Standard guideline for management (diagnosis, severity scoring and therapy) of atopic dermatitis (AD) is established. In this guideline, the necessity of dermatological training is emphasized in order to assure the diagnostic skill and to evaluate the severity of AD. The present standard therapies for AD consist of the use of topical steroids and tacrolimus ointment for inflammation as well as emollients for dry and barrier-disrupted skin as the first-line topical applications, systemic anti-histamines and anti-allergic drugs for pruritus, avoidance of apparent exacerbating factors, psychological counseling, and advice about daily life. Tacrolimus ointment (0.1%) and its low density ointment (0.03%) are available for adult patients and 2–15 years old patients, respectively. The importance of suitable selection of topical steroids according to the severity of the lesion is also emphasized.
Chemical peeling is one of dermatological treatments for certain cutaneous diseases or conditions or aesthetic improvement, which consists of the application of one or more chemical agents to the skin. Chemical peeling has been very popular in medical fields as well as aesthetic fields. Since scientific background and adequate approach is not completely understood or established, medical and social problems have been reported. This prompted us to establish and distribute standard guideline of care for chemical peeling. Previous guidelines such as 2001 version and 2004 version included the minimums for the indications, the chemicals used, their applications, associated precautions, and postpeeling care and findings. The principles were as follows :1) chemical peeling should be performed under the control and the responsibility of the physician. 2) the physician should have knowledge of the skin and subcutaneous tissue and understand the mechanism of wound-healing. 3) the physician should be board-certified in an appropriate specialty such as dermatology. 4) the ultimate judgment regarding the appropriateness of any specific chemical peeling procedure must be made by the physician in light of all standard therapeutic ways, which are presented by each individual patient. Keeping these concepts, this new version of guidelines includes more scientific and detailed approaches from the evidence-based medicine.
Activated vitamin D3, steroid as topical therapy, cyclosporine, etretinate as systematic therapy, and psoralen-ultraviolet A, narrow-band ultraviolet B as phototherapy are all used as treatments of psoriasis. The selections of these treatments are based on the severity of the disease; for example, topical therapy is used for patients with mild cases, and systematic therapy for patients with severe cases. However, the quality of life (QOL) of patients should be given as much consideration as their severity. Currently, it is possible to select systemic treatment for the patients whose cases aren’t severe but suffer from QOL impairment. The previous therapeutic guidelines or algorithms for psoriasis have been based only on the disease severity. This new algorithm for the selection of the treatments for psoriasis is based on nine factors; 1) disease severity, 2) symptoms, 3) QOL, 4) adherences, 5) stress of topical treatment, 6) expectation of rapid efficacy, 7) other complications of the patients, 8) requirement for hospitalization, and 9) adverse reactions to the treatment.
A salazosulfapyridine enteric-coated preparation (SASP) was found to be effective in treating the arthritis of two psoriasis patients. Case 1, a 59-year-old man, was diagnosed with psoriasis arthritis. Because the inflammatory course involving the knee joint differed from the res of his symp synovial fluid was collected through a puncture. A turbid yellowish fluid was obtained, leading to the diagnosis of an infectious patellar cyst. Oral administration of SASP resulted in ameliorating the arthritis, althogh methotrexate was added to the medication to combat an increasingly exaggerating articular deformation. Case 2, a 61-year-old male, suffered from droplet-type psoriasis vulgaris and polyarthritis. SASP administration resulted in eliminating the erythema and articular symptoms. A total of 8 patients with psoriasis and articular symptoms (including the two described above) have been treated with SASP. Based on these experiences and because of its efficacy (as well as its limitations), SASP is proposed for the treatment of psoriasis complicated by arthritis.
In the postoperative management of patients with malignant melanoma, CT and MRI are both used for screening of recurrent disease more frequently in Japan than in other countries. We evaluated the usefulness of various imaging methods during the postoperative period by retrospective analysis of 142 patients with Stage I–III malignant melanoma. Metastases were found in 44 of 142 patients (31%) during the follow-up period. In 28 cases, the metastases were detected by a routine physical examination, but by imaging tests including CT, MRI, Ga/Tc scintigraphy and PET in 16 cases. Elevated serum markers including 5-SCD, MIA and LDH were observed in 24%, 72%, and 12% of patients who developed metastases, respectively. There was no significant difference in overall survival rate between in patients with metastasis detected by a routine physical examination and in patients with metastasis detected by imaging methods (p=0.27). In contrast, there was a significantly longer overall survival rate in patients with operable metastasis compared with those with inoperable metastasis (p=0.001). Patients with operable stage IV disease showed a longer overall survival rate than did patients with inoperable disease (p=0.07). The results suggest that early detection of melanoma metastases may improve the survival rate of patients. However, frequent systemic evaluation by imaging methods is strongly discouraged due to costs and effects. An adequate follow-up schedule should be justified according to the risk of each patient.
Photodynamic therapy (PDT) has recently been applied to the treatment of several skin disorders. This study was performed to evaluate the efficacy of topical 5-aminolevulinic acid (ALA) PDT for intractable acne vulgaris. We tried it on ten patients with intractable acne vulgaris on the face and observed both the effects and adverse reactions. In one case, severe pigmentation occurred after test irradiation, so we canceled the treatment. The other nine patients had improvements of 1 to 2 grades on the Burton scale a month after just one exposure. As adverse reactions, erythema lasting for 1–4 days was observed in all cases in the irradiation region. One patient had a strong burning sensation and swelling for two days. In addition, the erythema was partially accompanied by excoriation in 5 cases and by accepted transient exacerbation of acne in 7 cases. Our data suggest that topical ALA-PDT may be effective for intractable acne vulgaris, but the problem of how we prevent adverse reactions remains.
We report a case of 55-year-old male who had diabetic foot ulcers and gangrene with MRSA that were unresponsive to conventional treatment. He was referred for amputation. We used living sterile maggots on the wounds to remove necrotic tissue, promote disinfection, and accelerate granulation tissue formation. We were thus able to rapidly debride the necrotic ulcers and avoid amputation.