Benign familial pemphigus (Hailey-Hailey disease). Treatment with the pulsed carbon dioxide laser.

BACKGROUND: Benign familial pemphigus (BFP) is a chronic blistering disease with significant morbidity. Surgical methods are often needed to control flares in difficult cases. OBJECTIVE: To describe the response of BFP to vaporization with a pulsed carbon dioxide (CO2) laser. METHODS: A 38-year-old woman with chest and axillary involvement unresponsive to conventional therapy was treated with the UltraPulse 5000 Laser (Coherent Medical Group, Palo Alto, CA). After active sites of BFP showed good response to treatment, we treated uninvolved skin of the left axilla to assess the efficacy of prophylactic therapy. RESULTS: Treatment of affected areas, except biopsy sites, resulted in clearing of active lesions after 1-2 weeks. We noted striking sparing of the treated areas from developing subsequent disease. The region that was later treated prophylactically has shown minor, asymptomatic recurrence of BFP in less than 5% of the area treated over an 18-month follow-up period. CONCLUSION: The pulsed carbon dioxide laser is a useful modality in treatment of BFP. In our patient, prophylactic treatment led to near complete eradication of disease in the treated area. A controlled, larger study is needed to confirm our results, and to determine optimal laser parameters. Long-term effects and duration of remission remain to be determined.

Once-weekly fluconazole (150, 300, or 450 mg) in the treatment of distal subungual onychomycosis of the toenail.

BACKGROUND: Onychomycosis is a prevalent infection of the nail caused primarily by dermatophytes. Fluconazole is active in vitro against the most common pathogens of onychomycosis, penetrates into the nail bed, and is clinically effective in the treatment of a wide variety of superficial fungal infections. OBJECTIVE: The purpose of this study was to compare the efficacy and safety of three different doses of fluconazole (150, 300, and 450 mg) given orally once weekly to that of placebo in the treatment of distal subungual onychomycosis of the toenail caused by dermatophytes. METHODS: In this multicenter, double-blind study, 362 patients with mycologically confirmed onychomycosis were randomized to treatment with fluconazole, 150, 300, or 450 mg once weekly, or placebo once weekly for a maximum of 12 months. To enter the study, patients were required to have at least 25% involvement of the target nail with at least 2 mm of healthy nail from the nail fold to the proximal onychomycotic border. Patients who were clinically cured or improved at the end of treatment were further evaluated over a 6 month follow-up period. At both the end of therapy and the end of follow-up, clinical success of the target nail was defined as reduction of the affected area to less than 25% or cure. RESULTS: At the end of therapy, 86% to 89% of patients in the fluconazole treatment groups were judged clinical successes as defined above compared with 8% of placebo-treated patients. Clinical cure (completely healthy nail) was achieved in 28% to 36% of fluconazole-treated patients compared with 3% of placebo-treated patients. Fluconazole demonstrated mycologic eradication rates of 47% to 62% at the end of therapy compared with 14% for placebo. The rates at the end of follow-up were very similar, indicating that eradication of the dermatophyte was maintained over the 6-month period. All efficacy measures for the fluconazole groups were significantly superior to placebo (p=0.0001); there were no significant differences between the fluconazole groups on these efficacy measures. The clinical relapse rate among cured patients over 6 months of follow-up was low at 4%. Fluconazole was well tolerated at all doses over the 12-month treatment period, with the incidence and severity of adverse events being similar between the fluconazole and placebo treatment groups. Mean time to clinical success in the fluconazole treatment groups was 6 to 7 months. This time frame may be used as a guideline for fluconazole treatment duration. CONCLUSION: The results of this study support the use of fluconazole in the treatment of distal subungual onychomycosis of the toenail caused by dermatophytes. Doses between 150 to 450 mg weekly for 6 months were clinically and mycologically effective as well as safe and well tolerated.

Pharmacokinetics of three doses of once-weekly fluconazole (150, 300, and 450 mg) in distal subungual onychomycosis of the toenail.

BACKGROUND: Preliminary clinical data suggest that fluconazole is effective in the treatment of patients with onychomycosis. To design optimum dosage regimens, a better understanding of fluconazole's distribution into and elimination from nails is needed. OBJECTIVE: The purpose of this study was to determine plasma and toenail concentrations of fluconazole. METHODS: In this multicenter, randomized, double-blind investigation, fluconazole (150 mg, 300 mg, or 450 mg) or matching placebo was administered once a week for a maximum of 12 months to patients with onychomycosis of the toenail. A total of 151 subjects participated in the pharmacokinetic assessment. Blood samples and distal toenail clippings from both affected and healthy nails were obtained for fluconazole concentration determinations at baseline, at the 2-week visit, at each monthly visit until the end of treatment, and then at 2, 4, and 6 months (nail samples only at the latter two) after fluconazole was discontinued. RESULTS: Fluconazole was detected in healthy and affected nails at the 2-week assessment in nearly all subjects. The median time to reach steady-state fluconazole concentrations in healthy nails was 4 to 5 months in the three fluconazole dose groups. In affected nails, steady-state fluconazole concentrations were achieved more slowly, with a median time of 6 to 7 months. At the 8-month assessment, affected toenail fluconazole concentrations were higher than corresponding plasma fluconazole concentrations, with ratios of 1.31 to 1.50 in the three active treatment groups. Toenail concentrations of fluconazole declined slowly after treatment was discontinued, with elimination half-lives of 2.5, 2.4, and 3.7 months for the 150, 300, and 450 mg doses, respectively. Measurable fluconazole concentrations were still present in toenails at 6 months after treatment in most subjects. CONCLUSION: Fluconazole penetrates healthy and diseased nails rapidly, yielding detectable concentrations after two weekly doses. Once it penetrates nail, fluconazole persists for up to 6 months or longer after therapy is stopped. These favorable pharmacokinetic characteristics support a once-weekly fluconazole dosage regimen for the treatment of patients with onychomycosis.

Effects of topical erythromycin on ecology of aerobic cutaneous bacterial flora.

We have demonstrated previously that application of topical erythromycin, an antibiotic commonly used for the treatment of acne, results in an increased density of cutaneous erythromycin-resistant (Emr) coagulase-negative staphylococci; however, it is unknown if this increase results in an overall higher density of total cutaneous staphylococci or if upon cessation of erythromycin use, Emr coagulase-negative staphylococci remain at an increased density compared with the pretreatment density. To investigate this, 2% erythromycin or vehicle was applied to each subject's forehead (n = 225) twice a day by laboratory personnel for a period of 6 weeks. Samples were obtained for culture from the forehead, anterior nares, and back of the subjects at baseline and at weeks 6, 9, and 12 of the study. Cultures were performed on differential media. Plates into which erythromycin was incorporated (8 micrograms/ml) were used to identify Emr coagulase-negative staphylococci. The species of all Emr coagulase-negative staphylococci were determined, and an antibiogram for 16 antibiotics was obtained. The baseline prevalence of Emr coagulase-negative staphylococci on the forehead and nose was about 80% at the two study sites, whereas that on the back was 50%. The baseline density of Emr coagulase-negative staphylococci on the forehead, nose, and back was approximately 20% of the total flora. Following 6 weeks of erythromycin treatment, the prevalence of Emr coagulase-negative staphylococci on the forehead and nose was nearly 100% and the densities were 73 and 62%, respectively; the prevalence and density for the back were 78 and 42%, respectively. The most prevalent erythromycin resistance gene expressed by the Emr coagulase-negative staphylococci was ermC. There was no increase in the numbers of Staphylococcus aureus, gram-negative rods, or yeasts, nor was there increased resistance to any other antibiotic except clindamycin. The density of total aerobic organisms also remained static. There were no changes in the prevalence or density of Emr coagulase-negative staphylococci in the vehicle group. A statistically significant decrease in the prevalence and density of Emr coagulase-negative staphylococci in the erythromycin group was observed within 3 weeks posttreatment and by 6 weeks posttreatment, the prevalence and density returned to baseline values. These data demonstrate that the increased prevalence and density of Emr coagulase-negative staphylococci as a result of topical 2% erythromycin use are transient on both population and individual levels.

Adverse drug interactions clinically important for the dermatologist.

BACKGROUND: All physicians, including dermatologists, are at risk for prescribing drugs that interact in a harmful way. Although prescribing a harmful drug combination may have serious consequences, no review has examined the drug-drug combinations that are of greatest concern for dermatologists. Our goal is to review the pharmacologic mechanisms of adverse drug interactions, the risky drugs, and the patients who are most vulnerable. In so doing, we hope to provide guidance through a potential minefield of adverse interactions. OBSERVATIONS: Although there are only sparse epidemiologic data regarding the prevalence or cost of adverse drug interactions in dermatology, the consequences may range from a minor loss of therapeutic effect of an administered agent to a life-threatening toxic reaction. We will review methotrexate, cyclosporin A, antifungal agents, antibiotics, retinoids, and antihistamine interactions with each other and with other systemic medications. CONCLUSIONS: An organized reporting system needs to be developed so that statistically meaningful epidemiologic data can be obtained for adverse drug interactions, such as the Medwatch program recently proposed by the Food and Drug Administration. Such a system will provide valuable data regarding drug combinations that may be dangerous and determine the scope of the problem as a public health issue.

UDP-glucose dehydrogenase from bovine liver: primary structure and relationship to other dehydrogenases.

The primary structure of bovine liver UDP-glucose dehydrogenase (UDPGDH), a hexameric, NAD(+)-linked enzyme, has been determined at the protein level. The 52-kDa subunits are composed of 468 amino acid residues, with a free N-terminus and a Ser/Asn microhetergeneity at one position. The sequence shares 29.6% positional identity with GDP-mannose dehydrogenase from Pseudomonas, confirming a similarity earlier noted between active site peptides. This degree of similarity is comparable to the 31.1% identity vs. the UDPGDH from type A Streptococcus. Database searching also revealed similarities to a hypothetical sequence from Salmonella typhimurium and to "UDP-N-acetyl-mannosaminuronic acid dehydrogenase" from Escherichia coli. Pairwise identities between bovine UDPGDH and each of these sequences were all in the range of approximately 26-34%. Multiple alignment of all 5 sequences indicates common ancestry for these 4-electron-transferring enzymes. There are 27 strictly conserved residues, including a cysteine residue at position 275, earlier identified by chemical modification as the expected catalytic residue of the second half-reaction (conversion of UDP-aldehydoglucose to UDP-glucuronic acid), and 2 lysine residues, at positions 219 and 338, one of which may be the expected catalytic residue for the first half-reaction (conversion of UDP-glucose to UDP-aldehydoglucose). A GXGXXG pattern characteristic of the coenzyme-binding fold is found at positions 11-16, close to the N-terminus as with "short-chain" alcohol dehydrogenases.(ABSTRACT TRUNCATED AT 250 WORDS)

Staphylococcal and streptococcal pyodermas.

The pathophysiology, clinical features, and therapy of the common pyodermas, those caused by Staphylococcus aureus and Streptococcus pyogenes, are reviewed.

Physiological responses to maximal treadmill and handweighted exercise.

The purpose of this investigation was to compare the peak physiological responses among four protocols that employed different amounts of handweighted exercise in 16 males (aged 26.3 +/- 4.1 years). The four protocols were (a) uphill treadmill running (UR; 3.36 m.s-1, 2.5% grade increase-3 min-1); (b) uphill treadmill walking while pumping 1.36-kg handweights (HW) (UWHW; 1.79 m.s-1, 5.0% grade increase x 3 min-1; (c) treadmill walking while pumping .91-kg HW (WHW; 1.79 m.s-1, 0% grade, .91-kg HW increase x 3 min-1); and (d) standing in place and pumping HW (SHW; arm work as described in WHW). It was hypothesized that the peak responses would be inversely proportional to the estimated muscle mass activated (i.e., UR = UWHW > WHW > SHW). Dependent variables included peak oxygen uptake (VO2 peak), peak heart rate (HRpeak), peak ventilation (Ve peak), and peak respiratory exchange ratio (RERpeak). No differences were noted between UR and UWHW with respect to any of the dependent variables. All variables (except RERpeak) were greater (p < .01) in UR and UWHW than either WHW or SHW. RERpeak was greater (p < .01) in UR and UWHW than in WHW. VO2 peak and HRpeak were greater (p < .01) in WHW when compared to SHW. Mean VO2 peak was 97.5, 69.7, and 60% of UR for UWHW, WHW, and SHW, respectively. Therefore, walking and pumping handweights provides a maximal stimulus to the oxygen transport system.

Augmentation of natural killer cell activity in mice by Bru-Pel.

The immunomodulatory and anti-tumor activity of Bru-Pel, an aqueous-ether extracted residue of Brucella abortus (strain 456), was investigated. Bru-Pel was administered to C57BL/6 mice intraperitoneally (i.p.) and tested for its effect on natural killer (NK) cell activity in spleen cells, liver, and peritoneal cavity. Three days after injecting 100 micrograms of Bru-Pel i.p., the cytotoxicity of spleen cells against YAC-1 target cells, assessed by LU20 increased by approximately two-fold and nonparenchymal cells of liver by greater than six-fold. The highest stimulatory effect of Bru-Pel was seen with peritoneal exudate cells, and 47-fold augmentation of NK cell activity was observed. Bru-Pel treatment made spleen, liver, and peritoneal exudate cells capable of lysing P815 mastocytoma cells, a tumor cell line highly resistant to lysis by unstimulated NK cells. In vivo, Bru-Pel inhibited the formation of experimental BL6 melanoma metastases; however, there was no significant effect on the eradication of established pulmonary metastatic lesions. These results demonstrate that in addition to its previously described macrophage-activating ability, Bru-Pel is highly efficient in stimulation of NK cell-mediated cytotoxicity in mice.

Formation of UDP-2-acetamido-2-deoxy-L-galactose and UDP-2-acetamido-2-deoxy-L-galacturonic acid by Pseudomonas aeruginosa.

The O-specific polysaccharide from the lipopolysaccharide of Pseudomonas aeruginosa NCTC 8505 (IATS serotype O:3) consists of a tetrasaccharide repeating unit comprising L-rhamnose, N-acetyl-D-glucosamine (GlcNAc), bacillosamine, and N-acetyl-L-galactosaminuronic acid (L-GalNAcA) (Y. Tahara and S. G. Wilkinson, Eur. J. Biochem. 134:299-304, 1983). Incubation of GlcN or UDP-GlcNAc with cell extracts or EDTA-treated cells of P. aeruginosa NCTC 8505 yielded a mixture of UDP-ManNAc, UDP-GalNAc, UDP-GlcNAcA, UDP-ManNAcA, UDP-L-GalNAc, and UDP-L-GalNAcA. The last two compounds, here identified for the first time, may be intermediates in the synthesis of the L-GalNAcA moiety of the O-specific portion of the lipopolysaccharide of P. aeruginosa.

Purification and characterization of guanosine diphospho-D-mannose dehydrogenase. A key enzyme in the biosynthesis of alginate by Pseudomonas aeruginosa.

Alginate-producing Pseudomonas aeruginosa are usually associated with the cystic fibrosis lung environment and contribute to the high mortality rates observed among these patients. The present paper describes the purification and enzymatic properties of guanosine diphospho-D-mannose dehydrogenase (EC 1.1.1.132), a key enzyme in alginate biosynthesis by mucoid P. aeruginosa. The enzyme was overproduced using a plasmid vector containing algD (the gene encoding this enzyme) under control of the tac promoter. It was purified from cell-free lysates by lowering the pH to 5.0, heating the extract to 57.5 degrees C for 10 min, and discarding the protein pellet. The enzyme was selectively precipitated from the supernatant fraction with 45% acetone, resuspended in a 100 mM triethanolamine acetate buffer, pH 7.6, and ultimately purified by Bio-Sil TSK-400 gel filtration chromatography. The subunit molecular weight (Mr 48,000) as well as the N-terminal amino acid sequence corresponded to those predicted from the DNA sequence of algD. The native protein migrated as a hexamer of 290,000 molecular weight upon Bio-Gel A-1.5m gel filtration chromatography. Kinetic analysis demonstrated an apparent Km of 14.9 microM for the substrate GDP-D-mannose and 185 microM for the cofactor NAD+. GDP-D-mannuronic acid was identified as the enzyme reaction product. Several compounds (including GMP, ATP, GDP-D-glucose, and maltose) were found to inhibit enzymatic activity. GMP, the most potent of these inhibitors, exhibited competitive inhibition with an apparent Ki of 22.7 microM. Enzyme activity was also sensitive to the sulfhydryl group modifying agents iodoacetamide and p-hydroxymercuribenzoate. The addition of excess dithiothreitol restored enzyme activity, suggesting a possible involvement of cysteine residues in enzymatic activity.

Bacterial infections of the skin.

This report reflects the best data available at the time the report was prepared, but caution should be exercised in interpreting the data; the results of future studies may require alteration of the conclusions or recommendations set forth in this report.

Biosynthesis of heparin. Modulation of polysaccharide chain length in a cell-free system.

The formation of heparin-precursor polysaccharide (N-acetylheparosan) was studied with a mouse mastocytoma microsomal fraction. Incubation of this fraction with UDP-[3H]GlcA and UDP-GlcNAc yielded labelled macromolecules that could be depolymerized, apparently to single polysaccharide chains, by alkali treatment, and thus were assumed to be proteoglycans. Label from UDP-[3H]GlcA (approx. 3 microM) is transiently incorporated into microsomal polysaccharide even in the absence of added UDP-GlcNAc, probably owing to the presence of endogenous sugar nucleotide. When the concentration of exogenous UDP-GlcNAc was increased to 25 microM the rate of incorporation of 3H increased and proteoglycans carrying polysaccharide chains with an Mr of approx. 110,000 were produced. Increasing the UDP-GlcNAc concentration to 5 mM led to an approx. 4-fold decrease in the rate of 3H incorporation and a decrease in the Mr of the resulting polysaccharide chains to approx. 6000 (predominant component). When both UDP-GlcA and UDP-GlcNAc were present at high concentrations (5 mM) the rate of polymerization and the polysaccharide chain size were again increased. The results suggest that the inhibition of polymerization observed at grossly different concentrations of the two sugar nucleotides, UDP-GlcA and UDP-GlcNAc, may be due either to interference with the transport of one of these precursors across the Golgi membrane or to competitive inhibition of one of the glycosyltransferases. The maximal rate of chain elongation obtained, under the conditions employed, was about 40 disaccharide units/min. The final length of the polysaccharide chains was directly related to the rate of the polymerization reaction.

Mucoid strains of Pseudomonas aeruginosa are devoid of mannuronan C-5 epimerase.

Mucoid strains of Azotobacter vinelandii, Pseudomonas aeruginosa and Pseudomonas syringae var glycinia synthesize alginate, an extracellular copolymer comprising D-mannuronosyl and L-guluronosyl moieties. Extracellular mannuronan C-5 epimerase, which converts polymannuronate to alginate, was demonstrated in supernatant fluid from cultures of A. vinelandii. However, the enzyme could not be demonstrated, using the same assay, in supernatant fluids of cultures of mucoid strains of P. aeruginosa or of P. syringae var glycinia, or in cell-free sonic extracts of P. aeruginosa. The results suggest that the pathways of alginate biosynthesis in A. vinelandii and Pseudomonas species may differ.

Dissociation and in vitro reconstitution of bovine liver uridine diphosphoglucose dehydrogenase. The paired subunit nature of the enzyme.

Uridine diphosphoglucose dehydrogenase (EC 1.1.1.22: UDPglucose dehydrogenase) at pH 5.5-7.8 is a stable homohexamer of 305 +/- 7 kDa that does not undergo concentration-dependent dissociation at enzyme concentrations greater than 5 micrograms/mL. Chemical cross-linking of the native enzyme at varying glutaraldehyde concentrations yields dimers, tetramers, and hexamers; at greater than 2% (w/v) glutaraldehyde, plateau values of 21% monomers, 16% dimers, 5% tetramers, and 58% hexamers are obtained. Dissociation at acid pH (pH 2.3) or in 4-6 M guanidine hydrochloride leads to inactive monomers (Mr 52,000). Denaturation at increasing guanidine hydrochloride concentration reveals separable unfolding steps suggesting the typical domain structure of dehydrogenases holds for the present enzyme. At greater than 4 M guanidine hydrochloride complete randomization of the polypeptide chains is observed after 10-min denaturation. Reconstitution of the native hexamer after dissociation/denaturation has been monitored by reactivation and glutaraldehyde fixation. The kinetics may be described in terms of a sequential uni-bimolecular model, governed by rate-determining folding and association steps at the monomer level. Trimeric intermediates do not appear in significant amounts. Reactivation is found to parallel hexamer formation. Structural changes during reconstitution (monitored by circular dichroism) are characterized by complex kinetics, indicating the rapid formation of "structured monomers" (with most of the native secondary structure) followed by slow "reshuffling" prior to subunit association. The final product of reconstitution is indistinguishable from the initial native enzyme.