Search

Background/Objectives Stevens–Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are medical emergencies. Mainstays of treatment include removal of the offending agent, supportive care, and wound care. The use of immunosuppressive agents such as corticosteroids and intravenous immunoglobulin (IVIg) is controversial. Some case reports and small studies report the successful use of cyclosporin A (CsA) for SJS/TEN in halting disease progression, fostering reepithelialization, and reducing mortality. Objective To report on the efficacy of cyclosporine A in the treatment of SJS/TEN in three pediatric patients. Methods We describe three pediatric patients seen at a tertiary care hospital in Boston, Massachusetts, diagnosed with SJS/TEN confirmed by skin biopsy who were successfully treated with CsA with improvements seen in time to cessation of disease progression or new lesion formation, reepithelialization, and duration of hospital stay. Results The average time cessation of disease progression or new lesion formation after CsA administration was 2.2 days (range 1.5–3 days) and average time to remission or reepithelialization was 13 days (range 10–15 days). The average length of hospital stay was 11.7 days (range 4–19 days). Conclusions We describe three pediatric patients treated successfully with CsA and provide evidence for the use of cyclosporine in children with SJS/TEN. These results further support previous observations that CsA use for SJS/TEN produces consistently favorable outcomes. The results in this case series are limited by their observational nature. Additional trials are needed to evaluate the safety and efficacy of CsA use in children.

Background The diagnosis of Lyme disease relies on the accurate diagnosis of erythema chronicum migrans (ECM) because serologic tests, culture, and polymerase chain reactions are often inaccurate. Although ECM is classically associated with a targetoid rash, there are many variants of this lesion. These variants of ECM are often initially diagnosed as cellulitis or spider bite reactions and treated with oral antibiotics. Inappropriate treatment further delays the diagnosis of Lyme disease, leading to late complications. Methods We present four cases of vesiculobullous and hemorrhagic ECM, a less common variant of ECM. Results All four patients had a history of exposure to wooded areas in Massachusetts during the summer months. In these patients, ECM presented with central vesicles and bullae with hemorrhage, crusting, and in some cases necrosis. Serologic testing was positive in three of the four cases at presentation. In one case, microscopic examination of a skin biopsy showed epidermal spongiosis with parakeratosis, focal necrosis, papillary dermal edema, erythrocyte extravasation, and a superficial and deep perivascular lymphocytic infiltrate with neutrophils and eosinophils of the dermis. No fungal organisms or bacteria were identified. All four patients were treated with doxycycline with complete resolution of symptoms. Conclusions It is important to recognize the vesiculobullous and hemorrhagic variants of ECM in order to minimize the provision of inappropriate antibiotic treatment for other diagnoses. Early diagnosis of ECM and the initiation of appropriate antibiotics may prevent late complications of Lyme disease.

Systemic lupus erythematosus (SLE) and chronic cutaneous lupus (CCLE) therapy has changed little over the past 50 years. In March 2011, the US Food and Drug Administration (FDA) approved belimumab, complementing the three preexisting approved therapies: low dose aspirin, prednisone, and hydroxychloroquine.The objectives for this study were to evaluate trends in the medications prescribed for the management of lupus erythematosus (LE) and to assess how treatment varies among different specialists.Outpatient visits for treatment of lupus and its comorbidities were identified in the National Ambulatory Medical Care Survey (NAMCS), a representative survey of visits to physician offices in the United States. Data was evaluated to determine patient demographics, treatments prescribed by each specialty, and comorbidities encountered during the study period of 1993-2010.From 1993-2004, prednisone was the most frequently prescribed medication; however, prednisone became the second most frequently prescribed medication in 2005-2010, as hydroxychloroquine became the leading medication prescribed for LE. In primary care physicians and other non-dermatology specialists, the most frequently prescribed medications for lupus were prednisone and hydroxychloroquine; whereas, hydroxychloroquine and triamcinolone were the top two medications preferred by dermatologists.The NAMCS collects cross-sectional data, such that individual patients cannot be followed over time. Hence, it does not provide data regarding the incidence of disease, patient age at the time of diagnosis, change in individual patient's medication regimens over time, or prognosis related to patient demographics. In addition, it is possible that the physician did not always record nonprescription medication use, such as NSAIDS, since these are typically used first line.First-line treatment of LE changed minimally from 1993 to 2010, with prednisone and hydroxychloroquine serving as the primary medications utilized by most physicians for the management of LE.

This study investigates the importance of communication in surgery and how delivering preoperative patient education can lead to better health outcomes postoperatively, via promoting tolerable pain scores and minimizing the use of narcotics after surgery. Patients who underwent outpatient surgery were randomly divided into groups to compare the pain scores of those who received preoperative patient education, the experimental group, and those who did not receive any form of patient education, the control group. Two weeks before surgery, the experimental group subjects received oral and written forms of patient education consisting of how the body responds to pain, and how endorphins cause natural analgesia. Moreover, patients were educated on the negative effects narcotics have on endorphin production and activity, as well as mechanisms of non-opioid analgesics. Of the 69 patients in the experimental group, 90% declined a prescription for hydrocodone after receiving preoperative education two weeks prior to surgery. The control group consisted of 66 patients who did not receive preoperative patient education and 100% filled their hydrocodone prescriptions. Patients in both groups were offered and received gabapentin and celecoxib preoperatively for prophylaxis of postoperative pain unless they declined. The control groups were found to have average pain scores significantly greater (P