Journal of the American Academy of Dermatology
122 Brief communications noses described in the dermatologic literature. A child with a dermatosis that may resembleAPPM wasreported by Lum. 2 There were multiple papules localized to the upper limbs. However,in this case, fibroblast proliferation was not described and the mucin deposit in the reticular dermis was more superficial than in APPM and without any visiblegrenz zone.No cases of APPM were reported before 1986, with the possible exception of the patient presented by N aeyaert and Kint under the title "papular mucinosis" at the Symposium of Dermatology at Ghent, Belgium, in April 1985.3 Since the description of the original cases I in two women, three additional patients (two women and one man) with this novel clinical entity have been reported.v 5 As in our case, adults were affected by a protracted coursebut without apparent systemic involvement or spontaneous resolution. REFERENCES 1. Rongioletti F, Rebora A, Crovato F. Acralpersistent papular mucinosis: a new entity. Arch Dermatol 1986;122: 1237-9.
2. Lum D, Cutaneous mucinosis of infancy: a congenital and linear variant. ArchDermatol 1983;119:272-3. 3. Naeyaert 1M, Kint A. Papular mucinosis [Abstract]. Dermatologica 1985;171:508. 4. Ravella A, Garcia P, MorenoA, et al. Mucinose papuleuse persistante acrale. AnnDermatol Venereal 1987;114:143840.
5. Royer P, Beylot C, Garabiol B, et al. Acromucinose papuleuse persistante. Ann Dermatol Venereal 1988;115:82731.
Susceptibility to irritant dermatitis induced by sodium lauryl sulfate
Klaus-P, Wilhelm, MD,a. b, * and Howard 1. Maibach, MDa San Francisco, California, and Lubeck, West Germany Irritant thresholds and dose responses vary considerably among personswhen tested with lowconcentrated or mild irritants.l-? Relatively little is known about endogenous factors that contribute to this variability. Because irritation changes skin physiology in many ways, we evaluated whether certain biophysical aspects of apparently healthy skin related to the vulnerability of skin to the model irritant sodium lauryl sulfate (SLS). From the Departments ofDermatology, School ofMedicine, University ofCalifomia SanFrancisco,' andtheMedical University ofLubeck," Presented in part at the combined SID/ESDR/JID meeting, Washington, D.C., April 26-30,1989. Reprint requests: Howard I.Maibach, MD,Department ofDermatology. School ofMedicine, University ofCalifornia SanFrancisco. Box 0989,Surge 110,San Francisco, CA 94143-0989. *Dr. Wilhelm received a postdoctoral fellowship from theGerman Research Foundation. 16/4/18522
Method Study population. Tenhealthy, whitewomen between 29 and 42 years of agewerethevolunteer subjects afterthey had given theirwritten informed consent. The studyhadbeenapproved by the University of California San Francisco Committee for Human Research. Applications. SLS I % (Sigma ChemicalCo.,St Louis, Mo.) in distilled water (0.1 ml) was applied to the midvolarforearm andto the upperbackfor 24 hourswithocclusive plastic chambers (Hilltop Laboratory, Cincinnati, Ohio). Water served as the vehicle control. The patches were fixed with nonocclusive paper tape (Scanpore, Norgeplaster, Oslo, Norway). Measurements. Twenty-four hours after patch removal transepidermal water loss (mWL) was measured with an Evaporimeter (BPI, ServoMed, Stockholm, Sweden). Skin surfacepH was measured at three different sites of the volar forearm witha fiat surfaceelectrode (model 91-35, Orion Research Inc., Boston, Mass.) connected to a pH meter (model 130,Corning Corp.,Medfield, Mass.). Measurements wererepeatedafter removal of superficial corneallayers by five tape strips(Scotch 600, 3MCo.,St.Paul,Minn.).Stratum corneum turnover time(SCTT) was determined by meansof the dansyl chloride staining method.I Because forearmsebumlevels were often below the sensitivity of the instrument, the upper back (lower third of scapula) waschosen. Measurements were performed in sixreplicas adjacent to the SLS patch with a Sebumeter (SM 410 PC, Courage & Khazaka, Cologne, F.R.G.) Before measurements allvolunteer subjects had beenresting at room temperature for at least 15 minutes. All measurements were performed at constant ambient conditions (200 ± 2 0 C; 45% to 65% relative humidity). Statistical analysis. Differences in TEWL were tested for their significance withStudent's t testfor paired samples,"The relation between skinbaseline measurements and SLS-induced TEWL increase wasstudied by simple linear correlation." Results. Values of pH are the mean of three replicas per subject. Skin surface values (5.5 ± 0.1 [±SEM]) decreased to 5.1 ± 0.1 after removal of superficial corneal layers by fivetape strips. The difference between surface pH and pH after fivetape strips tended to be greater with higher surface values (Table I). Twenty-four hours after patch removal, TEWL was significantly increased in SLS-treated sites compared with controls (Table I). The correlation coefficients between TEWL after SLS treatment and all baseline measurements are shown in Table II. Of all measurements only skin surface pH (r:::::l 0.66; p -< 0.02) and skin pH after five tape strips (r « 0.81; p -< 0.005) correlated significantly with TEWL after SLS exposure (Fig. 1). Discussion.The response to skin irritants exhibits great variability with a range from no reaction to severe blistering or corrosive reactions.l-? SLS-induced irritation changes several biophysical skin properties. It increases TEWL, skin blood flow, SeTT, skin pH, waterholding capacity of the stratum corneum, and stratum corneum water content. 2,5,7 After the induction of acute irritant dermatitis with a single 24-hour patch application, no significant correlation between TEWL before and
Volume 23 Number 1 July 1990
Brief communications 123 20
20
r:0.81; pS:O.OO5
r=0.66: pS:O.02
l:l
0 l:l
l:l
0
:f '"
~
0
Ii!! 0
10
~ EJ
0
~
0
10
OJ
0
0
m
:2 -.
m
0
....J
~
0
III
m
III
l-
I-0
tn
0
0 5.0
5.2
5.4
a
5.8
5.6
4.6
6.0
b
pH
4.8
5.0
5.2
5.4
5.6
pH (after stripping)
Fig. 1. Valuesof pH ofuntreatedvolarforearmskin(a)and pH after removal ofsuperficial corneallayers by five tape strips (b) significantly correlated with SLS-induced irritation, as quantified by transepidermal water loss increase (N = 10 volunteer subjects).
Table I. Skin baseline pH and transepidermal water loss (TEWL) after sodium lauryl sulfate (SLS) application TEWL (gmJm2Jbr) Subject
Pre
1 2 3 4 5 6 7 8 9 10
3.9 4.9 3.5 3.8 5.5 4.7 4.2 2.9 5.5 2.8 4.2 ± 0.3
Mean ± SEM
I
Control
4.6 5.4 3.7 3.5 7.8 4.3 5.4 3.8 6.0 2.5 4.7 ± 0.5
pH
I
I
1% SIS
Surface
12.1 6.5 13.7 8.4 9.8 17.4
5.88 5.14 5.69 5.37 5.36 5.96 5.07 5.46 5.87 5.29 5.51 ± 0.10
lOA
16.4 12.4 3.6 11.1*±1.4
Strip
5.09 4.90 5.08 4.81 4.94 5.42 4.83 5.31 5.56 4.65 5.06* ± 0.09
TEWL of volarforearmskinpretreatment (pre) (meanof fourreplicas), 24 hr after24-hrapplication of 1%SLS or water(control); pHat skinsurface (surface) and after five tape strips (strip) are mean of three replicas per subject. *Significantly different from control:p :$ 0.05 (paired Student's t test).
Table II. Correlation matrix TEWL1
TEWLI TEWL2 pH 1 pH2
SeTT Sebum
TEWL2
pH 1
pH2
SCTT
Sebum
1
0.067 0.154 0.348 0.149 0.287
1
0.658* 0.814t 0.282 0.004
1
0.769t n.d. n.d.
1 n.d,
1
n.d.
n.d.
1
TEWL 1. Baseline TEWL (mean of four replicas; forearm exceptfor correlation withsebum [upper back]); TEWL 2. TEWL 24 hr after 24-hrSLS exposure (forearmexceptfor comparison with sebum [upperback]); pH 1, skin surfacepH; pH 2,pH afterfive tapestrips; SCTT, stratumcorneum turnover time (dansyl chloride method); Sebum. sebumconlenl(upperback;meanof sixreplicas); level ofsignificance, notsignificant unless otherwise indicated; n.d., not determined.
Journal of the American Academy of Dermatology
124 Brief communications after patch application was seen. This confirms earlier studies from this and other laboratories-? but contrasts with findings by Murahata et a1. lo and Tupker et aLII Both groups found a significant correlation between baseline TEWL and TEWL after SLS application. However, in their studies, SLS was applied cumulatively for 5 days , several hours per day. This difference in the experimental design might explain the contradictory observations. In addition, we measured TEWL 1 day after SLS patch removal to avoid artifacts caused by the increased hydration, a measurement not performed by the other groups. No influence of the pH of different soap or detergent solutions on their irritant potential was noted in the range of pH 4.0 to 10.5. 1, 12 In the present study, a significant correlation was observed between skin surface pH (even more strongly, of skin pH after five tape strips) and the severity of SLS-induced dermatitis . After five tape strips, skin pH is supposedly less influenced by sebum and external factors and may thus better reflect the chemical composition responsible for barrier properties. The observed correlation between skin pH and SLS-irIduced TEWL increase might be explained by lower lipid concentration'? and/or more hydrated stratum corneum.l" Lower lipid concentration'! and more hydrated stratum corneum'" have been related to higher skin pH and both would weaken the skin barrier against the hydrophilic SLS. No corr susceptibility to SLS-elicited irritant dermatitis was not correlated with casual sebum content, despite a great interindividual variability (factor 100) for this factor. REFERENCES I. Frosch PJ. Irritancy ofsoaps and detergent bars. In: Frost P, Horwitz SN, eds. Principles of cosmetics for the dermatologist. St. Louis: CV Mosby, 1982;5-12. 2. WilhelmKP, SurberC, Maibach HI. Quantification ofsodium lauryl sulfate irritantdermatitis inman. Comparison of four techniques: skin color reflectance, transepidermal water loss, laser Doppler flow measurement and visual scores. Arch Dermatol Res 1989;281 :293-5. 3. Jansen LH, Hojyo-Tomoko MT, Kligman AM. Improved fluorescence staining technique for estimating turnover of the human stratumcorneum. Br J DermatoI1974;90:9-12. 4. Zar JH. Biostatistical analysis. Englewood Cliffs, N.J.: Prentice-Hall, 1974:121-4,236-40. 5. Elsner P, Wilhelm D, Maibach HI. Physiological skinsurface waterloss dynamics ofhumanvulvar and forearmskin. Acta Derm Venereol (Stockh) 1990;70:141-4. 6. Berardesca E, Maibach HI. The effect of nonvisible damage on the water holding capacity of thestratum corneum, utilizing the plastic occlusion stresstest(POST). In: Frosch PI, ed. Current topics in contact dermatitis. Heidelberg: Springer-Verlag, 1989. 7. Wilhelm KP, Saunders JC, Maibach HI. Subclinical chronic irritation increased stratum corneum turnover [Abstract]. J Invest DermatoI1989;92:542. 8. Goh CL, Chia SE. Skin irritability to sodium lauryl sulphate--as measured byskinwatervapourloss-by sex and race. Clin Exp Dermatol 1988;13:16-9.
9. Lammintausta K, Maibach HI, WilsonD.Susceptibilityto cumulative and acuteirritant dermatitis. An experimental approach in human volunteers. Contact Dermatitis 1988; 19:84-90. 10. Murahata RI, Crowe DM, Roheim JR. The use of transepidermal water loss to measure and predictthe irritation response to surfactants. 1nt J Cosmet Sci 1986;8:225-31 . 11. Tupker RA, Coenraads PJ, Pinnagoda J, et at. Baseline transepidermal waterloss (TEWL) as a prediction of susceptibility to sodium lauryl sulphate. Contact Dermatitis 1989;20:265-9. 12. Murahata RI, Teton-Quinn R, Finkey MB. Effectof pH on the production ofirritation in a chamberirritation test. JAM ACAD DERMATOL 1988;18:62-6. 13. Thune P, Nilsen T, Hanstad IK, et al. The water barrier function ofthe skinin relation to the watercontentofstratumcorneum, pH andskinlipids.Theeffectofalkaline soap andsyndet on dry skin in elderly, non-atopic patients. Acta Derm Venereal (Stockh) 1988;68:277-83. 14. Locher G. Permeabilitatsprufung der Haut Ekzemkranker und Hautgesunder fur den neuen Indikator Nitrazingelb "Geigy," Modifzierung derAlkaliresistenzprobe, pH-Verlauf in der Tiefe des stratum corneum. Dermatologica 1962;124:159-82.
Captopril and alopecia: A case report and review of known cutaneous reactions in captopril use Peter J. Motel, MD Philadelphia, Pennsylvania Captopril (Capoten) is one of several drugs in a group known as angiotensin converting enzyme inhibitors that are useful in the treatment of hypertension and congestive heart failure. Many adverse cutaneous reactions to captopril have been reported, including rash (usually maculopapular or morbilliform, only rarely urticarial), which occurs in approximately lO%of patients usually appears within 4 weeks of starting therapy. 1-3 Pruritus and occasionally fever and eosinophilia can accompany the rash. 1 The rash usually resolves with dosage reduction and may resolve even if therapy is continued without change.t-" Pruritus without rash has been noted in 2% of patients." Reactions that occur in less than 2% of patients include angioedema of the face and mucous membranes, laryngeal edema (one case), pemphigus-like lesions,exfoliative dermatitis, pityriasis-like eruption, and photosensitivity. All are reversible when the dosage of the drug is reduced or when the drug is discontinued." Case report. A 68-year-old woman with congestive heart failureand no historyofallergic drug reactions or alopecia had beentreated for3 months withfurosemide (Lasix), 40 mgjday orally, and potassium without complication. On a follow-upvisit she reported increasing dyspnea onexertion; treatmentwithoral captopril (l2.5 mg orally every 8 hours) was started. Furo-
From the Department ofDermatology, Thomas Jefferson University. Reprint requests: Peter J. Motel, MD, Thomas Jefferson University. Department ofDermatology, III S. Eleventh St., Philadelphia, PA 19107. 16/4/17043
122 Brief communications noses described in the dermatologic literature. A child with a dermatosis that may resembleAPPM wasreported by Lum. 2 There were multiple papules localized to the upper limbs. However,in this case, fibroblast proliferation was not described and the mucin deposit in the reticular dermis was more superficial than in APPM and without any visiblegrenz zone.No cases of APPM were reported before 1986, with the possible exception of the patient presented by N aeyaert and Kint under the title "papular mucinosis" at the Symposium of Dermatology at Ghent, Belgium, in April 1985.3 Since the description of the original cases I in two women, three additional patients (two women and one man) with this novel clinical entity have been reported.v 5 As in our case, adults were affected by a protracted coursebut without apparent systemic involvement or spontaneous resolution. REFERENCES 1. Rongioletti F, Rebora A, Crovato F. Acralpersistent papular mucinosis: a new entity. Arch Dermatol 1986;122: 1237-9.
2. Lum D, Cutaneous mucinosis of infancy: a congenital and linear variant. ArchDermatol 1983;119:272-3. 3. Naeyaert 1M, Kint A. Papular mucinosis [Abstract]. Dermatologica 1985;171:508. 4. Ravella A, Garcia P, MorenoA, et al. Mucinose papuleuse persistante acrale. AnnDermatol Venereal 1987;114:143840.
5. Royer P, Beylot C, Garabiol B, et al. Acromucinose papuleuse persistante. Ann Dermatol Venereal 1988;115:82731.
Susceptibility to irritant dermatitis induced by sodium lauryl sulfate
Klaus-P, Wilhelm, MD,a. b, * and Howard 1. Maibach, MDa San Francisco, California, and Lubeck, West Germany Irritant thresholds and dose responses vary considerably among personswhen tested with lowconcentrated or mild irritants.l-? Relatively little is known about endogenous factors that contribute to this variability. Because irritation changes skin physiology in many ways, we evaluated whether certain biophysical aspects of apparently healthy skin related to the vulnerability of skin to the model irritant sodium lauryl sulfate (SLS). From the Departments ofDermatology, School ofMedicine, University ofCalifomia SanFrancisco,' andtheMedical University ofLubeck," Presented in part at the combined SID/ESDR/JID meeting, Washington, D.C., April 26-30,1989. Reprint requests: Howard I.Maibach, MD,Department ofDermatology. School ofMedicine, University ofCalifornia SanFrancisco. Box 0989,Surge 110,San Francisco, CA 94143-0989. *Dr. Wilhelm received a postdoctoral fellowship from theGerman Research Foundation. 16/4/18522
Method Study population. Tenhealthy, whitewomen between 29 and 42 years of agewerethevolunteer subjects afterthey had given theirwritten informed consent. The studyhadbeenapproved by the University of California San Francisco Committee for Human Research. Applications. SLS I % (Sigma ChemicalCo.,St Louis, Mo.) in distilled water (0.1 ml) was applied to the midvolarforearm andto the upperbackfor 24 hourswithocclusive plastic chambers (Hilltop Laboratory, Cincinnati, Ohio). Water served as the vehicle control. The patches were fixed with nonocclusive paper tape (Scanpore, Norgeplaster, Oslo, Norway). Measurements. Twenty-four hours after patch removal transepidermal water loss (mWL) was measured with an Evaporimeter (BPI, ServoMed, Stockholm, Sweden). Skin surfacepH was measured at three different sites of the volar forearm witha fiat surfaceelectrode (model 91-35, Orion Research Inc., Boston, Mass.) connected to a pH meter (model 130,Corning Corp.,Medfield, Mass.). Measurements wererepeatedafter removal of superficial corneallayers by five tape strips(Scotch 600, 3MCo.,St.Paul,Minn.).Stratum corneum turnover time(SCTT) was determined by meansof the dansyl chloride staining method.I Because forearmsebumlevels were often below the sensitivity of the instrument, the upper back (lower third of scapula) waschosen. Measurements were performed in sixreplicas adjacent to the SLS patch with a Sebumeter (SM 410 PC, Courage & Khazaka, Cologne, F.R.G.) Before measurements allvolunteer subjects had beenresting at room temperature for at least 15 minutes. All measurements were performed at constant ambient conditions (200 ± 2 0 C; 45% to 65% relative humidity). Statistical analysis. Differences in TEWL were tested for their significance withStudent's t testfor paired samples,"The relation between skinbaseline measurements and SLS-induced TEWL increase wasstudied by simple linear correlation." Results. Values of pH are the mean of three replicas per subject. Skin surface values (5.5 ± 0.1 [±SEM]) decreased to 5.1 ± 0.1 after removal of superficial corneal layers by fivetape strips. The difference between surface pH and pH after fivetape strips tended to be greater with higher surface values (Table I). Twenty-four hours after patch removal, TEWL was significantly increased in SLS-treated sites compared with controls (Table I). The correlation coefficients between TEWL after SLS treatment and all baseline measurements are shown in Table II. Of all measurements only skin surface pH (r:::::l 0.66; p -< 0.02) and skin pH after five tape strips (r « 0.81; p -< 0.005) correlated significantly with TEWL after SLS exposure (Fig. 1). Discussion.The response to skin irritants exhibits great variability with a range from no reaction to severe blistering or corrosive reactions.l-? SLS-induced irritation changes several biophysical skin properties. It increases TEWL, skin blood flow, SeTT, skin pH, waterholding capacity of the stratum corneum, and stratum corneum water content. 2,5,7 After the induction of acute irritant dermatitis with a single 24-hour patch application, no significant correlation between TEWL before and
Volume 23 Number 1 July 1990
Brief communications 123 20
20
r:0.81; pS:O.OO5
r=0.66: pS:O.02
l:l
0 l:l
l:l
0
:f '"
~
0
Ii!! 0
10
~ EJ
0
~
0
10
OJ
0
0
m
:2 -.
m
0
....J
~
0
III
m
III
l-
I-0
tn
0
0 5.0
5.2
5.4
a
5.8
5.6
4.6
6.0
b
pH
4.8
5.0
5.2
5.4
5.6
pH (after stripping)
Fig. 1. Valuesof pH ofuntreatedvolarforearmskin(a)and pH after removal ofsuperficial corneallayers by five tape strips (b) significantly correlated with SLS-induced irritation, as quantified by transepidermal water loss increase (N = 10 volunteer subjects).
Table I. Skin baseline pH and transepidermal water loss (TEWL) after sodium lauryl sulfate (SLS) application TEWL (gmJm2Jbr) Subject
Pre
1 2 3 4 5 6 7 8 9 10
3.9 4.9 3.5 3.8 5.5 4.7 4.2 2.9 5.5 2.8 4.2 ± 0.3
Mean ± SEM
I
Control
4.6 5.4 3.7 3.5 7.8 4.3 5.4 3.8 6.0 2.5 4.7 ± 0.5
pH
I
I
1% SIS
Surface
12.1 6.5 13.7 8.4 9.8 17.4
5.88 5.14 5.69 5.37 5.36 5.96 5.07 5.46 5.87 5.29 5.51 ± 0.10
lOA
16.4 12.4 3.6 11.1*±1.4
Strip
5.09 4.90 5.08 4.81 4.94 5.42 4.83 5.31 5.56 4.65 5.06* ± 0.09
TEWL of volarforearmskinpretreatment (pre) (meanof fourreplicas), 24 hr after24-hrapplication of 1%SLS or water(control); pHat skinsurface (surface) and after five tape strips (strip) are mean of three replicas per subject. *Significantly different from control:p :$ 0.05 (paired Student's t test).
Table II. Correlation matrix TEWL1
TEWLI TEWL2 pH 1 pH2
SeTT Sebum
TEWL2
pH 1
pH2
SCTT
Sebum
1
0.067 0.154 0.348 0.149 0.287
1
0.658* 0.814t 0.282 0.004
1
0.769t n.d. n.d.
1 n.d,
1
n.d.
n.d.
1
TEWL 1. Baseline TEWL (mean of four replicas; forearm exceptfor correlation withsebum [upper back]); TEWL 2. TEWL 24 hr after 24-hrSLS exposure (forearmexceptfor comparison with sebum [upperback]); pH 1, skin surfacepH; pH 2,pH afterfive tapestrips; SCTT, stratumcorneum turnover time (dansyl chloride method); Sebum. sebumconlenl(upperback;meanof sixreplicas); level ofsignificance, notsignificant unless otherwise indicated; n.d., not determined.
Journal of the American Academy of Dermatology
124 Brief communications after patch application was seen. This confirms earlier studies from this and other laboratories-? but contrasts with findings by Murahata et a1. lo and Tupker et aLII Both groups found a significant correlation between baseline TEWL and TEWL after SLS application. However, in their studies, SLS was applied cumulatively for 5 days , several hours per day. This difference in the experimental design might explain the contradictory observations. In addition, we measured TEWL 1 day after SLS patch removal to avoid artifacts caused by the increased hydration, a measurement not performed by the other groups. No influence of the pH of different soap or detergent solutions on their irritant potential was noted in the range of pH 4.0 to 10.5. 1, 12 In the present study, a significant correlation was observed between skin surface pH (even more strongly, of skin pH after five tape strips) and the severity of SLS-induced dermatitis . After five tape strips, skin pH is supposedly less influenced by sebum and external factors and may thus better reflect the chemical composition responsible for barrier properties. The observed correlation between skin pH and SLS-irIduced TEWL increase might be explained by lower lipid concentration'? and/or more hydrated stratum corneum.l" Lower lipid concentration'! and more hydrated stratum corneum'" have been related to higher skin pH and both would weaken the skin barrier against the hydrophilic SLS. No corr susceptibility to SLS-elicited irritant dermatitis was not correlated with casual sebum content, despite a great interindividual variability (factor 100) for this factor. REFERENCES I. Frosch PJ. Irritancy ofsoaps and detergent bars. In: Frost P, Horwitz SN, eds. Principles of cosmetics for the dermatologist. St. Louis: CV Mosby, 1982;5-12. 2. WilhelmKP, SurberC, Maibach HI. Quantification ofsodium lauryl sulfate irritantdermatitis inman. Comparison of four techniques: skin color reflectance, transepidermal water loss, laser Doppler flow measurement and visual scores. Arch Dermatol Res 1989;281 :293-5. 3. Jansen LH, Hojyo-Tomoko MT, Kligman AM. Improved fluorescence staining technique for estimating turnover of the human stratumcorneum. Br J DermatoI1974;90:9-12. 4. Zar JH. Biostatistical analysis. Englewood Cliffs, N.J.: Prentice-Hall, 1974:121-4,236-40. 5. Elsner P, Wilhelm D, Maibach HI. Physiological skinsurface waterloss dynamics ofhumanvulvar and forearmskin. Acta Derm Venereol (Stockh) 1990;70:141-4. 6. Berardesca E, Maibach HI. The effect of nonvisible damage on the water holding capacity of thestratum corneum, utilizing the plastic occlusion stresstest(POST). In: Frosch PI, ed. Current topics in contact dermatitis. Heidelberg: Springer-Verlag, 1989. 7. Wilhelm KP, Saunders JC, Maibach HI. Subclinical chronic irritation increased stratum corneum turnover [Abstract]. J Invest DermatoI1989;92:542. 8. Goh CL, Chia SE. Skin irritability to sodium lauryl sulphate--as measured byskinwatervapourloss-by sex and race. Clin Exp Dermatol 1988;13:16-9.
9. Lammintausta K, Maibach HI, WilsonD.Susceptibilityto cumulative and acuteirritant dermatitis. An experimental approach in human volunteers. Contact Dermatitis 1988; 19:84-90. 10. Murahata RI, Crowe DM, Roheim JR. The use of transepidermal water loss to measure and predictthe irritation response to surfactants. 1nt J Cosmet Sci 1986;8:225-31 . 11. Tupker RA, Coenraads PJ, Pinnagoda J, et at. Baseline transepidermal waterloss (TEWL) as a prediction of susceptibility to sodium lauryl sulphate. Contact Dermatitis 1989;20:265-9. 12. Murahata RI, Teton-Quinn R, Finkey MB. Effectof pH on the production ofirritation in a chamberirritation test. JAM ACAD DERMATOL 1988;18:62-6. 13. Thune P, Nilsen T, Hanstad IK, et al. The water barrier function ofthe skinin relation to the watercontentofstratumcorneum, pH andskinlipids.Theeffectofalkaline soap andsyndet on dry skin in elderly, non-atopic patients. Acta Derm Venereal (Stockh) 1988;68:277-83. 14. Locher G. Permeabilitatsprufung der Haut Ekzemkranker und Hautgesunder fur den neuen Indikator Nitrazingelb "Geigy," Modifzierung derAlkaliresistenzprobe, pH-Verlauf in der Tiefe des stratum corneum. Dermatologica 1962;124:159-82.
Captopril and alopecia: A case report and review of known cutaneous reactions in captopril use Peter J. Motel, MD Philadelphia, Pennsylvania Captopril (Capoten) is one of several drugs in a group known as angiotensin converting enzyme inhibitors that are useful in the treatment of hypertension and congestive heart failure. Many adverse cutaneous reactions to captopril have been reported, including rash (usually maculopapular or morbilliform, only rarely urticarial), which occurs in approximately lO%of patients usually appears within 4 weeks of starting therapy. 1-3 Pruritus and occasionally fever and eosinophilia can accompany the rash. 1 The rash usually resolves with dosage reduction and may resolve even if therapy is continued without change.t-" Pruritus without rash has been noted in 2% of patients." Reactions that occur in less than 2% of patients include angioedema of the face and mucous membranes, laryngeal edema (one case), pemphigus-like lesions,exfoliative dermatitis, pityriasis-like eruption, and photosensitivity. All are reversible when the dosage of the drug is reduced or when the drug is discontinued." Case report. A 68-year-old woman with congestive heart failureand no historyofallergic drug reactions or alopecia had beentreated for3 months withfurosemide (Lasix), 40 mgjday orally, and potassium without complication. On a follow-upvisit she reported increasing dyspnea onexertion; treatmentwithoral captopril (l2.5 mg orally every 8 hours) was started. Furo-
From the Department ofDermatology, Thomas Jefferson University. Reprint requests: Peter J. Motel, MD, Thomas Jefferson University. Department ofDermatology, III S. Eleventh St., Philadelphia, PA 19107. 16/4/17043
