are discussed.

Case report: myiasis--the botfly boil.

Cutaneous furunculoid myiasis arises from the infestation of skin or mucous membranes with dipterous larvae. Myiasis from the botfly Dermatobia hominis is a common parasitic disease of the tropics of Central and South America, and may present in the United States. With increasing travel by U.S. citizens, there is potential for increased occurrence; it is important to be able to accurately diagnose myiasis and differentiate it from entities with similar presentations, such as leishmaniasis. The authors describe four cases of myiasis from D. hominis infestation and review clinical features, differential diagnosis, and treatment.

Anecdotal therapies.

Traditionally, many advances in medicine have been serendipitous. Are serendipitous and anecdotal synonymous? Many of our materia medica today relate to initial probes and anecdotal reports that matured to full investigation and therapeutic indications. The recent situation regarding Skin Cap is one that highlights the downside of this scenario. Several drugs in the US continue usage largely related to anecdotal indications, and anecdotal extension of legend indications is a standard for American Dermatology. The situation with systemic drugs, such as Trental, zinc preparations, imidazoles for extended indications, lysine and melatonin, all will be discussed. Topical preparations such as skin cap, cantharone, Vioform, all also are included in this category. It is important to place this topic in perspective in regards to geographic variation and therapeutic need. Many diseases lacking specific therapy are important targets for anecdotal therapy, and this will foster continued approaches in this area. The growing standardization of medicine and pharmaceutical regulation, threatens the anecdotal approach, but it provides still an important link to the future for some forms of therapy in diseases that are difficult to treat. Traditionally, the anecdote has been the first step in the therapeutic chain. Withering discovery of the benefits of the common fox glove in dropsy, was followed by many other anecdotes arriving via folk-medicine in the New World. This approach of utilizing folk medicine has now reached new heights, with very active searches by major pharmaceutical companies throughout the third world for remedies that may have potential. Couched with this is the history of anecdotal "snake-oil" remedies, that clearly had no benefit to anyone except the huckster marketing same. The excesses in this area of unproven and false therapies, led to the gradual organization of therapeutic trials and the Food and Drug Administration in the US as we know it today. The biggest shot in the arm for enhancing FDA protocols was the thalidomide situation, an outgrowth of an ethically studied and used medication that perhaps had been released too soon, prior to sufficient trials to determine the total patient risk. As in many situations, the pendulum swings in both directions, and after thalidomide, the acceptance of new treatments required more and more rigorous studies, and studies from other countries often were not acceptable unless a small part of a larger, whole proposal. The AIDS crisis has prompted a swing back, away from such expensive and rigorous pre-marketing review, to more expedited processes for the relief of patients with this fatal disease. This has streamlined the FDA, and hopefully the swing of the pendulum will not go too far, to result in problems in the future. Anecdotal therapies and medications are the first step in many parts of the world to therapeutic trials. The most widely used aspects of anecdotal therapies, again, remains in the situation with diseases without good therapies at the present time. The so-called orphan drugs and orphan diseases, while a serious medical problem, do not present a significant volume for effective drug screening in many instances, and the FDA has developed some new approaches to circumvent this very expensive development process for patients suffering from these rare and unusual disorders. The most recent example of anecdotal therapy catching the public fancy in dermatology was the Skin-Cap Spray. This product, over the period of twelve months, got rave reviews in the lay press in the non-peer reviewed dermatologic periodicals, and amassed impressive sales figures in this period of time. It was extremely effective, and most dermatologists who used it have patients who consider it the most effective therapy in the last year. The formulation of a low concentration of zinc pyrithione seemed unusual, and this truly was an anecdotal approach, using a homeopathic dosage of a commonly used p

Treatment of gonococcal infections with a single 250 mg intramuscular injection of trospectomycin sulphate vs ceftriaxone sodium.

Trospectomycin sulphate is a new, more potent analog of spectinomycin, which is active in vitro against penicillin-sensitive and penicillin-resistant strains of Neisseria gonorrhoeae. This study was designed to determine the bacteriologic and clinical efficacy as well as safety of a single intramuscularly administered 250 mg dose of trospectomycin sulphate in the treatment of uncomplicated gonorrhoea (cervical, urethral, pharyngeal and anal). Ceftriaxone sodium was used as a comparator antibiotic in a single 250 mg intramuscular dose. Seventy-four patients (36 women and 38 men) were evaluable in the trospectomycin treated group and 40 patients (22 women and 18 men) in the ceftriaxone treated group. The overall bacteriologic cure rate was 98.6% (73/74) for trospectomycin and 95% (38/40) for ceftriaxone. Bacteriologic failures were observed among women 1/36 (2.8%) treated with trospectomycin and 2/22 (9.1%) treated with ceftriaxone. The overall clinical success rate (clinically cured plus clinically improved) was 90.5% for trospectomycin and 100% for ceftriaxone. Adverse events were reported rarely in both groups. Less than 10% of patients complained of pain and/or tenderness at the injection site for both drugs; one patient developed a generalized, pruritic rash which occurred three days after administration of trospectomycin and resolved within six days. In conclusion, a single dose of 250 mg i.m. trospectomycin appears to be at least as effective and safe as a single dose of ceftriaxone in the treatment of uncomplicated gonorrhoea.

Role of oral antifungal agents for the treatment of superficial fungal infections in immunocompromised patients.

Superficial fungal infections or tinea infections (also known as the dermatophytoses) are commonly encountered conditions in clinical practice, affecting the skin, hair, and nails. The most commonly prescribed modality to treat these infections is topical antifungal therapy. However, this method of treating tinea infections may be less convenient and efficacious in the immunocompromised patient. In such patients, skin infections are more difficult to treat because the disease is often more extensive and severe. Tinea infections of the hair and nails usually require oral therapy. Further, topical treatment is not as efficacious as oral antifungal therapy and, with the exception of the topical antifungal agent ciclopirox, is not indicated for the treatment of tinea unguium (onychomycosis). The 2 most frequently prescribed oral antifungal agents to treat onychomycosis are itraconazole and terbinafine. In the general population, both agents are effective in treating fungal nail infections; however, differences in the agents' mechanism of action and metabolic pathways result in differences in efficacy and drug-drug interaction potential. However, limited data exist on the use of these agents in immunocompromised patients for the treatment of onychomycosis and superficial tinea infections. The available efficacy data we have are limited to case reports or small pilot studies; thus, data supporting the efficacy of these agents for the treatment of tinea infections in the immunocompromised patient must be extrapolated from the general population. For safety issues, however, some postmarketing data exist supporting the safety of these agents in the diabetic and human immunodeficiency virus (HIV) patients populations; indeed, both agents appear to be safe. However, one contrasting point between these 2 agents is drug interactions. Oral terbinafine, unlike itraconazole (a potent cytochrome P-450 [CYP] 3A4 inhibitor), has a relatively low potential for drug-drug interactions, making terbinafine a useful agent for the treatment of tinea infections in immunocompromised patients (e.g., those who are HIV positive and those with diabetes), who are likely to be receiving concomitant medications. Further, recently conducted studies of terbinafine for the treatment of tinea pedis, tinea cruris, and tinea corporis infections in these high-risk patient groups also support efficacy claims and reemphasize its relatively safe profile and low potential for drug interactions. Additional studies in other immunocompromised patient populations may be useful to confirm recent studies and expand the potential use for this agent.

Use of Buf-Puf and benzoyl peroxide in the treatment of acne.

forty-eight acne patients added Buf-Puf epidermabrasion on one side of their faces to underlying bilateral treatment with benzoyl peroxide (BPO) in a 12-week study. This study included acne patients with grades II to IV (Pillsbury classification), but no patients with nodulocystic involvement. Significant clinical improvement was seen in those who used BPO alone or in combination with Buf-Puf; however, the magnitude and importance of improvement of each lesion type with the latter regimen was much greater. We conclude that Buf-Puf epidermabrasion is an effective and safe adjunct to overall management of mild to severe acne vulgaris.

Cutaneous vasculitis.

Cutaneous vasculitis is a common but confusing clinical syndrome. We report three illustrative cases demonstrating the variable nature of the process. Renal disease is generally a poor prognostic sign; therefore, the renal status should be evaluated early. The process probably represents an immune complex disorder. Although various therapies have been used, an aggressive corticosteroid regimen is the preferred mode of treatment at the current time.

Treatment of tinea pedis with econazole nitrate cream.

This study investigated the clinical effectiveness and the long-term relapse rate of the topical imidazole, econazole nitrate, in the treatment of tinea pedis. Econazole nitrate cream was applied by twenty-two patients with tinea pedis for twenty-eight consecutive days. Therapy was then discontinued and patients were evaluated to determine the long-term relapse rate. Nineteen (86 percent) of the twenty-two patients were considered cured at the end of twenty-eight days of treatment. At the follow-up examinations, 74 percent of the group considered to be clinically cured at the end of therapy remained clear for one month, 84 percent for two months, and 63 percent for three months after stopping active treatment. These data demonstrate that econazole nitrate is a highly effective topical agent in the treatment of tinea pedis and that clinical and mycologic cures in almost two thirds of the patients last for at least three months.

Topical metronidazole for severe and recalcitrant rosacea: a prospective open trial.

Nineteen patients with severe or recalcitrant rosacea were treated twice daily with 0.75 percent metronidazole topical gel in an open label study. Sixteen of the patients (84 percent) showed 50 percent or greater reduction in inflammatory lesions, while fifteen (79 percent) demonstrated a reduction in erythema severity and an improvement when evaluated by the investigator global assessment. No positive response was recorded for any patient prior to topical medication, whereas six of nine patients previously treated with tetracycline/minocycline demonstrated improvement. Seven of these nine patients responded to topical metronidazole treatment. One additional patient who did not respond to minocycline or desonide treatment showed a good response to topical metronidazole. Only one patient reported local irritation after using metronidazole. These results demonstrate that topical metronidazole gel is safe and effective for the treatment of severe or recalcitrant rosacea.