42 Skin Disorders FAMILY P RACTICE N EWS • September 1, 2005

D ERM D X Low-Dose May Help girl born at 41 weeks’ gestation was apneic upon delivery Aand had a rash from head to toe. She was intubated and Treat Female Refractory sent to the NICU. Skin exam showed erythematous papules with purpura, crusting, and ulceration that involved the face, trunk, arms, legs, palms, and soles. The mother had a history BY JEFF EVANS 51 years who received a prescription for flu- of spontaneous , but was up to date on vaccinations Senior Writer tamide at 125 mg/day, 17 of the 21 patients who and her screening exams were normal. What’s your diagnosis? returned for follow-up visits had marked im- Q UEBEC C ITY — Dosages of the androgen re- provement of their acne. The length of treat- ceptor blocker flutamide at 125 mg/day appear ment in the 21 patients ranged from about 2 to be effective in treating acne in women who months to 21 months, Dr. Shaw and his associ- have not responded to other medications, James ates wrote on a poster. C. Shaw, M.D., reported at the annual conference Overall, five women discontinued treatment be- of the Canadian Association. cause of emotional lability (two patients), minor Flutamide has been reported to be effective in GI distress (two), or a slightly elevated level of ala- treating acne at doses of 500 mg/day and 250 nine aminotransferase (one). With the exception mg/day. But flutamide has not been used as of four patients, none the women had responded widely as other androgen receptor blockers such adequately to or had tolerated other therapies. as and be- Dr. Shaw said that he regularly conducts cause of an incidence of hepatotoxicity ranging function tests. Flutamide has been associated from 1% to 5% at dosages greater than 500 with developmental abnormalities in exposed fe- mg/day and in isolated cases at 250 mg/day, ac- tal rats, so all patients must be advised about cording to Dr. Shaw of the division of derma- contraceptive use during treatment. The drug is tology at the University of Toronto. most often used to treat prostate cancer in men In a review of 32 consecutive women aged 14- and in women. ■

S AN D IEGO — The most ag- combination chemotherapy can

gressive variant of Langerhans be tried. HAW

cell histiocytosis, Letterer-Siwe The response rate to mono- C. S disease is characterized by cuta- chemotherapy can reach 90%, neous involvement, organo- but the overall outcome is usual- AMES . J R

megaly, and , ly fatal, especially in the congen- D Joseph P. Janik, M.D., said during ital form of Letterer-Siwe (Cancer a poster session at the annual 1988;62:2528-31). At press time, meeting of the Society for Pedi- this patient is alive at the age of 21 atric Dermatology. months, after a year of treatment HOTOS COURTESY

The patient was thrombocy- with vinblastine, prednisone, and P topenic and had an enlarged 6-mercaptopurine. This patient’s acne was refractory to Her acne responded to 8 months of flutamide spleen and liver, but there were Dr. Janik discussed another treatment with isotretinoin. 125 mg/day plus oral contraceptives. no lung abnormalities. The re- case of the Letterer-Siwe variant sults of two shave biopsies con- of congenital Langerhans cell firmed the diagnosis, said Dr. histiocytosis in a baby born at 28 Janik, the lead author of the case weeks’ gestation. Apgar scores Tips for Improving Teenagers’ report, of the department of der- for the baby, who was delivered matology at the University of via emergent C-section, were 2 New Mexico, Albuquerque. at 1 minute, 1 at 5 minutes, and Adherence to Acne Treatment Few controlled studies exist for 1 at 10 minutes. Resuscitation the treatment of the Letterer- attempts were unsuccessful, and BY ROBERT FINN tions of and ben- Ǡ Remember that your clini- Siwe variant of Langerhans cell the baby expired 25 minutes af- San Francisco Bureau zoyl peroxide are available now. cal assessment of disease histiocytosis, let alone the con- ter birth. Coming soon there may be severity may differ dramati- genital form. PUVA and topical Ran H. Bang, M.D., Charles H. S AN F RANCISCO — Lack plus and cally from the patient’s as- nitrogen mustard seem to be Palmer, M.D., E. Ben Smith, of treatment efficacy is only retinoids plus . sessment. A single pustule on most effective for the skin lesions M.D., and R. Steven Padilla, one of the reasons that acne Ǡ Minimize the adverse ef- otherwise porcelain skin may while vinblastine or etoposide M.D., all of University of New therapy often fails in teenagers, fects. Because benzoyl peroxide be more damaging psycholog- have been used for the systemic Mexico, assisted with the case Lee T. Zane, M.D., reported at can be especially irritating, max- ically than widespread disease. manifestations (J. Pediatr. 1991; reports. a meeting on clinical pediatrics imize therapy before Ǡ Peer opinion is often far 119:317-21). For nonresponders, a —Doug Brunk sponsored by the University of maximizing benzoyl peroxide. more compelling than scien- California, San Francisco. With retinoids and benzoyl tific data. The physician may Poor adherence is also a fac- peroxide, advise patients that a be focusing on the patient’s face, tor, said Dr. Zane of the uni- pea-sized dollop should be but if his friends are making versity. And poor adherence enough to cover the face. Using fun of the acne on his back, he’ll can stem from several things. more will not improve the re- be more concerned about that. The treatment regimen may sult, but will increase irritation. Ǡ Warn patients about be- be too complex, or patients Advise them to apply topical haviors that worsen acne. may stop treatment prema- agents to dry skin, waiting 20- Physicians have long advised turely when they don’t see 30 minutes after washing. against picking or squeezing,

ANIK quick results. Adverse effects Ǡ Set realistic expectations. but they also should point out

P. J of therapy often lead to poor Tell patients to try a therapy for that scrubbing or exfoliating can adherence too. In some cases, at least 2 full months before de- promote the formation of OSEPH the patient may have concep- ciding whether it’s effective. comedones. Rubbing the skin . J R

D tual opposition to certain “I’m going for a slow and during sports or other activities modes of therapy. steady course of therapy fol- also can promote acne. Dr. Zane offered these tips to lowed by long-term mainte- Finally, some medications optimize adherence: nance,” Dr. Zane said. “It’s not can exacerbate symptoms. Ǡ Simplify the treatment reg- a quick cure. It’s really about These include lithium, topical HOTOS COURTESY

P imen. Use fewer agents or management of a chronic con- and oral , and combination agents. Combina- dition and prevention. androgenic steroids. ■