Treatment of plantar warts is often difficult and may be painful, often employing destructive treatment modalities. We
report the successful treatment of a patient with a large plantar wart using Imiquimod 5% cream under occlusion with a
40% salicylic acid pad. This combination treatment modality likely allows successful delivery of Imiquimod through the
thick skin on the plantar surface. Once penetrated, an anti-viral state is created by upregulating specific cytokines to
eradicate the human papilloma virus (HPV).
David J. Goldberg, MD and Chrys Delling Schmults, MD
Whether and when to use prophylaxis for the prevention of endocarditis has been a subject of debate among
dermatologic surgeons for over 20 years. The available literature and current recommendations are reviewed.
Areas of controversy are examined and proposals for future research are made.
Jeffrey M. Weinberg, MD; James G. Bowerman, MD; Stuart M. Brown, MD; David Gerstein, MD; Kay S. Kane, MD; James Selevan, MD and Sat Virdee, MD
Atopic dermatitis (AD), often called eczema, is a disease characterized by intense pruritus, erythema, dry skin,
and inflammation. Pimecrolimus is a novel steroid-free treatment for AD. Consistently positive results have
been found with pimecrolimus treatment in infants, children/adolescents, and adults. Its safety record is excellent,
and studies have found no clinically relevant drug-related systemic adverse events. In this article, we first
review atopic dermatitis and conventional treatment strategies. We then discuss various aspects of pimecrolimus,
including pharmacologic properties, toxicology, short- and long-term studies, and safety and adverse
events. Finally, we propose a new steroid-sparing treatment strategy for AD.
Craig G. Burkhart, MPH,MD and Heidi R. Burhart, BA
Contact irritant dermatitis can be defined by four interrelated elements: skin barrier disruption, epidermal skin
changes, cytokine release, and nerve ending changes. The predominant symptom of eczema relates to the fourth
constituent, which produces pruritic symptoms that are often neglected when using pre-formulated topical steroids
and immunomodulators. Although the induction of pruritus with proteinases and cytokines demonstrates the
close connections between immune and neurotrophic factors in the pathophysiology of pruritus, agents that specifically
affect the cutaneous nerve endings are often beneficial for use in patients affected by dermatitis. Besides
avoiding triggering factors, agents such as pramoxine, phenol, camphor, and menthol are extremely valuable in
allaying patients’ symptoms of pruritus. Indeed, therapeutic remedies, which incorporate anti-pruritic agents in
their formulation, may be advantageous for the bulk of patients with contact irritant dermatitis.
S.I. Colby, BA; E.H. Schwartzel, PhD; F.J. Huber, BS; A. Highton, MD; D.J. Altman, MD, PHD; W.W. Epinette, MD and A. Highton, MD and E. Lyons, BS
The purpose of this open-label study was to determine the adverse event rate of topical 4HA/tretinoin when
used twice daily for up to 24 weeks with concomitant sunscreen in the treatment of solar lentigines and related
hyperpigmented lesions. There were two treatment areas: bilateral dorsal forearms, including the back of the
hands; and the face, including the forehead and cheek areas. Each treatment area had a target lesion at least
5mm in diameter and was moderately darker than the surrounding skin. A nine-point bipolar scale was used for
evaluation of Target Lesion Pigmentation (0 = extremely lighter than pigment of the surrounding skin, 4 =
equal with pigment of surrounding skin, 8 = extremely darker than pigment of surrounding skin). The other
solar lentigines present in the treatment areas also had to have an overall pigmentation grade of at least Grade
6. Twice daily applications to individual lesions in each treatment area were made for up to 24 weeks followed
by a 4-week follow-up phase. Sunscreen applications (sunscreen with sun protection factor (SPF) 25 or greater)
were made every morning and reapplied after six hours if additional sun exposure was expected. Clinical evaluations
were performed at weeks 0, 4, 8, 16, 24 and 28. The clinical signs of Target Lesion Pigmentation and
Overall Lesion Pigmentation were evaluated at each visit.
A total of 96 subjects were enrolled at four study centers; 77 (80%) subjects completed the study. Treatment-related
adverse events (AEs) for 4HA/tretinoin included erythema, burning/stinging/tingling, desquamation, pruritus,
skin irritation, halo hypopigmentation and hypopigmentation. Five (5%) subjects discontinued from the study due
to adverse events considered to be related to study medication. When used with sunscreen of SPF 25 or greater,
4HA/tretinoin was safe and well tolerated and did not produce any unexpected or unusual adverse events.
Cutaneous T-cell lymphomas (CTCLs) are a relatively uncommon group of lymphoproliferative disorders in
which a malignant population of T cells is localized to the skin at presentation. Of the 4 classic CTCL phases
(patches, infiltrated plaques, tumors, Sézary syndrome), the majority of patients present with early stage patch
or plaque disease, which can usually be effectively managed using skin-directed therapies. Traditional skindirected
therapies include topical corticosteroids, topical chemotherapeutic agents (mechlorethamine, carmustine),
electron beam therapy (local and total skin), and phototherapy (UV-A, UV-B). Each of these has
demonstrated efficacy in early stage disease; however, with the exception of topical corticosteroids, all have
some disadvantages and are associated with significant adverse events, particularly secondary skin malignancies
and skin damage. Bexarotene is a synthetic retinoid analog that selectively activates retinoid X receptors. In
clinical trials, bexarotene gel demonstrated efficacy for the topical treatment of cutaneous lesions in patients
with stage IA or IB CTCL who have refractory or persistent disease following other therapies or who cannot
tolerate other therapies. Initial evidence indicates that bexarotene gel may be active as first-line therapy in
early stage disease. Its role in combination with other treatments remains to be determined. Topical bexarotene
gel is generally well tolerated and offers patients greater convenience compared with traditional skin-directed
therapies, with a flexible administration regimen. The availability of bexarotene gel provides patients and
physicians with a new skin-directed treatment option for early stage CTCL.
Guillermo Blugerman, MD; Diego Schavelzon, MD and Ruben Dreszman, MD
5-fluorouracil (5-FU) is an antimetabolic cytostatic drug that inhibits DNA formation. It is potentially toxic for the dysplasic epithelium, and it has therefore been used successfully as an antineoplastic for the treatment of various types of cancer. It has been successfully applied topically to treat pre-malignant and malignant skin and mucous membrane lesions.
5-FU was first used as an antifibrotic in the 1960s in the field of ophthalmology to prevent scarring after glaucoma surgery, and to prevent recurrence after pterygia surgery1,2,3,4. In February of 1999 it was suggested as a potential way to prevent the formation of fibrotic adhesion after tendon surgery5. In March of 1999, Fitzpatrick published his paper on the use of 5-FU for the treatment of scar hypertrophy and keloids, presenting his results in some 1000 patients over 7 years6. Reading that paper inspired us immediately to use that drug ourselves in those difficult types of lesions7. Moved and excited by the results obtained, we decided to use the drug in other type of lesions in the subcutaneous tissue, due to the fact that in our practice we frequently see other pathologies linked to the excessive production of fibrous tissue.
It has been proved that in laboratory cultures the 5-FU barely reduces collagen reduction in normal fibroblasts, but produces a drastic reduction in the altered fibroblasts, as happens in Dupuytren's disease, acting on the gene controlling the amount of protein or the messenger8. It also seems to counteract the capacity of growth factor TGF-1 to stimulate collagen production8.
Laura Thomas and Henry W. Lim, MD
The "Focus On:" section is designed to provide a background on one of the basic areas of our practice - A common condition, subject, or process which we as dermatologists often deal with, yet might not intimately understand. This new feature will appear each issue as an informative review of a different dermatological topic.
Susan Boiko, MD and Allan C. Halpern, MD, MS
No abstract details for the moment.