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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

Low-dose methotrexate is an effective agent in the treatment of psoriasis. However, haematological and hepatic side-effects may necessitate termination of treatment. Leucovorin has been used to prevent toxicity from high- dose methotrexate used to treat neoplastic diseases. In 1988 we reported on two psoriatic patients who developed severe pancytopenia due to low-dose methotrexate. Following failure of other therapeutic agents we restarted methotrexate. Treatment with methotrexate was successfully rein-stituted in these two patients by the use of oral leucovorin for 48 h commencing 18 h after methotrexate. Neither patient experienced recurrence of pancytopenia or deterioration of renal or hepatic function. The literature discussing the use of leucovorin with low-dose methotrexate in the treatment of psoriasis is reviewed. We suggest that leucovorin may decrease the toxicity and expand the usefulness of methotrexate in dermatological and other diseases, particularly in patients considered to be at risk of ...

Background: Hyperlipidemia has received little attention as a side effect of cyclosporine therapy for severe psoriasis. Objective: We report changes in fasting serum lipids in patients treated with low-dose oral cyclosporine for psoriasis and discuss their significance. Methods: Twenty-two patients with severe, recalcitrant, plaque-type psoriasis were treated with cyclosporine, 5 mg/kg/day, for 12 to 16 weeks. Fasting serum lipid levels (triglycerides, cholesterol, and high-density lipoproteins) were measured at 2-week intervals. Results: The mean serum triglyceride level increased from 117.8 ± 11.7 mg/dl before initiation of therapy to 183.9 ± 31.4 mg/dl after 2 weeks of treatment, without further significant change during the remainder of the study ( p p p Conclusion: Serum lipids should be closely monitored in psoriasis patients receiving intermediate or long-term therapy with cyclosporine, especially in the presence of elevated baseline values.

• Background and Methods.— Because acne is androgen dependent, antiandrogen therapy might improve the condition. Inocoterone acetate (RU 882) is a nonsteroidal antiandrogen that binds to the androgen receptor and has antiandrogenic activity in animal models. To test its topical effect on acne, 126 male subjects with facial acne completed a 16-week, multicenter, double-blind study in which the twicedaily application of a 10% solution of inocoterone was compared with vehicle solution. Baseline and monthly examinations included acne lesion counts and general and endocrine laboratory tests. Results.— Inflammatory papules and pustules showed greater reduction in the inocoterone-treated subjects than in the subjects treated with vehicle. This difference achieved statistical significance by week 12 (24% reduction vs 10%) and week 16 (26% reduction vs 13%) and, with longitudinal analysis, throughout the course of the study. Global assessments and changes in comedo counts and sebum excretion rates were not significantly different between the groups. No serious adverse reactions were encountered. Conclusions.— In this double-blind study of 126 male subjects with acne, a topical solution of the antiandrogen inocoterone, compared with vehicle, produced a modest but statistically significant reduction in the number of inflammatory acne lesions. ( Arch Dermatol. 1992;128:1197-1200)

Background: Patients with tinea pedis often discontinue treatment before eradication of the fungus when their symptoms improve. The result is an incomplete cure/recurrence. Objective: Terbinafine, a topical fungicidal agent, was evaluated in double-blind, placebo-controlled trials (159 patients) for its abilityto achieve cure and relief of symptoms in the same time frame, that is, before compliance wanes. Methods: Mycologic characteristics (with potassium hydroxide examination and culture) and clinical signs and symptoms were assessed at baseline, at the end of a 1-week, twice-daily treatment and at 1, 3, and 5 weeks after the completion of therapy. Results: Both terbinafine and vehicle provided early relief of symptoms. However, only terbinafine gave progressive mycologic improvement such that at 5 weeks after treatment, 88% of the patients receiving terbinafine had converted from positive to negative mycology compared with 23% of the patients treated with vehicle. Conclusion: The rapid and potent fungicidal action of terbinafine results in a high cure rate in interdigital tinea pedis with 1 week of treatment and may avoid failures caused by noncompliance.

Background: Epithelioid sarcomas are rare mesenchymal tumours that infrequently present to dermatologists. The often banal spindle and polygonal cell histology can mimic granulomas. Objective: Our aim is to raise the clinician's awareness of a potentially devastating malignancy that can remain unsuspected. Method: We present a case of an epithelioid sarcoma that was misdiagnosed as a benign foot ulcer and treated as such for nearly half a year. An uncertain histology further delayed definitive treatment. At the time of surgery, the tumour had infiltrated deeply. Conclusion: The often nondescript clinical and histologic nature of epithelioid sarcomas demands a high level of vigilance on the part of the clinician.

Background: Nonsteroidal anti-inflammatory drugs (NSAIDs) have been an important therapy in the treatment of a large number of cutaneous pathologies for more than three decades. Objective: In this retrospective review, we document the use of NSAIDs in more than 15 common and uncommon dermatoses, including acne, psoriasis, sunburn, erythema nodosum, cryoglobulinemia, Sweet's syndrome, systemic mastocytosis, as well as urticarial, livedoid, and nodular vasculitis. NSAIDs act mainly by inhibiting prostaglandin synthesis by the cyclooxygenase (COX) pathway. Conclusion: Recent studies link prostaglandin to cutaneous carcinogenesis, thus expanding the dermatologic use of NSAIDs. They may be effective in the treatment and prevention of non-melanoma skin cancer, and specific COX-2 inhibitors promise safer, broader, long-term use of these pharmacologically innovative drugs. Antecedents: Depuis plus de trois decennies, les anti-inflammatoires non steroidiens (AINS) ont joue un role important dans le traitement de nombreuses dermatoses. Objectifs: Dans cette etude retrospective, nous documentons l'usage d'AINS dans plus de 15 dermatoses frequentes et peu frequentes, notamment l'acne, le psoriasis, les coups de soleil, l'erytheme noueux, la cryglobulinemie, le syndrome de Sweet, la mastocytose systemique ainsi que les vascularites urticariens, livedoides et nodulaires. Les AINS agissent principalement en inhibant la synthese des prostaglandines par les voies d'acces de la cyclooxygenase. Conclusion: Des etudes recentes ont lie la prostaglandine a la carinogenese cutanee, elargissant ainsi l'usage des AINS en dermatologie. Les AINS peuvent etre efficaces dans la prevention et le traitement des cancers de la peau benins. Les inhibiteurs de COX-2 promettent de produire des medicaments innovateurs plus surs, a usage plus etendu, a plus.

In their 60-year history, dapsone and the sulfones have been used as both antibacterial and anti-inflammatory agents. Dapsone has been used successfully to treat a range of dermatologic disorders, most successfully those characterized by abnormal neutrophil and eosinophil accumulation. This article reviews and updates the chemistry, pharmacokinetics, clinical application, mechanism of action, adverse effects, and drug interactions of dapsone and the sulfones in dermatology.

Lichen planus is often found in association with a variety of underlying conditions. In particular, liver diseases such as primary biliary cirrhosis, primary sclerosing cholangitis, hepatitis C, and hepatitis B have been implicated in cutaneous lichen planus. Of interest, there is mounting evidence that lichen planus-like eruptions can occur following administration of the hepatitis B vaccine, which has recently become a routine immunization in many parts of the world. We present what we believe to be the first North American case of lichenoid drug eruption associated with the hepatitis B vaccine and provide a brief review of other reported cases of lichenoid eruption seen following hepatitis B vaccination.

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.

Background: The clinical characteristics of photodamaged skin, such as coarse and fine wrinkling, sallowness, hyperpigmentation, tactile roughness, laxity, and erytherma, are not accurately evaluable from photographic records. Objective: The purpose of this study was to develop accurate and reproducible photographic techniques that generate an evaluable record of the characteristics of photodamaged skin. Methods: The method used involved illumination and photography through polarizing filters (polarized light photography). Results: Polarized light photography generates images that selectively enhance either the surface features or the subsurface features of the skin, providing an accurate and evaluable record for evaluation of photodamaged skin. Conclusion: Polarized light photography, when coupled with precise framing and mapping, yields an accurate and evaluable record of photodamaged skin.

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.)

We report the first case of primary cutaneous aspergillosis caused by Aspergillus ustus , a species that seldom infects human beings. The patient, a 62-year-old liver transplant recipient with end-stage hepatitis C-induced cirrhosis, was receiving the experimental immunosuppressive drug FK-506. Trauma to the skin of the right arm from tape and from an arm board holding intravenous and intraarterial catheters in place and to the left leg from an occlusive knee brace may have contributed to this unusual mycosis. The patient's cutaneous aspergillosis responded to a combination of intravenous amphotericin B and topical terbinafine cream. Although the patient died shortly thereafter from hepatic failure, there was no evidence of systemic aspergillosis. (J Am Acad Dermatol 1994;31:344-7.)

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.

The epidemic of human immunodeficiency virus type 1 (HIV-1) has emerged among children as a major public health problem in the United States and in many countries of the world. Pediatric acquired immunodeficiency syndrome (AIDS) was first reported to the Centers for Disease Control (CDC) in 1982. 1 By October, 1989, a total of 1908 cases of AIDS in children under the age of 13 had been reported to the CDC. 2 Selected hospitals in Newark, NJ, Miami, FL, and New York now report seropositivity in 3–4% of newborns, and experts project 6,000–20,000 cases of AIDS among children in the United States within the next several years. 3

• 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)