Hyperandrogenemia in patients presenting with acne.

OBJECTIVE: To determine whether acne is associated with hyperandrogenemia, regardless of age of presentation. DESIGN: Prospective controlled study. SETTING: Tertiary-care medical center. PATIENT(S): Thirty consecutive unselected women presenting with acne and no hirsutism and 24 eumenorrheic healthy controls. INTERVENTION(S): Serum samples was taken in all patients, and an acute 60-minute ACTH-(1-24) test was performed in 19 patients. MAIN OUTCOME MEASURE(S): Total and free T, sex hormone-binding globulin (SHBG), and DHEAS levels in basal samples, and ACTH-stimulated 17-hydroxyprogesterone (17-HP) response to exclude 21-hydroxylase (21-OH)-deficient nonclassic adrenal hyperplasia (NCAH) were determined. RESULT(S): Nonhirsute patients with acne demonstrated significantly lower levels of SHBG and higher free-T and DHEAS levels than controls. Nineteen (63%) acneic patients had at least one androgen value above the 95% of controls. In patients aged 12-18 years, 7/8 (88%) had at least one increased androgen value, compared with 12/22 (55%) patients aged 19-43 years. One patient (5.3%) was found to have 21-OH-deficient NCAH. CONCLUSION(S): Hyperandrogenemia was evident in a majority of nonhirsute acneic patients studied, regardless of age. These data suggest that androgen suppression may be useful in treating acne in many of these patients.

The dermatology-industry interface: defining the boundaries.

Support from industry has become an important factor in the growth of the dermatologic profession. However, the relationship creates inevitable conflicts of interest. This article explores these potential conflicts, including (1) giving and receiving of gifts, (2) conduct of clinical trials, (3) appearance of advertisements in professional journals, (4) continuing medical education programs and educational grants to societies and departments, and (5) drug sampling.

Consensus statement on the ethic of medicine.

Because Of Increasing Concern With The Ethical Challenges To Physicians In Recent Years, A Committee Of The Council Of Medical Specialty Societies (CMSS), Under The Chairmanship Of Sara C. Charles, Md, Organized A 2-DAY Symposium On The Ethic Of Medicine In April 1997. During This Conference 6 Workgroup Sessions Were Held For The Purpose Of Developing A Consensus Among The 17 Represented Medical And Surgical Specialties On Whether The Traditional Medical Ethic Remains Applicable Or Is In Need Of Adaptation Or Change To Guide Physician Behavior In The 21ST Century. An Initial Statement Was Developed At The Time Of The Meeting, Then Modified By Mail And Finally Presented To All 17 Member Societies For Further Comment. The Following Is The Result Of That Extended And In-DEPTH Review.

Durable loss of a malignant T-cell clone in a stage IV cutaneous T-cell lymphoma patient treated with high-dose interferon and photopheresis.

Stage IV cutaneous T-cell lymphoma (CTCL) has a notoriously poor prognosis and many treatment options exist. We describe the successful treatment of a case of stage IV CTCL with combination photopheresis and high-dose interferon alfa (IFNalpha). The patient was treated with combination therapy of monthly photopheresis and daily doses of IFNalpha up to 36 MU. Response to therapy was followed by clinical observation and Southern blot analysis for the detection of a malignant clone. The findings of this case were compared with others using a computer-based literature review. A complete clinical response lasting 64 months was achieved. Clinical relapse was preceded by an increase in the CD4/CD8 ratio and by reappearance of the T-cell receptor gene rearrangement. Combined photopheresis and high-dose IFNalpha led to a durable and sustained complete response in stage IV CTCL. CD4/CD8 ratios and T-cell gene rearrangements may be helpful in patient management.

Urinary adenosine and aminoimidazolecarboxamide excretion in methotrexate-treated patients with psoriasis.

BACKGROUND: We hypothesized that low-dose methotrexate treatment for patients with psoriasis would block purine biosynthesis at the step catalyzed by aminoimidazolecarboxamide (AICA) ribotide transformylase and would inhibit adenosine metabolism as evidenced by increased urinary levels of AICA and adenosine, respectively. Eight patients collected a 24-hour urine specimen on the day before their methotrexate dose and the next day during their methotrexate dose. Eight age- and sex-matched controls also collected a 24-hour urine sample. Urinary AICA and adenosine were assayed by spectrophotometric and radioimmune assays, respectively; means are reported as micromole per millimole of creatinine and were compared by the paired t test (1-tailed). OBSERVATIONS: Mean AICA excretion increased from 1.30 micromol/mmol on the day before to 1.85 micromol/mmol on the day during methotrexate dosing (P<.01). Mean adenosine values increased from 0.68 to 1.07 micromol/mmol, (P<.03). Controls had mean AICA and adenosine levels of 1.29 and 0.50 micromol/mmol, respectively. During the day of methotrexate dosing, patients had higher mean AICA and adenosine levels when compared with controls (P<.01). Mean AICA levels increased from 1.36 to 2.06 micromol/mmol (P<.025), and mean adenosine levels increased from 0.72 to 1.25 micromol/mmol (P<.025) in 5 patients showing improvement in clinical disease activity. In contrast, 3 patients with no change or worsening in clinical disease activity had smaller increases. CONCLUSIONS: Methotrexate treatment of patients with psoriasis inhibits AICA ribotide transformylase and adenosine metabolism. Since adenosine is a T-lymphocyte toxin, it may be partially responsible for the immunosuppressive effect.

Merkel cell carcinoma occurring in renal transplant patients.

Merkel cell carcinoma is a rare, highly aggressive tumor that usually affects the head and neck of elderly patients. We describe 3 cases of this high-grade, malignant tumor occurring in the setting of renal transplantation.

Assessment of the photosensitive patient.

Photosensitivity is an abnormal cutaneous response to photosensitizing substances and sunlight or artificial light. Proper assessment of the photosensitive patient is important in defining photosensitive diseases and reactions.

Cutaneous silica granuloma. A rare entity or rarely diagnosed? Report of two cases with review of the literature.

Cutaneous silica granuloma is a poorly understood, uncommon condition that may mimic cutaneous sarcoidosis. We describe two cases of this entity and their characteristic latency period (between the time of silica exposure to the time of clinical onset of granuloma). We also review the histologic and energy dispersive x-ray analysis data, which prove the diagnosis. This condition should be recognized as an occupational dermatosis as well as the result of past incidental cuts or abrasions, which result in the development of granulomas, many in old wound scars. Differentiation from cutaneous sarcoidosis is possible with polarized light microscopy and energy-dispersive x-ray analysis.

Urticaria pigmentosa and preleukemia: evidence for reactive mast cell proliferation.

A 64-year-old man had urticaria pigmentosa and myelodysplasia (refractory anemia with excess blast cells; partial trisomy 8 syndrome) without increased numbers of marrow mast cells. Clonal marrow assays in agar demonstrated normal to increased colony-forming units of granulocytes/macrophages. In long-term liquid cultures containing mast cell growth factor (interleukin 3), his marrow cells proliferated after 3 weeks to produce abnormal myeloid precursors similar to those in the corresponding marrow aspirate specimen. Cells with basophilic-staining granules were less abundant in comparison with normal marrow specimens cultured similarly. These results suggest that the mast cells in this patient are not of the same clone as the preleukemic marrow cells, although the possible marrow-cell origin of urticaria pigmentosa mast cells cannot be excluded. Previous reports suggest that urticaria pigmentosa without systemic mastocytosis occurs as a nonspecific abnormality in a variety of myeloid, lymphoid, and nonhematologic malignancies. Our data also support this hypothesis that urticaria pigmentosa is a reactive process rather than a manifestation of clonal proliferation of the primary malignancy.

Hypersensitivity angiitis.

Hypersensitivity angiitis is a disease in which patients present with palpable purpura dominant on the lower legs. As lesions evolve they become confluent, and sometimes hemorrhagic and ulcerate. Other organ systems may be involved, particularly the joints, gastrointestinal tract, and kidneys. Current evidence supports an immune complex pathogenesis in which a variety of antigens including bacteria, viruses, drugs, or chemicals are involved. Therapy consists of identifying the potential offending agent and administration of antiinflammatory drugs.

Sun-induced aging. Clinical and laboratory observations in humans.

Chronic sun exposure can result in numerous changes in human skin, particularly the skin of fair-skinned individuals. These changes include wrinkling, elastosis, actinic keratoses, irregular pigmentation, telangiectasia, and skin cancer. Most of these alterations had been considered to be caused by UVB wavelengths. However, a number of recent studies have demonstrated that UVA can also cause burning, elastosis, and skin cancer. Thus, individuals exposed to intense UVB from sunlight coupled with intense UVA from suntan parlors are likely at increased risk.

Human hypersensitivity angiitis.

Human hypersensitivity angiitis is a disease involving deposition of immune complexes in which patients present with palpable purpuric lesions most often on the lower extremities and sometimes associated with multiple organ involvement. There are numerous potential antigens in the immune complex and the disease may be derived from an infectious organism such as Streptococcus or the hepatitis virus, from a drug, or from a variety of other chemicals which may be ingested or inhaled. In addition, the antigen may be part of another systemic disease. This complex of circulating antigen and antibody may become fixed within the vessel wall activating the complement cascade with elaboration of factors chemotactic for neutrophils. These cells then release lysosomal enzymes which result in destruction of the vessel wall and leakage of red blood cells into the tissue. This produces the typical purpura and palpability seen clinically. A central question in the pathogenesis of this disease is to explain why the immune complex is seemingly so selective in its site of deposition as it may be deposited in postcapillary venules in some patients and medium-sized muscular arteries in other patients. Part of the reason for this must be related to the lattice formation of a particular complex, while other reasons are likely related to alterations in vascular permeability, to the integrity of clearance mechanisms for the complex, or possibly even to a genetically determined defect of the phagocytic system.

Livedo vasculitis. Therapy with pentoxifylline.

Eight patients with livedo vasculitis of four to 30 years' duration that was unresponsive to a variety of medications were treated with pentoxifylline. Three patients experiences complete healing and remained free of active lesions while receiving the drug, four noted much improvement, and one had no change.

Pemphigus vulgaris. Combined treatment with intravenous corticosteroid pulse therapy, plasmapheresis, and azathioprine.

A 13-year-old child is described who presented with generalized pemphigus vulgaris associated with extraordinarily high titers of circulating autoantibodies against the pemphigus antigen. Because of the lack of response to treatment with reasonably high doses of oral corticosteroids, as well as the very high titer of circulating autoantibodies observed, this patient was treated with intravenous corticosteroid pulse therapy followed by plasmapheresis and then by combination immunosuppressive therapy (prednisone and azathioprine). A rapid clinical response was induced, correlating with reduction and subsequent elimination of the circulating pemphigus autoantibodies. Using such combination therapy, a remission of 12 months was achieved, and prednisone therapy was completely, albeit temporarily, tapered and then discontinued. Subsequent disease flare was then easily controlled with a short course of low-dose oral corticosteroid therapy.