Clinical Dermatology

>масиmin A deficiency results in the development of hyperkeratosis and scaling skin lesions. Not surprisingly, this observation has led many clinicians to treat various types of keratinizing disorders with vitamin A. Some beneficial effects were noted, but vitamin A toxicity often supervened before adequate therapy had been accomplished. This led to a search for safer variants of the vitamin A molecule. The first clinically successful retinoid was the trans form of retinoic acid (Tretinoin, Retin-A), which, when topically applied to the face in acne patients, results in loosening and dissolution of the follicular plugs responsible for the initiation of acne lesions. Considerable unwanted inflammation occurs concomitantly with this keratolytic effect, but in spite of this drawback, topically applied transretinoic acid remains a first-line medication in the treatment of acne. Recently, several studies have demonstrated that topically applied tretinoin can, at least to a modest degree, reverse the cutaneous effects of photoaging.

Two retinoids, the cis form of retinoic acid (Isotretinoin, Accutane) and the aromatic retinoid (Etretinate, Tegison), are available for oral use in the United States. The former has shown remarkably good results in the treatment of acne, and both produce considerable improvement in some of the papulosquamous diseases such as psoriasis, lichen planus, pityriasis rubra pilaris, Darier’s disease, and ichthyosis. The retinoids also have an antioncogenic effect. Specifically, there is about a 40% response rate in patients with mycosis fungoides and other forms of cutaneous T-cell lymphoma. One can also temporarily delay the appearance of skin tumors in patients with xeroderma pigmentosum and nevoid basal cell carcinoma syndrome.

The dosage of isotretinoin used in acne patients is 0.5 to 1.5 mg/kg. For practical purposes a decision is usually made to use either 40 or 80 mg/ day. The lower dose is associated with£ewer side effects and thus has better patient compliance. Unfortunately, the interval until return of sebaceous gland function and the reappearance of acne is shorter (6 to 18 months) than it is when the larger dose is used. The beneficial effect in acne occurs as a result of dissolution of the follicular plug, reduction in sebaceous gland size and activity, and, possibly, antibacterial and anti-inflammatory effects.

Etretinate (Tegison) is the retinoid usually used for the treatment of psoriasis and other papulosquamous diseases. Usually, dosage is limited to 1.0 mg/kg (75 mg/day) because of the onset of unacceptable side effects above that level. Etretinate has a particularly good effect in pustular psoriasis, but for the other forms, PUV A therapy is sometimes added (RePUV A-retinoids plus PUV A) to obtain an optimal response.

Many toxic effects are associated with the oral use of retinoids. Patients taking isotretinoin for acne regularly develop severe xerosis and cheilitis. Less often, myalgia, arthralgia, conjunctivitis, epistaxis, and hair loss are experienced. Triglyceride levels increase in these patients and must be monitored. Cholesterol levels may also rise, and some disturbance in liver function studies may be noted. Long-term administration is accompanied by idiopathic calcification of the spine in an unknown percentage of patients.

Of greatest importance is the fact that the retinoids are among the most potent teratogens ever used in medicine. Retinoids may not be given until it is certain that a patient is not already pregnant, and pregnancy must then be prevented until 2 months after 13-ci,-retinoic acid is discontinued, The teratogenic risk with isotretinoin cannot be overemphasized; tragic birth defects have been reported all too often through careless prescribing and contraceptive failure. Etretinate, because it remains at detectable levels for years after its use has been stopped, cannot be given to women capable of conceiving.

A wart is a lump on the skin produced when a virus invades skin cells and causes them to multiply rapidly. Some people have a low resistance to the various viruses that can cause warts and are therefore more likely to have them. Wart viruses spread by touch or by contact with the skin shed from a wart.

Warts are common in teenagers, less so in children, and even less so in adults. There are no serious health risks associated with warts, but they can cause embarrassment because of their appearance.

What are the symptoms of Warts?

There are several different types of warts, each produced by a specific virus. The common wart, also called a verruca or a plantar wart, is a small, hard, horny, white or pink lump with a cauliflower-like surface. Inside are small, clotted blood vessels that resemble black splinters. The common wart can grow anywhere on your body but is most likely to develop on your hands. On the bottoms of your feet and palms of your hands, a common wart tends to become pushed in so that its surface is level with the rest of the skin. Several warts may appear next to one another on your foot, forming a mosaic-like area 25 mm (1 in) or more across.

Common warts on most parts of the body are usually painless. However, a wart on the underside of your foot can make you feel quite uncomfortable, as though you are walking with a stone in your shoe.

Among the other types of warts are plane warts, which are small, brown, smooth warts that occur most often on children’s faces .Another type of wart is called molluscum contagiosum. These are tiny, white, pearly lumps, each with a central depression. These are also most common in children. peline warts and vulval warts also occur.

What should be done?

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Most warts disappear naturally, often within a few months but sometimes over several years. You may prefer to wait for this to happen. But if you have any warts that you consider unsightly or annoying, carry out the self-help described below to remove them.

However, there are two cases in which you should consult a physician. One is if you penile or vulval warts. The other is if you develop any sort of wart and you are over the age of 45. In older people, what looks like” wart may be a more serious skin condition. such as skin cancer.

What is the Treatment of warts?

Self-help: There are many folk remedies for removing warts, but their apparent effectiveness is simply due to the fact that most warts eventually disappear of their own accord. The best way to treat unsightly warts is to apply a wart remedy in the form of paint. cream or plaster. These are available without a prescription at most drugstores. These preparations contain chemicals that destroy the abnormal skin cells. However, these chemicals will also damage surrounding healthy cells, so the preparations should always be applied carefully to minimize soreness.

Do not treat warts on your face or genitals with a wart remedy, because the skin on these areas is very sensitive. And never allow these preparations to get into your eyes.

If you have an unsightly or annoying wart that does not respond to this treatment, see your physician.

Professional help: Your physician may prescribe a more effective kind of wart preparation. If this fails, the doctor can remove the wart by freezing it with liquid nitrogen or burning it off with electricity. A few days after this rather painful treatment, the wart will probably fall off. If it does not, repeated treatment should remove it. As an alternative to freezing or burning, a wart can be scraped off (curettage) after first being numbed by a local anesthetic. Occasionally a wart seems to be resistant to all forms of treatment.

Considerable controversy exists regarding the degree to which psychologic factors can adversely affect the skin. But even those who doubt the etiologic effect of psychic disability recognize that the presence of skin disease often results in the development of anxiety or depression. Whether cause or effect, these psychologic factors can often be handled by a simple, common sense approach: warmth, a willingness to listen, and support. When more than this is needed, the clinician must be ready either to treat the patient with psychotropic medication or to offer appropriate referral.

Benzodiazepines such as chlordiazepoxide (Librium), diazepam (Valium), and the shorter acting agent alprazolam (Xanax) are useful adjuncts in the treatment of associated anxiety. They are particularly helpful in the control of pruritus and will often work in situations where antihistamines alone have failed. As in the case with antihistamines, the usefulness of the benzodiazepines, particularly Librium and Valium, is often limited by the side effect of drowsiness. This can be partially circumvented by the administration of chlordiazepoxide (10 to 25 mg) or diazepam (5 to 10 mg) at suppertime and, if necessary, again at bedtime. These medications are particularly helpful in the control of the nighttime scratching that is so characteristically present in patients with atopic dermatitis. They are also worth trying in chronic urticaria unresponsive to conventional antihistamine therapy. Habituation, of course, is a problem of considerable importance. This risk can be lessened by avoiding the use of these agents in people with past drug-dependency problems, by limiting the number of pills prescribed, and by sharp restriction on refills.

Phenothiazines such as chlorpromazine (Thorazine) and trifluoperazine (Stelazine) are at least as effective as the benzodiazepines. They are used less often because of a greater frequency of side effects and because of a widespread belief that they are too potent to be used by clinicians other than psychiatrists. The phenothiazines have a chemical structure that is very close to that of some of the antihistamines. It is possible that the efficacy of both groups of drugs depends on their mixed antihistaminic and tranquilizing effect.

Recently, a new, nonsedating, non habituating anxiolytic agent (buspirone, Buspar) has become available. It differs from the above agents inasmuch as it acts on serotonin receptors rather than on y-aminobutyric acid (GABA) receptors. In my experience it is somewhat less effective than the benzodiazepines, but I use it fairly frequently because of its excellent safety profile. I generally start with a dose of 5 mg b.i.d. and increase to a final dose of 10 mg b.i.d.

Depression is a problem that is overlooked to an even greater degree than anxiety. I believe that it is present in at least 10% to 20% of patients with serious dermatologic disease. Mild depression often improves as the skin disease clears and, of course, requires no specific therapy. Depression of greater severity deserves greater attention. Patients should be offered the opportunity for psychotherapy or medical treatment or both. Endogenous depression is thought to be more amenable to treatment with medication than are other forms of depression, but many clinicians believe that a therapeutic trial is worthwhile regardless of diagnosis.

The tricyclics amitriptyline (Elavil) or doxepin (Sinequan, Adapin) given in a single daily dose at bedtime are used most often. The usual starting dose with either is 25 mg, but this can gradually be increased to 150 mg as necessary. The tricyclics are extraordinarily effective antihistamines and appear to be particularly effective in the treatment of resistan t chronic urticaria. Imipramine (Tofranil) is also effective and may be somewhat less sedating. Both physician and patient need to remember that the maximum effect of these medications is not apparent until they have been taken for 3 weeks. Side effects of drowsiness and confusion are fairly common, but other more serious cardiovascular and CNS side effects are only rarely seen.

Toxicity associated with the use of tricyclics often leads to a low level of patient acceptance. Several other alternative drugs are available and are well worth trying in certain circumstances. Alprazolam (Xanax) has antidepressant effects as well as the anxiolytic effects. Trazodone (Desyrel) is chemically unrelated to the tricyclics and appears to function as a serotonin antagonist. Fluoxetine (Prozac) is another serotonin antagonist that produces very little drowsiness. Recently, some concerns have been raised about its ability to potentiate suicidal ideation, but most doubt that this occurs. I have used it very effectively in a dosage of 20 mg each morning. Clomipramine (Clozaril) may have particularly good effect on obsessive-compulsive disorders such as trichotillomania, but high cost and concerns about safety have kept it from more widespread use.