The efficacy of cyclosporine microemulsion preconcentrate (cyclosporine MEPC) in the treatment of severe psoriasis is well-established, as demonstrated by numerous clinical trials. However, many dermatologists still continue to have some concerns regarding its use. These are mainly related to preconceptions about its side effects which include renal impairment and hypertension, and to the lack of guideline for the appropriate and effective use of cyclosporine MEPC in the treatment of severe psoriasis. A Japanese consensus conference was convened following an international conference held in Paris in order to amend The Japanese Guideline for Psoriasis Therapy with Cyclosporine MEPC. Expert reviewers presented and deliberated Japanese as well as international evidence on cyclosporine MEPC related to clinical efficacy, patient selection, and profiles of adverse drug reactions. They reached a consensus as to the proposed recommendations of the use of cyclosporine MEPC. The definition of difficult-to-treat in the context of patient selection for cyclosporine MEPC was changed from a PASI score ≧ 18 to 12, and “patients unsatisfied with the effects of their current therapy” was newly added concerning the impact of psoriasis on patients’ QOL in QOL assessments by patients. Because a dose of 2.5mg/kg/day has been reported to show adequate efficacy, a suggested range of 2.5 to 5.0mg/kg/day was set. Because, at the dose of 2.5 mg/kg/day, 70% improvement of PASI scores was achieved at 12-weeks, it was recommended that the course of subsequent therapy should be re-examined based on the efficacy checked after three months following the start of therapy. Patients’ QOL and patient assessment of efficacy were also added as efficacy outcome measures in addition to PASI score, affected body surface area, and degrees of pustules and pruritus. Serum creatinine level (S-Cr) was recommended as a measure for assessing renal impairment, and it was stated that a detailed kidney test should be performed by a renal specialist if S-Cr levels do not show any improvement about one month after withdrawal of treatment. The Guidelines will be revised in 2004 based on the consensus reached.
Gefitinib (Iressa®) is an epidermal growth factor receptor tyrosine kinase inhibitor that and inhibits the growth of various tumor cells. Fifteen patients out of 41 patients with non-small cell lung cancers who received gefitinib 250mg daily at our hospital during the year of 2002-2003, developed cutaneous side-effects. After reducing the gefitinib dose from every day to every other day, the cutaneous side-effects resolved or decreased. This observation indicates that the cutaneous side-effects are dose-dependent. Skin biopsies were taken from acneiform follicular eruptions, paronychia, and infiltrative erythema. In spite of the differences in the clinical type of eruptions, histologically, enlargement of intercellular spaces in the basal and suprabasal layers were observed in all specimens. Our findings suggest that direct effect of gefitinib on the epidermal growth factor receptor signal pathway in the keratinocytes is related to the cutaneous side effects.
We experienced 33 cases of contact dermatitis syndrome in a duration of 10 years and 4 months from March of 1992 to June of 2002. They included 16 males and 17 females between 17 and 79 years old. Primary regions of localized dermatitis were scalps in 15 cases, upper extremities in 9, and lower extremities in 9. No case was seen on the trunk. We confirmed their causative agents by patch testing, which revealed that the causative products were hair dyes in 13 cases, rubber products in 12 cases, topical medications in 7 cases, and others in 3 cases. Two patients showed positive reactions to more than one product in patch testing. Allergens that showed positive reactions in high incidence were paraphenylenediamine, paraaminoazobenzene, paratoluenediamine relevant to hair dye dermatitis, 6-ethoxy-2, 2, 4-trimethyl-1, 2-dihydroquinoline, N-isopropyl-N’-phenyl-p-phenylen ediamine, PPD black rubber mix, thiuram mix relevant to rubber dermatitis, cobalt chloride, and neomycin sulphate relevant to other dermatitis. Eight cases showed peripheral eosinophilia of the fifteen cases tested.
We used topical psoralen plus ultraviolet-A (PUVA) photochemotherapy to treat six patients with chronic graft-versus-host disease of the oral mucosa. The patients suffed from intractable oral pain and had difficulty eating because they had erosive oral lichen planus-like lesions. The PUVA therapy was carried out using spot UVA light with a light guide that could be inserted into the oral cavity. The lesions in the irradiated site markedly improved after 8-29 irradiations in all patients but recurred in two patients who required additional PUVA treatment. Proximal non-irradiated oral lesions also improved, as did those in the irradiated site. There were no significant side effects except for a mild phototoxic reaction in all patients. Intraoral PUVA seems to be a useful adjuvant therapy for treatment of refractory oral erosive lichen planus-like graft-versus-host disease.
The aim of this clinical study was to evaluate an allogeneic cultured dermal substitute (CDS) as a biological dressing for highly extended mesh auto-skin grafting. Allogeneic CDS was prepared by seeding fibroblasts onto a spongy matrix of hyaluronic acid and atelo-collagen. The patient was an 88-year-old female suffering from necrotizing fasciitis on the back lumbar region (size 39×28 cm). Necrocectomy was first performed up to the fat layer, and 6-fold extended mesh auto-skin fragments were grafted onto the debrided wound (size 27×13 cm), followed by application of allogeneic CDS. A conventional ointment-gauze dressing was used to protect the CDS. The CDS was applied repeatedly at intervals of 5 to 7 days. Take and epithelization of the grafted skin were good on day 28 after grafting. The cicatrices were thin and soft, indicating good condition. The application of 6-fold extended auto-skin graft in conjunction with allogeneic CDS appears to be an effective method for treatment of extensive full-thickness skin defects.