Journal of the American Academyof DermatologyVolume 30, Number 3

Abstracts from the literature

Pearls of wisdom 483

Nail dust aerosols from onychomycotic toenails:Part II. Clinical and serologic aspects

Abramson C, Wilton J. J Am Podiatr Med Assoc

1992;82:116-23.

A common podiatric procedure is electric burr reduc­tion of hyperkeratotic onychomycotic toenails. A largequantity of nail dust aerosol is produced that, wheninhaled, easily reaches the bronchi and alveoli and is de­posited there. In this study the authors report a significantincidence of clinical symptoms in podiatrists chronicallyexposed to nail dust. These include conjunctivitis, rhini­tis, asthma, persistent coughing, and impaired pulmonaryfunction. A high level of serum IgE and precipitin anti­bodies to Trichophyton rubrum was also recorded. Cur­rently, dust extractors are not required by law.

Stuart J. Salasche. MD

N-of-one clinical trials: the practice of environ­mental and occupational medicine

Hodgson M. J Occup Med 1993;35:375-80.

This article reviews the N-of-one clinical trial conceptand extends the principles to the cause-and-effect ques­tion that arises in sorting our environmental or work-re­lated contribution to disease. A hypothetical case presen­tation is given, with discussion of the methods used to de­termine whether the patient's symptoms were related towork activities. Use of a clinical model of causation withpower that would help physicians have reasonable cer­tainty about causal relations would be helpful for the pa­tient, for legal inquiries, and for employers since random­ized exposure trials (for example) raise ethical concerns.The N-of-one clinical trial approach may also be appli­cable to evaluating exogenous exposures and skin disease.

Elizabeth F. Sherertz, MD

The influence of food on 8-methoxypsoralenserum concentration and minimal phototoxicdose

Bech-Thomsen N, Angelo HR, Knudsen EA. Br JDermatol 1992;127:620-4.

The influence of food on the kinetics of a liquid formu­lation of 8-methoxypsoralen (8-MOP) was studied in 10healthy volunteers. Each volunteer took 8-MOP, 0.46 to0.56 mg/kg, on three separate mornings, 3 days apart

under three conditions: fasting overnight, 1 hour after alow-fat breakfast, and 1 hour after a fat-rich breakfast.The 8-MOP serum levels at 0.5 and 1.0 hour, measuredby a modified high-pressure liquid chromatographymethod, were significantly higher after fasting than aftereither the low-fat or fat-rich meal. The fat content of fooddid not affect the serum drug level.Photosensitivity at 0.5to 4 hours after drug ingestion as measured by the min­imal phototoxic dose response was greatest when 8-MOPwas taken during fasting. Ingestion of the drug with foodto decrease nausea and other side effects delayed the timeto the lowest minimal phototoxic dose. Intraindividualvariations related to food intake were lowest at 2 hoursafter drug ingestion. For patients with irregular dietaryhabits, unexpected phototoxic reactions can be decreasedby delaying the time of UVA exposure to 2 hours afterdrug ingestion.

Elizabeth A. Abel, MD

Oral acyclovir to suppress frequently recurrentherpes labialis: a double-blind, placebo-controlledtrial

Rooney JF, Straus SE, Mannix ML, et a1. Ann In­

tern Med 1993;118:268-72.

This study consisted of22 patients (20 completed) whowere selected from 56 patients who reported six or morerecurrences of herpes simplex labial is per year. These 56patients were observed for 4 months; only those who hadtwo or more episodes (one of which was culture-proven)were enrolled. This study involved a 4-month treatmentphase with a cross-over phase. Both the number of recur­rences and the time to first recurrence after active ther­apy were statistically significantly reduced. This studyestablished the effectiveness of this therapy for recurrentherpes labialis,

Jeffrey P. Caller, MD

Bacillary angiomatosis and bacillary splenitis inimmunocompetent adults

Tappero JW, Koehler JE, Berger TG, et a1.Ann In­

tern Med 1993;118:363-5.

Bacillary angiomatosis, a disorder most commonlyseen in patients with HIV infection, was confirmed byclinical, microbiologic, and molecular biologic data in fiveimmunocompetent patients.

Clay J. Cockerell, MD

484 Pearls ofwisdom

Multiple sclerotic fibromas of the skin: a cutane­ous marker of Cowden's disease

Requena L, Gutierrez J, Sanchez-Yus E. J CutanPathol1992;19:346-51.

The authors report a case of Cowden's syndrome asso­ciated with multiple sclerotic fibromas of the skin. Thisrepresented the primary cutaneous manifestation of thesyndrome in this patient who also had colonic polyposisand Hodgkin's disease. Although previously reported, theauthors call attention to the fact that multiple sclerotic fi­bromas may be seen in lieu of or in addition to trichilem­momas in this cutaneous genodermatosis.

Clay J. Cockerell, M D

Histologic features predictive of basal cell carci­noma recurrence: results of a multivariate analy­sis

Dixon A Y, Saing HL, McGregor DH. J CutanPathol 1993;20: 137 -42.

The authors had previously identified several variablesassociated with basal cell carcinoma recurrence, namely,close proximity of tumor to surgical margin, infiltrative,morpheaform or superficial multicentric pattern, "spiky"shaped aggregations ofcells, poorly developed peripheralpalisading of nuclei, and marked nuclear pleomorphism.This study performed a multivariate analysis 0 f thesedatato assess the relative importance of these factors. It wasdetermined that resection margin distance, growth pat­tern, and shape of cell aggregations were the most impor­tant predictors of recurrence and could be used to give apredicted probability of recurrence using a logistic re­gression equation. COMMENT: Although models such asthese are worthwhile attempts at predicting biologic be­havior, they are often difficult to apply and are limited inaccuracy by the inherent subjectivity of the observer. Thebest predictor of nonrecurrence remains surgical excisionwith appropriate margins.

Clay J. Cockerell, M D

Immunoblotting of streptococcal antigens in gut­tate psoriasis

McWilson AG, Clark r, Heard SR, et al. Br J Der­mato11993;128:151-8.

The immune response to streptococcal antigens wasstudied by means of immunoblotting in 26 patients witha first or recurrent episode of acute guttate psoriasis.Eighteen (18) of the 26 patients responded to streptococ­cal antigens. Antibody detection scores from patients withacute guttate psoriasis were significantly higher than

Journal of the American Academy of DermatologyMarch 1994

control subjects. Because monoclonal antibodies againstgroup A streptococci cross-react with normal and psori­atic epidermis, and because computer-assisted analysis ofthe amino acid sequences of the streptococcal M-6surface protein (common to streptococcal groups A, C,G) show almost 20% identity with several types of humankeratin, an immunologic response to streptococcal pro­teins may cause acute guttate flares of psoriasis.

Mark V. Dahl, MD

Epidemiology of lymphomatoid papulosis

Wang HH, Lach L, Kadin ME. Cancer1992;70:2951-7.

This case study of patients with lymphomatoid papu­losis characterizes 57 patients and compares them with 67individually matched control subjects. Of the patientswith lymphomatoid papulosis three had a history ofHodgkin's disease, three had non-Hodgkin's lymphoma,and 10 had mycosis fungoides. Patients with lymphoma­toid papulosis have a significantly increased frequency ofprevious or coexisting lymphoproliferative disorders, anincreased frequency of nonlymphoid malignant lesions,and exposure to radiation therapy.

Mark V. Dahl, MD

Apocrine carcinoma of the skin: a clinicopatho­logic immunocytochemical and ultrastructuralstudy

Paties C, Taccagni GL, Papotti M, et al. Cancer1993;71:375-81.

Six primary apocrine carcinomas were identified andevaluated extensively.The clinical courseof these patientsshowed that three of the six had no evidence of disease 2to 4 years after diagnosis, whereas two were alive withdisease 3 to 10 years after diagnosis. One patient died ofother causes 2Y2 years after presentation. The authorsoutline their most reliable criteria for diagnosis of apo­crine carcinoma of the skin. These include (1) decapita­tion secretion, (2) periodic acid-schoff-positive, diastase­resistant staining in the cells or lumina, and (3) positiveimmunostaining for gross cystic disease fluid protein 15(a histiocytic secretive marker).

Mary E. Maloney, MD

Treatment of oral Kaposi sarcoma with intrale­sional vinblastine

Epstein JB. Cancer 1993;71:1722-5.

Kaposi's sarcoma (KS) can be difficult to treat. In thisstudy 31 patients with oral KS were treated with a single

Journal of the American Academy of DermatologyVolume 30, Number 3

intralesional vinblastine injection of 0.2 rng/ml (with arange of volume of 0.8 to 4.0 ml). The largest or mostsymptomatic lesion treated was reported. Twenty patients(48%) had a 75% to 100% reduction with six having acomplete remission. An additionalll patients (26%) hada 50% to 75% reduction in the tumor. Pain was the mostfrequent complication, but lasted only 1 to 2 days. Dura­tion of response was 4.25 months (as measured in time torecurrence). The duration of response is similar to thatreported with radiation or systemic chemotherapy. Assingle injection therapy, intralesional vinblastine mayprovide a useful option, especially with more limitednumbers of lesions.

Mary E. Maloney, MD

Diagnostic outcome in children with multiple ca­fe-au-lalt spots

Korf BR. Pediatrics 1992;90:924-7.

Forty-one children, I month to 14 years old, with six ormore cafe-au-lait spots were examined annually for atleast 2 years. The diagnosis was usually made before 5years of age. Other signs of neurofibromatosis type 1(NF-l) appeared in 24 of the 41 children: skinfold freck­ling (18), Lisch nodules (5), and neurofibromas (3). Seg­mental neurofibromatosis was found in six of the children.Other diagnoses were made in three children, includingmultiple lentigines syndrome, polyostotic fibrous dyspla­sia, and Bannayan-Riley-Ruvalcaba syndrome. The au­thor concluded that a definite diagnosis, usually of NF-1,can be established in most children with multiple cafe­au-lait spots by regular physical and ophthalmologic ex­aminations.

Amy S. Paller, MD

Eosinophilic pustular folliculitis in infancy andchildhood

Duarte AM, Kramer J, Yusk JW, et al. Am J DisChild 1993;147:197-200.

The authors describe nine infants with eosinophilicpustular folliculitis and note that the entity should beconsidered in the differential diagnosis of pustular disor­ders of infancy. All of the infants had recurrent crops ofpruritic papules and pustules, particularly on the scalpand brow regions of the face. Smears showed manyeosinophils and peripheral eosinophilia was common. Bi­opsy specimens of lesional skin revealed large numbers ofperifollicular and often dermal eosinophils, Most patientsresponded to topical corticosteroid preparations and/orsystemic antibiotics.

Amy S. Paller, MD

Pearls ojwisdom 485

DNA repair and aging in basal cell carcinoma: amolecular epidemiology study

WeiQ, Matanoski GM, Farmer ER, eta1. ProcN atlAcad Sci USA 1993;90:1614-8.

The D~A repair capacity of patier.ts with basal cellcarcinoma was compared with that of control subjects.An age-related decline in DNA repair capacity was ob­served, amounting to 0.61%per year in controls. ReducedDNA repair capacity was an especially important riskfactor for young persons with basal cell carcinoma or witha family history of skin cancer. The authors postulate thatthe normal decline in DNA repair with age may accountfor the increased risk of skin cancer that begins in mid­life and also suggest that occurrence of skin cancer inyounger persons may represent precocious aging.

lVeaIS.Penneys,AfD

Painful gingivitis may be an early sign of infec­tion with the human immunodeficiency virus

Rowland RW, Escobar MR, Friedman RB, et a1.Clin Infect Dis 1993;16:233-6.

Seven of 20 patients with painful gingivitis were serop­ositive for HIV. Three of these patients were unaware oftheir HIV infection. Painful gingivitis may be an earlysign of HIV infection.

NeaIS.Penneys,AfD

Associated sensitization to latex and chestnut

Anibarro B, Garcia-Ara MC, Pascual C. Allergy1993;48:130-1.

A child with a history of contact urticaria to latexmedical devices had urticaria and angioedema after eat­ing chestnuts. Prick and RAST tests confirmed theimmediate reactions to latex. Oral challenge with chest­nuts reproduced the urticaria. There appeared to becross-reactive peptides that may cause the cross-sensitiv­ity between latex and chestnut. Add chestnuts to the list(along with banana and avocado) of foods of whichlatex-allergic patients should be wary.

Elizabeth F. Sherertz, MD

Antibiotic therapy for cat-scratch disease: clini­cal study of therapeutic outcome in 268 patientsand a review of the literature

Margileth AM. Pediatr Infect Dis J 1992;11:474-8.

Two hundred two patients with cat-scratch disease re­ceived 18 different antimicrobial agents during 24 months

486 Pearls of wisdom

in an uncontrolled, retrospective study of 268 patientswith the disease. Clinical improvement and 3 or moredays of therapy were the basis for effective therapy.Fourteen agents had little or no benefit. Four were effi­cacious: rifarnpin (87% effective), ciprofloxacin (84%),trirnerhoprim-sulfarnethoxazole (58%), and gentamicinsulfate, intramuscularly (73%) . Antibiotic therapy iswarranted for patients with severe cat-scratch disease.However, most patients require only symptomatic treat­ment.

Kenneth J. Tomecki, MD

A controlled trial of antimicrobial prophylaxisfor Lyme disease after deer-tick bites

Shapiro ED, Gerber MA, Holabird NB, et al. NEngl J Med 1992;327:1769-73.

Three hundred eighty-seven subjects who had beenbitten by deer ticks in an area endemic for Lyme diseasereceived either arnoxicillin (53%) or placebo (47%) for 10days in a double-blind, placebo-controlled study to assessrisk of infection with Borrelia Burgdorferi and efficacy ofprophylactic treatment Evaluation for signs of disease,which lasted a year, revealed erythema migrans in twosubjects, both of whom received placebo, and no sign ofasymptomatic seroconversion (via serum sampling forantibodies at 6 weeks and 3 months) or late manifesta­tions of disease. Of 344 examined deer ticks, 15% wereinfected with B. burgdorferi. In this study the risk of in­fection was 1.2%, too low to warrant prophylactic antibi­otic treatment.

Kenneth 1. Tomecki, MD

Journal of the American Academy of DermatologyMarch 1994

Bottom Line Basic Science BrowsersSkn-La and Skn-Ii: two functionally distinctOct-2-related factors expressed in epidermis

Andersen B, Schonemann MD, Flynn SE, et al.

Science 1993;260:78-81.

A genefamilywitha DNA binding site called thePOUdomain regulates differentiation in the neurons, pituitary,and B lymphocytes. A 38 kd similar protein was clonedfrom epidermis and shown to be expressed in skin andcortex of hair. A second spliced form, lacking the N-ter­rninal region that inhibits DNA binding, was also foundin skin and shown to activate the promoter of keratin 10which is expressed with differentiation of epidermis.

Bottom line: Sknl ali may regulate epidermal develop­ment. This may be the discovery we've all been waitingfor!

Preferential migration of activated CD4+ andCD8+ cells in response to MIP-la and MIP-lb

Taub DD, Conlon K, Lloyd AR, et al. Science

1993;260:355-7.

Human macrophage inflammatory protein (MIP-Iaand M IP-l b) attracted only activated T cells, not un­stimulated ones. MIP l-a attracted CD4+ (helper) T cellsand MIPI-b attracted CDS+ (suppressor) T cells. Acti­vated naive and memory cells also migrated and boundbetter to endothelial cells. Thus MIP cytokines recruitspecific T-cell subsets during the immune response.

Bottom line: The migration of T cells into skin keepsdermatologists in practice busy,' therefore they shouldknow what causes this and eventually how to prevent it.

Madeleine Duvic, MD

What disorder may be associated with the appearance of peculiar orange blotches

when the skin is rubbed or scratched?Jeffrey D. Bernhard, MD

Answer will appear in Part I or the April issue of the JOURNAl..