758
Journal of the American Academy of Dermatology
Brief communications
treatment of chronic idiopathic urticaria. J Allergy Clin Immunol 1986;77:37-42. 10. Van WauweJ, Awouters F, Niemegeers ClE, eta!. In vivo pharmacology of astemizole, a new type of Hj-antihistaminie compound. Arch Int Pharmacodyn Ther 1981; 251:39-51.
The use of isotretinoin in a patient undergoing kidney hemodialysis Eloise L. Beightler, MD,a and Stephen K. Tyring, MD, PhDa,b
Galveston, Texas Isotretinoin is generally accepted as the treatment of choice in recalcitrant nodulocystic acne vulgaris. I We report the case of a diabetic man receiving kidney hemodialysis who was successfully treated with isotretinoin for cystic acne. To our knowledge, the use of isotretinoin in a similar patient has not been reported.
Case report. A 49-year-old man had a long-standing history of severe recalcitrant cystic acne of the face and back. He had a 20-year history of adult-onset diabetes mellitus complicated by severe nephropathy that required hemodialysis. Laboratory data were as follows: Liver function tests were within normal limits. The fasting cholesterol level was 150 rng/dl (normal 120 to 220 mg/dl) and the triglyceride level was 92 mg/dl (normal 30 to 170 mg/dl). Serum chemistry panels were normal except for the following values: creatinine, 19.2 mgjdl (normal 0.5 to 1.5 mg/dl); blood urea nitrogen, 112 mg/dl (normal 7 to 26 mg/dl), The RBC count revealed anemia associated with chronic disease. The patient was referred to the Dermatology Clinic for recommendations to clear the skin eruption. Oral isotretinoin was prescribed at a dosage of 20 mg three times a week for 2 weeks. This was increased to 20 rug/day for 2 weeks, then 40 mg daily. The patient continued the 40 mg daily dosage until a follow-up examination 2 months later. At that time, an approximate 30% to 40% reduction in the severity of the acne was noted. The dosage of isotretinoin was increased to 80 mg. Three months later, the patient was 90% clear of the acne, and isotretinoin was discontinued. Close monitoring ofliver function tests, blood chemistry values, and cholesterol, triglyceride, and glucose levelswere performed weekly for the first 2 months, then biweekly thereafter. No change from pretreatment values was noted (creatinine level, 17 to 22 mg/dl; blood urea nitrogen, 95 to 115 mg/dl),
kidney transplantation.2,3However, no data are available on the influence of isotretinoin on renal insufficiency or kidney hemodialysis. In our patient, isotretinoin was protected from removal by hemodialysis through its protein binding. In addition, the elimination of isotretinoin and its metabolites by the urinary route is negligible. There seems to be no apparent contraindication to the use of isotretinoin in patients undergoing hemodialysis, and it deserves consideration in the appropriate clinical setting. REFERENCES 1. Peck G L, Olsen TG, Yoder FW, et al. Prolonged remissions
of cystic and conglobate acne with 13-cis-retinoic acid. N Engl J Med 1979;300:329-33. 2. Marcussen JA, Tyden G. Acne conglobata in transplant patients treated with isotretinoin. Br J Dermatol 1988;118: 310-2. 3. Tam M, Cooper A. The use of isotretinoin in a renal transplant patient with acne [Letter]. Br J DermatoI1987;116:463.
Palmoplantar pustulosis as a manifestation of cutaneous T cell lymphoma (mycosis fungoides) J. C. Moreno, MD, M. Ortega, MD, J. S. Conejo-Mir, MD, and P. Sanchez-Pedrefio Seville, Spain Case report. A 60-year-old man had had psoriasisvulgaris for 5 years. Three years ago an erythematous scaling eruption de-
veloped. A biopsy specimen revealed mycosis fungoides. The Fromthe Department of Medical Surgical Dermatology and Venereology, University of Seville School of Medicine. Reprint requests: 1. C. Moreno, MD,Department of Medical Surgical Dermatology and Venereology, University School of Medicine, Avda. Dr. Fedriani 3, Seville 41009, Spain. 16/4/19462
Discussion, Our case represents a unique situation in which the patient was a diabetic with end-stage kidney disease and undergoing hemodialysis. There are two reports of the successful use of isotretinoin in patients with From the Departments of Dermatology" and Microbiology," The University of Texas Medical Branch. Reprint requests: Eloise L. Beightler, MD, Department of Dermatology, G-83, University of Texas Medical Branch, Galveston, TX 77550. 16/4/19559
Fig. 1. Clinical appearance of palmar pustulosis.
Volume 23 Number 4, Part 1 October 1990
Brief communications 759
Fig. 2. A, Typical spongiform microabscess composed of lymphocytes. B, Detail of lymphocyte infiltration. patient was treated by Re-PUV A for 3 months and improved. Two years later, the patient was seen again with a severe palmoplantar pustulosis(Fig. I). Physical examination revealed typical tumors of mycosis fungoides on the trunk. Fungal and bacterial cultures of the pustules were negative. A biopsyspecimen from the palm revealeda large Pautrier abscessand other features of mycosis fungoides (Fig. 2). Partial regression of the pustulosis was achieved by UVA therapy. The patient died 3 months later of Pseudomona aeruginosa sepsis. The family refused an autopsy.
Discussion. Atypical manifestations of mycosis fungoides have been described, such as pustular, I bullous.s 3 granulomatous," hypopigmented.t and verrucous.f Previously reported pustular cases of mycosis fungoidesshowed no involvement of palms and soles. When the palms and soles are affected by mycosis fungoides, hyperkeratotic,?,8 eczematous.? and vegetating lesions have been reported. To our knowledge this is the first case of palmar and plantar pustulosis as a manifestation of mycosis fungoides.
REFERENCES
ac, Shapiro L. Pustular mycosis fungoides. Arch Dermatol 1966;93:221-5. Rocnigk HH Jr, CastrovinciAJ. Mycosisfungoides bullosa. Arch Dermatol 1966;I04:402-6. Chargin L. Mycosisfungoides with many lesions resembling fixed eruptions. Arch Derrnatol Syph 1950;62:762-4. Ackerman B, Flaxman BA. Granulomatous mycosis fungoides. Br J Dermatol 1970;28:397-401. Breathnach DM, McKee PH, Smith NP. Hypopigmented mycosis fungoides: report of five cases with ultrastructural observations. Br J DermatoJ 1982;106:643-9. Kanitakis C, Tsotis G. Mycosis fungoide et mucinose folicular avec tres importantes lesions papillomateuscs ct verruqueuses. Dermatologica 1977;155:268-74. Milian G, Perin L. Mycosis fungoide avec erithroderrnic psoriasiforme et hyperkeratose vegetante. Bull Soc Fr Dcrmatol Syph 1923;30:394-8. Price M, Fuks ZY, Hoffman TE. Hyperkeratotic and verru-
I. Ackerman AB, Miller
2. 3.
4. 5.
6.
7. 8.
cous features of mycosis fungoides. Arch Dermatol 1977;113:67-70. 9. Voigtlander V, Hartmann AA, Adam W, ct a!' Mycosis fungo'ide: etiologic inattendue d'un eczema chronique des mains avec gigantisme digital. Ann Dermatol Venereal 1988;115:1212-4.
Complete resolution of generalized eczema craquele after treatment with metronidazole of occult amebiasis Asher V. Wahba-Yahav, MD'" Jerusalem, Israel Eczema craquele has an irregular, erythematous, reticulate, dry, fissured appearance. The localized form is especially common in elderly hospital inpatients. It usually affects the shins and has been attributed to low environmental humidity and excessive washing.' The generalized form is rare, has a rapid onset, and is refractory to topical treatrnent.? Generalized eczema craquele has been described as a presenting feature of Hodgkin's disease! and adenocarcinoma of the stomach.? as well as in association with angioimmunoblastic lymphadenopathy.' It has also been linked to myxedema" and zinc deficiency- I recently treated a patient with generalized eczema craquele and an occult amebic infection of the intestines who had a prompt and dramatic resolution of the eruption after oral treatment with metronidazole. This appears to be the first case of generalized eczema craquele associated with intestinal amebiasis reported in the literature.
Reprint requests: A. V. Wahba-Yahav, MD, City Tower Bidg., Room 1622,34 Bcn-Ychuda St., Jerusalem, Israel.
*I n private practice. 16/4/20047
Journal of the American Academy of Dermatology
Brief communications
treatment of chronic idiopathic urticaria. J Allergy Clin Immunol 1986;77:37-42. 10. Van WauweJ, Awouters F, Niemegeers ClE, eta!. In vivo pharmacology of astemizole, a new type of Hj-antihistaminie compound. Arch Int Pharmacodyn Ther 1981; 251:39-51.
The use of isotretinoin in a patient undergoing kidney hemodialysis Eloise L. Beightler, MD,a and Stephen K. Tyring, MD, PhDa,b
Galveston, Texas Isotretinoin is generally accepted as the treatment of choice in recalcitrant nodulocystic acne vulgaris. I We report the case of a diabetic man receiving kidney hemodialysis who was successfully treated with isotretinoin for cystic acne. To our knowledge, the use of isotretinoin in a similar patient has not been reported.
Case report. A 49-year-old man had a long-standing history of severe recalcitrant cystic acne of the face and back. He had a 20-year history of adult-onset diabetes mellitus complicated by severe nephropathy that required hemodialysis. Laboratory data were as follows: Liver function tests were within normal limits. The fasting cholesterol level was 150 rng/dl (normal 120 to 220 mg/dl) and the triglyceride level was 92 mg/dl (normal 30 to 170 mg/dl). Serum chemistry panels were normal except for the following values: creatinine, 19.2 mgjdl (normal 0.5 to 1.5 mg/dl); blood urea nitrogen, 112 mg/dl (normal 7 to 26 mg/dl), The RBC count revealed anemia associated with chronic disease. The patient was referred to the Dermatology Clinic for recommendations to clear the skin eruption. Oral isotretinoin was prescribed at a dosage of 20 mg three times a week for 2 weeks. This was increased to 20 rug/day for 2 weeks, then 40 mg daily. The patient continued the 40 mg daily dosage until a follow-up examination 2 months later. At that time, an approximate 30% to 40% reduction in the severity of the acne was noted. The dosage of isotretinoin was increased to 80 mg. Three months later, the patient was 90% clear of the acne, and isotretinoin was discontinued. Close monitoring ofliver function tests, blood chemistry values, and cholesterol, triglyceride, and glucose levelswere performed weekly for the first 2 months, then biweekly thereafter. No change from pretreatment values was noted (creatinine level, 17 to 22 mg/dl; blood urea nitrogen, 95 to 115 mg/dl),
kidney transplantation.2,3However, no data are available on the influence of isotretinoin on renal insufficiency or kidney hemodialysis. In our patient, isotretinoin was protected from removal by hemodialysis through its protein binding. In addition, the elimination of isotretinoin and its metabolites by the urinary route is negligible. There seems to be no apparent contraindication to the use of isotretinoin in patients undergoing hemodialysis, and it deserves consideration in the appropriate clinical setting. REFERENCES 1. Peck G L, Olsen TG, Yoder FW, et al. Prolonged remissions
of cystic and conglobate acne with 13-cis-retinoic acid. N Engl J Med 1979;300:329-33. 2. Marcussen JA, Tyden G. Acne conglobata in transplant patients treated with isotretinoin. Br J Dermatol 1988;118: 310-2. 3. Tam M, Cooper A. The use of isotretinoin in a renal transplant patient with acne [Letter]. Br J DermatoI1987;116:463.
Palmoplantar pustulosis as a manifestation of cutaneous T cell lymphoma (mycosis fungoides) J. C. Moreno, MD, M. Ortega, MD, J. S. Conejo-Mir, MD, and P. Sanchez-Pedrefio Seville, Spain Case report. A 60-year-old man had had psoriasisvulgaris for 5 years. Three years ago an erythematous scaling eruption de-
veloped. A biopsy specimen revealed mycosis fungoides. The Fromthe Department of Medical Surgical Dermatology and Venereology, University of Seville School of Medicine. Reprint requests: 1. C. Moreno, MD,Department of Medical Surgical Dermatology and Venereology, University School of Medicine, Avda. Dr. Fedriani 3, Seville 41009, Spain. 16/4/19462
Discussion, Our case represents a unique situation in which the patient was a diabetic with end-stage kidney disease and undergoing hemodialysis. There are two reports of the successful use of isotretinoin in patients with From the Departments of Dermatology" and Microbiology," The University of Texas Medical Branch. Reprint requests: Eloise L. Beightler, MD, Department of Dermatology, G-83, University of Texas Medical Branch, Galveston, TX 77550. 16/4/19559
Fig. 1. Clinical appearance of palmar pustulosis.
Volume 23 Number 4, Part 1 October 1990
Brief communications 759
Fig. 2. A, Typical spongiform microabscess composed of lymphocytes. B, Detail of lymphocyte infiltration. patient was treated by Re-PUV A for 3 months and improved. Two years later, the patient was seen again with a severe palmoplantar pustulosis(Fig. I). Physical examination revealed typical tumors of mycosis fungoides on the trunk. Fungal and bacterial cultures of the pustules were negative. A biopsyspecimen from the palm revealeda large Pautrier abscessand other features of mycosis fungoides (Fig. 2). Partial regression of the pustulosis was achieved by UVA therapy. The patient died 3 months later of Pseudomona aeruginosa sepsis. The family refused an autopsy.
Discussion. Atypical manifestations of mycosis fungoides have been described, such as pustular, I bullous.s 3 granulomatous," hypopigmented.t and verrucous.f Previously reported pustular cases of mycosis fungoidesshowed no involvement of palms and soles. When the palms and soles are affected by mycosis fungoides, hyperkeratotic,?,8 eczematous.? and vegetating lesions have been reported. To our knowledge this is the first case of palmar and plantar pustulosis as a manifestation of mycosis fungoides.
REFERENCES
ac, Shapiro L. Pustular mycosis fungoides. Arch Dermatol 1966;93:221-5. Rocnigk HH Jr, CastrovinciAJ. Mycosisfungoides bullosa. Arch Dermatol 1966;I04:402-6. Chargin L. Mycosisfungoides with many lesions resembling fixed eruptions. Arch Derrnatol Syph 1950;62:762-4. Ackerman B, Flaxman BA. Granulomatous mycosis fungoides. Br J Dermatol 1970;28:397-401. Breathnach DM, McKee PH, Smith NP. Hypopigmented mycosis fungoides: report of five cases with ultrastructural observations. Br J DermatoJ 1982;106:643-9. Kanitakis C, Tsotis G. Mycosis fungoide et mucinose folicular avec tres importantes lesions papillomateuscs ct verruqueuses. Dermatologica 1977;155:268-74. Milian G, Perin L. Mycosis fungoide avec erithroderrnic psoriasiforme et hyperkeratose vegetante. Bull Soc Fr Dcrmatol Syph 1923;30:394-8. Price M, Fuks ZY, Hoffman TE. Hyperkeratotic and verru-
I. Ackerman AB, Miller
2. 3.
4. 5.
6.
7. 8.
cous features of mycosis fungoides. Arch Dermatol 1977;113:67-70. 9. Voigtlander V, Hartmann AA, Adam W, ct a!' Mycosis fungo'ide: etiologic inattendue d'un eczema chronique des mains avec gigantisme digital. Ann Dermatol Venereal 1988;115:1212-4.
Complete resolution of generalized eczema craquele after treatment with metronidazole of occult amebiasis Asher V. Wahba-Yahav, MD'" Jerusalem, Israel Eczema craquele has an irregular, erythematous, reticulate, dry, fissured appearance. The localized form is especially common in elderly hospital inpatients. It usually affects the shins and has been attributed to low environmental humidity and excessive washing.' The generalized form is rare, has a rapid onset, and is refractory to topical treatrnent.? Generalized eczema craquele has been described as a presenting feature of Hodgkin's disease! and adenocarcinoma of the stomach.? as well as in association with angioimmunoblastic lymphadenopathy.' It has also been linked to myxedema" and zinc deficiency- I recently treated a patient with generalized eczema craquele and an occult amebic infection of the intestines who had a prompt and dramatic resolution of the eruption after oral treatment with metronidazole. This appears to be the first case of generalized eczema craquele associated with intestinal amebiasis reported in the literature.
Reprint requests: A. V. Wahba-Yahav, MD, City Tower Bidg., Room 1622,34 Bcn-Ychuda St., Jerusalem, Israel.
*I n private practice. 16/4/20047
