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We report the first case of acquired dermal melanocytosis (ADM) appearing during pregnancy. A 23-year-old Hispanic woman presented to the Dermatology Clinic of Columbia-Presbyterian Medical Center during the second trimester of pregnancy with a nonpalpable blue-gray patch with interspersed discrete brown macules on the right lower extremity. It had appeared during the first trimester of pregnancy. Cutaneous biopsy specimens revealed dermal melanocytes. A review of all reported cases of this rare dermatosis in the international literature is presented. (J Am Acad Dermatol 2001;45:609-13.)

Background: Doxepin applied topically by itself or in combination with triamcinolone acetonide is a safe and effective treatment for atopic dermatitis. Objective: We evaluated the pharmacokinetic profile of doxepin and desmethyldoxepin after topical application of doxepin hydrochloride 5% cream alone or in combination with 0.025% triamcinolone acetonide (doxepin/TAC). Methods: Twenty-four subjects with atopic dermatitis received either doxepin or doxepin/TAC cream 4 times daily for 7 days in a randomized, double-blind, controlled trial. Serum samples were obtained and pharmacokinetic parameters estimated from the dose-normalized serum concentrations of doxepin and desmethyldoxepin. Efficacy and adverse experiences were determined by physician and subject evaluations. Results: Pharmacokinetic parameters (K e , t 1/2 and AUC) calculated in 9 subjects (doxepin/TAC = 4 subjects, doxepin=5 subjects) with detectable serum concentrations were similar for both groups. Pruritus relief and lessening of pruritus severity were significantly greater with doxepin/TAC than doxepin alone. Conclusion: Topically applied doxepin is safe and effective therapy for pruritus. (J Am Acad Dermatol 1999;41:209-14.)

I. Dicken CH, Carrington SG, Winkelmann RK. Generalized granulomaannulare. Arch DermatolI969;99:556-63. 2. Mobacken H, Gisslen H, Johannisson G. Granuloma annulare:cortisone-glucose tolerancetest in a non-diabetic group. Acta Derm Venereal (Stockh) 1970;50:440-4. 3. Williamson DM, Dykes JRW. Carbohydrate metabolism in granuloma annulare. J InvestDermatol 1972;58:400-4. 4. BlohmeG, MobackenH, WaldenstromJ. Early insulinresponseto glucoseinjectedintravenously in patientswith 10calizedgranulomaannulare. ActaDerm Venereal(Stockh) 1974;54:259-63. 5. Haim S, Friedman-BirnbaumR, Shafir A, et al. Generalized granulomaannulare: relationshipto diabetes mellitus as revealed in 8 cases. Br J DermatoI1970;83:302-5. 6. Hammond R, DyessK, Castro A. Insulin productionand glucosetolerancein patients with granuloma annulare. Br J DermatoI1972;87:540-7. 7. Andersen BL, VerdichJ. Granuloma annulare and diabetes mellitus. Clin Exp Dermatol 1979;4:31-7. 8. Muhlemann MF, Williams DDR. Localized granuloma Briefcommunications 663

Background : Visual examination and cutaneous biopsies, two major tools in dermatologie diagnosis, do not provide structural information regarding the entire tissue volume. Objective : Our purpose was to develop a high-resolution ultrasound system that quickly, with minimal operator interaction, displays structural data on the entire tissue volume. Methods : A prototype ultrasound B-scan system was developed and operated at nominal center frequencies between 35 and 50 MHz, with computer processing of data to produce three-dimensional images. These images displayed as three-dimensional "blocks" can be sectioned to provide multiple images of internal structure (i.e., "acoustic biopsies"). Results : B-scans and associated three-dimensional images were obtained from assorted skin sites in selected patients. Conclusion : This technique provides a valuable diagnostic tool that is now being further evaluated.

A prospective, randomized, double-blind, placebo-controlled multicentre study assessed the clinical efficacy and safety of pulsed electromagnetic limb ulcer therapy (PELUT) in the healing of recalcitrant, predominantly venous leg ulcers. The portable device was used at home for 3 h daily during this 8-week clinical trial as an adjunct to a wound dressing. Wound surface area, ulcer depth and pain intensity were assessed at weeks 0, 4 and 8. At week 8 the active group had a 47.7% decrease in wound surface area vs. a 42.3% increase for placebo (P < 0.0002). Investigators' global evaluations indicated that 50% of the ulcers in the active group healed or markedly improved vs. 0% in the placebo group, and 0% of the active group worsened vs. 54% of the placebo group (P < 0.001). Significant decreases in wound depth (P < 0.04) and pain intensity (P < 0.04) favouring the active group were seen. Patients whose ulcers improved significantly after 8 weeks were permitted to continue double-blind therapy for an additional 4 weeks. Eleven active and one placebo patient continued therapy until week 12, with the active treatment group continuing to show improvement. There were no reports of adverse events attributable to this device. We conclude that the PELUT device is a safe and effective adjunct to non-surgical therapy for recalcitrant venous leg ulcers.

Langerhans cells (LC), the best-understood antigen presenting cells (APC) of the skin, are functionally plastic. Freshly obtained LC readily activate allogeneic T cells, but are incapable of activating autologous, naive T cells. When placed in culture in the presence of GM-CSF, LC up-regulate surface expression of class I and II MHC molecules along with co-stimulatory molecules, such as B7, CD40 and IL-12. This functional transformation enables the cells to activate naive, autologous T cells in vitro. It is paradoxical that intracutaneous administration of exogenous GM-CSF fails to induce intraepidermal LC to undergo functional transformation in situ. It has been reported that serum contains a factor that prevents fresh LC from undergoing functional transformation in culture, and the relevant serum factor has now been identified as haptoglobin (Hp), based on the following experimental results: (a) SDS-PAGE, amino acid sequencing, and mass spectrometric analyses of the inhibitory factor purified by high performance liquid chromatography (HPLC) from normal human serum revealed molecules completely homologous to Hp alpha-1 chain; (b) pure human Hp, but not serum depleted of Hp, inhibited fresh LC from acquiring the capacity to activate autologous T cells in vitro; (c) abundant Hp was detected in cytoplasmic compartments of fresh, but not cultured, LC. It was concluded that Hp, an acute phase protein, is a systemically-derived factor that prevents epidermal LC from spontaneously undergoing functional maturation in the skin. This novel property of Hp may be important in ameliorating or preventing certain T cell-dependent inflammatory skin diseases.

Background: Onychomycosis impairs normal nail functions, causes considerable pain, interferes with daily activities, and has negative psychosocial effects. Objective: Our purpose was to determine patients' perception of onychomycosis on the quality of life. Methods: A total of 258 patients with confirmed onychomycosis were surveyed by telephone at three centers. Responses to a standardized quality-of-life questionnaire were analyzed for patient demographics, physical and functional impact, psychosocial impact, and economic impact. Results: Highest positive responses were nail-trimming problems (76%), embarrassment (74%), pain (48%), nail pressure (40%), and discomfort wearing shoes (38%). Ability to pick up small objects was impaired in 41% of subjects with fingernail involvement. More than 58 onychomycosis-related sick days and 468 medical visits (1.8 per subject) were reported during a 6-month period. Conclusion: Onychomycosis has significant social, psychologic, health, and occupational effects. Relevance of quality-of-life issues to overall health, earning potential, and social functioning should prompt reconsideration of the value of aggressive treatment of and financial coverage for onychomycosis. (J Am Acad Dermatol 1998;38:702-4.)

Low-dose cyclosporine therapy for severe plaque psoriasis is effective. Most side effects can be controlled by patient monitoring, with appropriate dose adjustment or pharmacologic intervention, or both, if indicated. Prevention or reversibility of laboratory and chemical abnormalities may be achieved by discontinuation of therapy after the induction of clearing. However, relapse occurs rapidly on discontinuation. Maintenance therapy with cyclosporine after induction has not been fully evaluated.Our purpose was to compare a regimen of 3.0 mg/kg per day of oral cyclosporine with placebo in maintaining remission or improvement in patients with psoriasis.After a 16-week unblinded induction phase in which 181 patients received cyclosporine, 5.0 mg/kg per day (an increase up to 6.0 mg/kg per day and a decrease to 3.0 mg/kg per day were allowed, if required, to achieve efficacy or tolerability, respectively), those patients showing a 70% decrease or more in involved body surface area (BSA) entered the 24-week maintenance phase and were randomly assigned to either placebo, cyclosporine, 1.5 mg/kg per day, or cyclosporine, 3.0 mg/kg per day. Patients were considered to have had a relapse when BSA returned to 50% or more of the prestudy baseline value. Clinical efficacy, adverse effects, and laboratory values were monitored regularly throughout both study phases.During induction, cyclosporine at approximately 5.0 mg/kg per day produced a reduction in BSA of 70% or more in 86% of the patients. During maintenance, the median time to relapse was 6 weeks in both the placebo and cyclosporine 1.5 mg/kg per day groups, but was longer than the 24-week maintenance period in the 3.0 mg/kg per day group (p0.001 vs placebo). By the end of the maintenance period, 42% of the patients in the 3.0 mg/kg per day cyclosporine group had a relapse compared with 84% in the placebo group. Changes in laboratory values associated with the higher induction dosage generally exhibited partial or complete return toward mean prestudy baseline values during the maintenance phase, with the greatest degree of normalization in the placebo group.Cyclosporine, 3.0 mg/kg per day, adequately and safely maintained 58% of patients with psoriasis for a 6-month period after clearing of their psoriasis with doses of approximately 5.0 mg/kg per day.

Background: Quantification of acne remains a challenge. It may be difficult to identify lesions by standard flash photography. Previous studies have shown that foci of light in fluorescence photographs correspond to high protoporphyrin IX production by Propionibacterium acnes in open comedones, follicles, and inflammatory lesions. Objective: Our purpose was to study the utility of fluorescence photography for evaluation of acne. Methods: Forty subjects with mild to moderate acne vulgaris were randomly selected to apply either clindamycin 1% topical solution or vehicle twice daily. Counts of acne lesions and flash and fluorescence photographs were obtained at baseline, and at 4, 8, and 12 weeks. Results: At 12 weeks, the treatment group had a larger percentage change in open comedones, less fluorescence in all areas assessed, and a larger percent decrease in fluorescence than the vehicle group. Conclusion: Fluorescence photography appears to be a useful tool to chart the course of acne treatment.

Confluent and reticulated papillomatosis is most probably a disorder of keratinization rather than a fungal infection. We describe an 18-year-old man who was effectively treated with high-dose oral isotretinoin. Our review of the literature on confluent and reticulated papillomatosis refutes previously accepted epidemiologic data. (J Am Acad Dermatol 1994:31:327-31.)

Background: Multiple immunologic abnormalities such as impaired T-cell function, elevated serum IgE level, and increased interleukin 4 production have been demonstrated in patients with atopic dermatitis. Objective: As part of a 12-week, multicenter, double-blind, placebo-controlled clinical trial, we evaluated the safety and efficacy of thymopentin (Timunox) as an adjunctive treatment in patients with severe atopic dermatitis. Methods: Thirty-nine patients at least 2 years old with severe atopic dermatitis on a minimum of 20% of their cutaneous surface area were randomly selected to receive either thrice-weekly subcutaneous injections of thymopentin, 50 mg, or placebo. Use of triamcinolone 0.1% or hydrocortisone 1.0% cream and oral antihistamines were permitted during this trial. Results: After 12 weeks, thymopentin-treated patients had significantly greater improvement than those receiving placebo. No thymopentin-related adverse events occurred. Conclusion: Thymopentin may be a safe effective adjunct to therapy in patients with severe atopic dermatitis.

Trichophyton rubrum is the most common cause of tinea pedis, onychomycosis, tinea manuum, tinea cruris, and tinea corporis in the United States, 1-3 but it rarely causes tinea capitis in this country. l, 4 Tinea capitis caused by T. rubrum seldom invades hair. However, endothrix, ectothrix, and rarely endoectothrix infections can occur." Kerion formation has also been reported.v? Tinea capitis is uncommon in adults.' Dermatophytes causing tinea capitis in adults include Trichophyton tonsurans, Trichophyton violaceum. Trichophyton verrucosum, Microsporum canis, Microsporum gypseum, and rarely Trichophyton rubrum.5, 8 Secretion of sebum and colonization by Pityrosporum orbiculare help to protect the scalp against invasion by dermatophytes.v!" When tinea capitis does occur in adults, it is most frequent in postmenopausal women.I We report a case of tinea capitis caused by T. rubrum in a 67-year-old woman with systemic lupus erythematosus (SLE). We believe this chronic disease made her a susceptible target for this unusual dermatophytosis.

Vulvar basal cell carcinoma is rare, accounting for less than 5% of vulvar neoplasms. There is great variation in the clinical appearance of this neoplasm, which occurs most commonly in older women. Metastasis seldom occurs, but the tumor may extend deeply into local tissues. We report the first case of bilateral vulvar basal cell carcinomata in a 66-year-old woman who had received radiotherapy for urethral carcinoma 35 years earlier. Both tumors were treated with Mobs micrographic surgery and have not recurred after 13 years.

Tretinoin administered topically in 0.1% concentration has been shown to improve the wrinkling and irregular pigmentation of photoaged skin.The purpose of this study was to assess the safety and efficacy of various concentrations of tretinoin in a new emollient cream base in the treatment of photoaged skin.Three concentrations of tretinoin (0.05%, 0.01%, and 0.001%) in a new emollient cream formulation were compared with vehicle in a 24-week, double-blind, randomized, multicenter study of 296 subjects with photodamaged facial skin.Tretinoin emollient cream 0.05% gave a significantly better global response to therapy than vehicle (p less than 0.001), with 68% of subjects exhibiting improvement at the end of therapy, compared with 43% of subjects in the vehicle group. An excellent or good response was found in 26% of subjects treated with tretinoin emollient cream 0.05% versus 11% of vehicle-treated subjects. Fine wrinkling, mottled hyperpigmentation, and roughness were more improved in subjects who received tretinoin emollient cream 0.05% than in vehicle-treated subjects (p less than 0.05). No significant difference was found between vehicle and tretinoin emollient cream 0.01% or 0.001%. Histologic examination showed increases in epidermal and granular layer thickness, decreased melanin content and compaction of the stratum corneum after therapy with tretinoin emollient cream 0.05% or 0.01%. Mild to moderate skin reactions, such as erythema, peeling, and burning, were the most common side effects and, although most prevalent in the group using the 0.05% concentration, generally did not limit tretinoin use.Tretinoin emollient cream 0.05% appears to be safe and effective in the treatment of photodamaged skin.

• There are many cutaneous abnormalities in the disorder consisting of mental retardation, broad thumbs and great toes, and characteristic facies known as the Rubinstein-Taybi syndrome. The findings highlighted in this case report are numerous and include, particularly, a tendency to form keloids, hypertrichosis, unusual dermatoglyphics, seborrheic dermatitis, and a possible increased susceptibility to dermatophyte infection. (Arch Dermatol1981;117:504-506)