Daniel Navi BS, John Koo MD
Crusted scabies, a rare variant of classical scabies, is a highly contagious condition in which the skin is infected with
thousands to millions of mites. It can be defined as a generalized severe scabies infestation usually affecting immunocompromised
patients. The diagnosis is becoming more relevant with the increasing use of immunosuppressive medications and the
HIV epidemic. To date, more than 200 cases have been reported in the literature. We present a review of the pathogenesis,
clinical manifestations, diagnostic considerations, and therapeutic options.
Cutaneous reactions to imatinib are common and occur in 9.5% to 69% of patients depending on the series reported.
Maculopapular eruptions, erythematous eruptions, edema, and periorbital edema are the most common adverse events
observed. Imatinib can also induce severe skin eruptions and generalized skin eruptions. Toxic epidermal necrolysis and
Stevens Johnson syndrome has been linked to the use of imatinib. Imatinib has caused acute generalized exanthematous pustulosis.
Purpuric vasculitis and mycosis fungoides-like reactions has occurred after imatinib use. Rarer side effects include:
hypopigmentation, lichenoid reactions, pityriasiform eruptions, pityriasis rosea, psoriasis, reactivation or induction of porphyria
cutanea tarda, neutrophilic eccrine hidradenitis, Sweet’s syndrome, erythema nodosum, EBV-positive cutaneous B-cell
lymphoproliferative disease, possible induction of squamous cell, hyaline cell syringomas, follicular mucinosis, pseudolymphoma-
type drug eruptions, and malpighian epitheliomas. Most cutaneous eruptions caused by imatinib do not necessitate
discontinuance of imatinib and are usually self limited, despite continued treatment. Administration of oral or topical
corticosteroids can ameliorate some of imatinib’s cutaneous side effects.
Dermatological research continues to move toward the goal of developing an effective psoriasis treatment that would rapidly
clear lesions and provide long-term freedom from visible signs and symptoms. Currently, topical corticosteroids remain a
pivotal treatment due to their effective anti-inflammatory properties; however, potential adverse effects associated with
chronic application limit long-term continuous therapy. Vitamin D analogues provide another mechanism of action, reducing
lesions through effects on both keratinocytes and on the cytokine environment. A topical combination of corticosteroid
and vitamin D derivative appears to provide a balanced approach to psoriasis treatment. The development of clobetasol
propionate foam 0.05% (clobetasol propionate foam/Olux) offers a convenient topical corticosteroid that can be used
concomitantly, that is, immediately followed by application of calcipotriene ointment 0.005% (Dovonex). This regimen has
been shown to offer an increased short-term efficacy compared with either agent alone. Continued application of
calcipotriene ointment on weekdays supplemented by long-term clobetasol propionate foam pulse therapy on weekends
appears to provide an enhanced maintenance of remission compared with calcipotriene monotherapy.
William Abramovits MD, Mark Boguniewicz MD
Background: MAS063DP cream has received marketing authorization in the US and the European Union for symptom
relief of atopic dermatitis (eczema) and contact dermatitis.
Design: A multicenter, randomized, vehicle-controlled, phase IV study was completed in the US.
Methods: 218 patients aged 18 to 84 years joined this 50-day study. Patients self-administered MAS063DP cream (N=145)
or vehicle cream (N=73) 3 times per day to affected areas and those areas prone to be affected. The primary endpoint for
efficacy was the change in EASI at Day 22 of treatment, comparing the 2 treatment groups. Secondary outcomes included
EASI scores at other time points, IGA, pruritus (100mm VAS), % BSA, and the need for rescue medication.
Results: MAS063DP was statistically (p<.0001) more effective than vehicle in all outcomes at all time points. The
incidence of rash was 2.1% in the MAS063DP group versus 5.5% in the vehicle group. Only 2 patients discontinued
MAS063DP due to an adverse event.
Conclusion: MAS063DP cream was confirmed to be a safe and effective treatment for mild to moderate atopic dermatitis in adults.
Timothy T. Chang MD, Susan T. Nedorost MD
Medication induced esophagitis (MIE) has been reported in dermatology patients taking tetracycline antibiotics. The symptoms
of esophagitis, preventable with proper instruction, can create morbidity and lead to increased costs for patients. Our
study sought to quantify the incidence of MIE in patients taking tetracycline antibiotics and to investigate how these patients
develop MIE. A cross-sectional questionnaire survey was given at outpatient dermatology clinics. Ninety-three surveys from
patients who had taken tetracycline antibiotics and 48 surveys from a control group were analyzed. Incidence of esophagitis
symptoms (difficulty or pain with swallowing) was measured in both survey and control groups. We found that esophagitis is
significantly more common in patients taking tetracycline and its derivatives as compared with a control group (p<.03).
Patients should be counseled to take tetracycline antibiotics in an upright position with a large amount of fluid and to report
esophagitis symptoms to the prescribing physician.
Richard A. Krathen MD, Cindy N. Berthelot MD, Sylvia Hsu MD
Background: Infliximab inhibits T-cell activation by binding tumor necrosis factor-? (TNF-?). This medication is widely
used in the US for treatment of psoriasis as an off-label indication. The durability of its effect is largely unknown.
Objective: To assess the proportion of patients still on infliximab 12 months after initiation of therapy for psoriasis.
Methods: Retrospective chart review analysis of 73 patients with psoriasis treated with infliximab for at least 12 months
or those who experienced treatment failure in less than 12 months. The point where infusions were deemed to no longer be
efficacious was determined by physicians global assessment (PGA).
Results: Of 73 patients who started infliximab at least 12 months prior to this chart review, 22 (30.1%) had discontinued
treatment secondary to loss of efficacy. Thirty seven patients (50.7%) had no loss of efficacy and continued to receive
infusions. Two patients (2.7%) discontinued due to loss of efficacy after greater than 12 months. Of the 22 patients who
discontinued treatment due to loss of efficacy, 2 were on concomitant methotrexate (5-7.5 mg/wk) therapy. Of the 37
patients still receiving treatment with no loss of efficacy at 12 months, 3 patients were on concomitant methotrexate
therapy. Five patients (6.8%) discontinued secondary to minor adverse events: sinus infection (1), acne (1), fever (1),
arthralgia (1), and transient rash (1). Three patients (4.1%) discontinued due to major adverse events: reactivation of
tuberculosis (1), breast cancer (1), and gastrointestinal bleeding (1). One patient discontinued infliximab secondary to
concerns of possible lymphoma risk (though there were no signs of symptoms of disease on examination), and 3 patients
discontinued due to insurance concerns.
Conclusion: Infliximab treatment resulted in significant improvement in psoriasis, with 37 out of 73 patients (50.7%) experiencing
no loss of efficacy. This longitudinal retrospective chart review demonstrates continued benefit of infliximab infusions in about half of parients after 1 year, though a notable percentag (30.1%) experienced loss of efficacy as determined by physicians global assessement (PGA) and a number of others discontinued due to adverse events or insurance difficulty.
Emil Tanghetti MD, William Abramovits MD, Barry Solomon MD, Keith Loven MD, Alan Shalita MD
Topical retinoids offer highly effective treatment for both inflammatory and non-inflammatory acne, with tazarotene demonstrating
greater efficacy than other topical retinoids. A multicenter, double-blind, randomized, parallel-group trial has been
performed to evaluate whether the adjunctive use of clindamycin/benzoyl peroxide could enhance the efficacy of tazarotene
still further. Patients with moderate to severe inflammatory acne applied tazarotene 0.1% cream each evening and were
randomly assigned to morning applications of vehicle gel or a ready-to-dispense formulation of clindamycin 1%/benzoyl
peroxide 5% gel containing 2 emollients. Tazarotene/clindamycin/benzoyl peroxide achieved a significantly greater reduction
in comedo count than tazarotene monotherapy and, among patients with a baseline papule plus pustule count of ?25 (the
median value), a significantly greater reduction in inflammatory lesion count. The combination therapy was also at least as
well-tolerated as tazarotene monotherapy. The adjunctive use of clindamycin/benzoyl peroxide gel with tazarotene cream
promotes greater efficacy and may also enhance tolerability. Any improvements in tolerability could be due to the emollients
in the clindamycin/benzoyl peroxide gel formulation.
Ajith C. MD, Somesh Gupta MD DNB, Amrinder Jit Kanwar MD MNAMS
Background: Immunotherapy with sqauric acid dibutyl ester (SADBE) is a well-accepted therapy for alopecia areata.
Objective: To study efficacy, safety, and factors influencing the outcome in the treatment of alopecia areata.
Method: During a 4-year period, 70 patients of alopecia areata, unresponsive to conventional therapies, were treated with
SADBE for a period of 4 months and thereafter depending on the response with initial therapy. The percent scalp hair loss
was calculated using “Severity of Alopecia Tool” (SALT) score before and after the therapy.
Results: Out of 70 patients, 6 were lost to follow-up and 4 could not develop sensitization; therefore, data of 60 patients
was available for analysis. The overall success rate was 43%. In patients with <50% scalp involvement; the success rate was
better (68%) than in those with >50% involvement (29%). The response was better in patients with late onset and shorter
duration of disease. Family history of alopecia areata or other autoimmune diseases, personal or family history of atopy,
presence of auto antibodies in serum, and presence of nail changes were associated with poorer prognosis. Out of 26 patients
who responded, relapse occurred in 21 (81%) patients.
Conclusion: In conclusion, SADBE is an effective and well-tolerated mode of therapy in Indian patients of AA, although
the long-term results of SADBE were not encouraging.
C. Ryan Kirkland MD, Christopher B. Yelverton MD MBA, Alan B. Fleischer Jr. MD, Fabian T. Camacho MS, Steven R. Feldman MD PhD
Background: It has been thought that topical gels are inherently more irritating than topical creams. Nevertheless, the
irritancies of topical products are potentially quite variable, and a priori assumptions about relative irritancy of gels versus
creams may not be accurate.
Purpose: To determine whether a metronidazole gel formulation is more or less irritating to the skin compared to metronidazole
Methods: A total of 32 normal, healthy volunteers were tested using irritancy patches with 0.75% metronidazole gel and
cream, 1% metronidazole cream, and petrolatum (used as the “negative control”). Blinded observers evaluated the
application sites for signs of irritancy. A numerical score was assigned to these irritancy patch sites each day for 21 days, or
until significant irritation developed, and cumulative irritancy scores were calculated for the study period. A mixed model
of variance analysis was performed.
Results: After 21 days of evaluation, analysis of the mean cumulative irritancy scores for each of the agents used showed
there to be no statistical difference in irritancy potential between the metronidazole gel and the metronidazole creams.
However, the 1% metronidazole cream was significantly more irritating than petrolatum.
Conclusion: There was no significant difference in the cumulative irritancy potential of cream and gel preparations of
metronidazole. The irritancy of topical formulations for treating rosacea should be considered on a case by case basis.
Lindsey Warino BS, James Libecco MD
Cancer is a major cause of death in immunosuppressed transplant patients. Therefore, sirolimus is frequently used in these
patients for its immunosuppressive and antineoplastic properties. However, a variety of cutaneous side effects have resulted
from sirolimus therapy. Consequently, dermatologists must be aware of such adverse events and understand the risks and
benefits of discontinuing therapy.