The newer corticosteroids for local application, betamethasone valerate and fluocinolone acetonide, are so much better than their predecessors that the need to use other routes of administration is diminishing. Lichen planus, lichen simplex and chronic discoid lupus erythematosus respond, particularly if penetration of the drug is assisted by the technique of occluding the anointed area with an impervious layer of material such as polythene sheeting. This improvement in therapeutic effect, however, has been achieved only by reducing the margin of safety; with the occlusive technique systemic absorption is increased to such a degree that adrenocortical suppression is possible. It is therefore advisable to limit the duration of occlusion to periods of 12 hours; and the area treated at one time must not exceed one-third of the total body surface.
Intra-cutaneous Injection.—Resistant patches of lichenification, lichen planus, discoid lupus erythematosus and psoriasis can be treated by the injection of triamcinolone around the lesions, the total volume used being not more than 0-5 ml. The injections are repeated at weekly intervals until a satisfactory response has been obtained. Small patches of alopecia areata are also suitable for such treatment, but widespread loss of hair cannot be treated by this method.
Systemic Treatment.—Corticosteroids are needed as a life-saving measure in fulminating illness associated with drug eruptions, urticaria and erythema multiforme of the Stevens-Johnson type. The treatment should be started by giving 0.1 g. of hydrocortisone hemisuccinate intravenously and 40 mg. of prednisolone in divided doses by mouth, during the first 24 hours. The dose is adjusted thereafter according to the patient's response; the daily dose should be tailed off and eventually stopped as soon as the activity of the disease has abated—which will probably be within three weeks.
Long-term corticosteroid treatment is required in exfoliative dermatitis, the pemphigus group of diseases, mycosis fungoides, the cutaneous reticuloses and disseminated lupus erythematosus. Since these are mortal diseases or at least endanger life, such treatment is manifestly justifiable. After initial high dosage of the order of 60 mg. of prednisolone daily to achieve control, a maintenance dose as low as 10 to 15 mg. of prednisolone daily is often possible.
Difficulty arises in deciding whether to use systemic corticosteroid treatment in chronic non-fatal dermatoses, for if such treatment is begun it may have to be continued indefinitely. It is established practice to use oral treatment to tide a patient over a severe attack of urticaria, erythema multiforme or a drug eruption since these are likely to be self-limiting. A severe attack of eczema which is attributable to some remediable stimulus such as contact with a known irritant can reasonably be suppressed during the period of its activity with the prospect of being able to stop the treatment within a few weeks. The management of lichen planus is more debatable since local application of the newer corti-costeroids under occlusion is so effective. Most debatable of all are cases of obstinate and disabling dermatosis when there is some prospect of being able to effect material improvement but at the risk of keeping the patient permanently on corticosteroid treatment. Many dermatologists regard the risk as too great to contemplate in any circumstances; but this is perhaps a somewhat extreme view, and it is not borne out by the experience of those who have used long-term treatment over a period of several years with strict supervision of the patients. It seems probable that if the maintenance dose can be kept at or below 10 mg. of prednisolone daily, and never exceeding 15 mg. daily (except under conditions of stress as mentioned below), the risks are very much reduced and may be acceptable for the few patients who would fall within the terms of the following conditions :
The dermatosis is so severe as to interfere seriously with the patient's life and ability to work, either by reason of physical incapacity or psychological handicap such as an overpowering feeling of inferiority.
A carefully supervised and adequately prolonged period of treatment (say one year) by other means has failed to bring substantial relief.
There is no history suggesting peptic ulceration, psychosis, diabetes mellitus, significant hypertension or severe osteoporosis.
There is no active focus of tuberculosis. A past history of this disease points to the need for a careful clinical and radiological survey and, even if no activity is detectable, anti tuberculous drugs should be given concurrently with corticosteroids. A close watch should be kept during treatment in all cases, irrespective of a known history of tuberculosis, for signs of this disease.
The patient is intelligent and co-operative. He should understand the nature of the risk involved in the treatment and accept it. He should be prepared to attend regularly for follow-up, and should carry a corticosteroid treatment card which should be kept up to date.
In the case of alopecia treatment should be restricted to those in whom the loss of hair is total, or nearly so; the alopecia should have occurred after puberty, and a wig should have proved unsatisfactory.
It is recommended that the initial daily dose of prednisone should be 15 mg., that, except as mentioned below, this dose should never be exceeded, and that the maintenance dose should be kept at or below 10 mg. daily at a level at which the disease is just active. If worthwhile improvement has not occurred within 12 weeks, the treatment should be abandoned by gradually tailing off the dose. The follow-up needs to be at weekly intervals initially until the disease has been controlled and the dosage stabilized, and thereafter at increasing intervals but never longer than eight weeks. At each visit the patient is assessed clinically, has his blood pressure taken, is weighed and has his urine examined for sugar and albumin. The most serious risk of the treatment is suppression of adrenocortical function which could lead to sudden adrenal failure in face of the stress of an infection, an anesthetic (even a dental gas) or an injury. The. remedy is to cover periods of stress with an increased dose of steroid, say three to four times the normal. The corticosteroid record card is the patient's only safeguard if he is involved in an accident and taken unconscious to hospital.
The method will be found applicable to selected cases of severe atopic eczema (Besnier's prurigo), generalized neurodermatitis and alopecia totalis. Psoriasis is unsuitable (even if triamcinolone, which has been specially recommended for this condition, is used) because the maintenance dose is usually above the recommended maximum, and there is also a tendency for the disease to relapse violently when the treatment is stopped.
It is possible that as far as their effect upon diseases of the skin is concerned, some corticosteroids are more effective than others. In pemphigus cortico-trophin injections can be much more effective than oral corticosteroids but this might be due to defective absorption from the gut. In alopecia there is an impression that methyl prednisolone and triamcinolone are more effective than prednisolone in equivalent dosage. On the other hand prednisolone is regarded as safer than triamcinolone.
Tuesday, July 29, 2008
URTICARIA Treatment
Urticaria is the result of localized ædema in the skin produced by leakage of fluid without red cells from the blood. The transient increased permeability of the vessels is usually brought about through the release of histamine (or histamine-like substances), by a variety of stimuli including injury, and the occurrence of antigen-antibody reactions. Some skins weal abnormally with injury (dermo-graphism). Others weal through the action of heat, cold or light; and among the less common precipitating factors are emotional stress and hypnotic suggestion. Urticaria is a common disability, but it is often of limited duration and the eruption can usually be controlled with oral antihistamines. Further the search for the provocative stimulus is difficult and time-consuming, and not surprisingly the cause is seldom found. Some cases become chronic, and then it is imperative to identify the cause if rational treatment is to be given.
Provocative Stimuli.—The search for possible antigens should be directed to the diet, to drugs, to inhalants, to the contents of the hollow viscera and to the patient's own tissues.
The diet should be recorded day by day, with a note on the condition of the skin written on the adjacent page. Things that have been eaten in the 24 hours preceding each fresh outbreak should be reviewed and any foodstuff common to each incident noted. All suspicious foods should be banned. If the urticaria disappears, the foods can be added one by one at intervals of a week and the results observed. If the true cause has been found it should be possible to make the urticaria appear and disappear at will by introducing and withholding it from the diet. Failing this the patient can be starved for two days, except for water ; persistence of the urticaria would make a dietary cause most unlikely. If the diet is suspected but observation has failed to identify the cause, skin tests may be successful provided that the test solutions used are potent.
Of drugs, penicillin and aspirin are said to be the commonest causes of chronic urticaria. The eruption can outlast the giving of penicillin by many months—possibly due in part to the ingestion of traces of penicillin in milk and partly by inhalation, for example in hospitals. Aspirin often acts as a nonspecific stimulus by aggravating urticaria due to other causes. A diary is necessary as in the case of the diet. One should remember that drugs can be taken unwittingly—for example quinine in drink and phenolphthalein in toothpaste ; and also that drugs can be ingested, injected, inhaled, anointed or placed in any of the natural orifices.
Inhalants, such as mould spores, dusts and pollens, which do not necessarily cause sneezing or ocular discomfort, produce a seasonal or intermittent pattern of attack according to the climatic conditions under which they are produced, or their location. Skin testing facilitates precise identification, but specific desensitization may not be practicable.
The hollow viscera, such as the gut and gall bladder can contain organisms or products of their activity which are absorbed and act as antigens. Yeast infection of the bowel or of diverticulae of the bowel (including blind loops left by surgery) often causes urticaria.
The patient's tissues may harbour infections such as dental infection or a tumour which is breaking down rapidly, and these can act as antigens. The auto-antibody disease, lupus erythematosus in its disseminate form, can present as urticaria, and so can the vascular disease, polyarteritis nodosa
Emotional stimuli can be entertained as factors only when, in addition to a lack of physical causes, there are positive psychological ones. Suppressed anger at some intolerable but apparently irremediable situation is a potent stimulus.
Symptomatic Treatment.—In many cases none of the above causes can be found and then the only available treatment is symptomatic. The antihistamine drugs, taken by mouth, are usually effective but it may be necessary to find by trial and error which drug suits the individual patient. The intramuscular injection of an antihistamine is worthy of trial if the response to oral treatment is poor. One of the chief anxieties about antihistamine treatment in the ambulant patient is its possible effect on the ability to handle machinery, particularly motor cars and aeroplanes, for even if antihistamines do not have an hypnotic effect they may impair judgment. The object is first to suppress the eruption with, for example, between 0-15 g. and 0.3 g. of diphenhydramine hydrochloride in divided doses daily, and then to find the minimal dose that will just control the eruption. Children tolerate these drugs well and for them elixirs are very acceptable. An alternative to the antihistamine drugs is to use chloroquine by mouth, for example from 0.25 g. to 0.5 g. of the phosphate daily; but chloro- quine given for long periods has important side- and toxic effects. Corticosteroids usually control urticaria but their use is justifiable only to tide the patient over an acute attack, particularly when the precipitating stimulus is known and can subsequently be avoided—as in urticaria caused by penicillin, In fulminating attacks or when the airway is threatened by ædema, adrenaline hvdrochloride solution, i ml. (i in 1000), is given subcutaneously. These circumstances also warrant giving hydrocortisone hemisuccinate parenterally.
Provocative Stimuli.—The search for possible antigens should be directed to the diet, to drugs, to inhalants, to the contents of the hollow viscera and to the patient's own tissues.
The diet should be recorded day by day, with a note on the condition of the skin written on the adjacent page. Things that have been eaten in the 24 hours preceding each fresh outbreak should be reviewed and any foodstuff common to each incident noted. All suspicious foods should be banned. If the urticaria disappears, the foods can be added one by one at intervals of a week and the results observed. If the true cause has been found it should be possible to make the urticaria appear and disappear at will by introducing and withholding it from the diet. Failing this the patient can be starved for two days, except for water ; persistence of the urticaria would make a dietary cause most unlikely. If the diet is suspected but observation has failed to identify the cause, skin tests may be successful provided that the test solutions used are potent.
Of drugs, penicillin and aspirin are said to be the commonest causes of chronic urticaria. The eruption can outlast the giving of penicillin by many months—possibly due in part to the ingestion of traces of penicillin in milk and partly by inhalation, for example in hospitals. Aspirin often acts as a nonspecific stimulus by aggravating urticaria due to other causes. A diary is necessary as in the case of the diet. One should remember that drugs can be taken unwittingly—for example quinine in drink and phenolphthalein in toothpaste ; and also that drugs can be ingested, injected, inhaled, anointed or placed in any of the natural orifices.
Inhalants, such as mould spores, dusts and pollens, which do not necessarily cause sneezing or ocular discomfort, produce a seasonal or intermittent pattern of attack according to the climatic conditions under which they are produced, or their location. Skin testing facilitates precise identification, but specific desensitization may not be practicable.
The hollow viscera, such as the gut and gall bladder can contain organisms or products of their activity which are absorbed and act as antigens. Yeast infection of the bowel or of diverticulae of the bowel (including blind loops left by surgery) often causes urticaria.
The patient's tissues may harbour infections such as dental infection or a tumour which is breaking down rapidly, and these can act as antigens. The auto-antibody disease, lupus erythematosus in its disseminate form, can present as urticaria, and so can the vascular disease, polyarteritis nodosa
Emotional stimuli can be entertained as factors only when, in addition to a lack of physical causes, there are positive psychological ones. Suppressed anger at some intolerable but apparently irremediable situation is a potent stimulus.
Symptomatic Treatment.—In many cases none of the above causes can be found and then the only available treatment is symptomatic. The antihistamine drugs, taken by mouth, are usually effective but it may be necessary to find by trial and error which drug suits the individual patient. The intramuscular injection of an antihistamine is worthy of trial if the response to oral treatment is poor. One of the chief anxieties about antihistamine treatment in the ambulant patient is its possible effect on the ability to handle machinery, particularly motor cars and aeroplanes, for even if antihistamines do not have an hypnotic effect they may impair judgment. The object is first to suppress the eruption with, for example, between 0-15 g. and 0.3 g. of diphenhydramine hydrochloride in divided doses daily, and then to find the minimal dose that will just control the eruption. Children tolerate these drugs well and for them elixirs are very acceptable. An alternative to the antihistamine drugs is to use chloroquine by mouth, for example from 0.25 g. to 0.5 g. of the phosphate daily; but chloro- quine given for long periods has important side- and toxic effects. Corticosteroids usually control urticaria but their use is justifiable only to tide the patient over an acute attack, particularly when the precipitating stimulus is known and can subsequently be avoided—as in urticaria caused by penicillin, In fulminating attacks or when the airway is threatened by ædema, adrenaline hvdrochloride solution, i ml. (i in 1000), is given subcutaneously. These circumstances also warrant giving hydrocortisone hemisuccinate parenterally.
SYCOSIS BARBAE Treatment
This form of chronic folliculitis of the beard region has become much less common since the days of antibiotics. The causative organism, usually staphylo-coccus aureus, lurks in the depths of the follicles and is not readily accessible to local applications. Local preparations should therefore be massaged well into the skin, night and morning. Experience has shown that it is best to prescribe a succession of different antibacterial applications rather than to continue with the same one : thus, chlortetracycline ointment could be followed by quinolor compound ointment, neomycin ointment, iodochlorhydroxyquinoline ointment, etc. A small amount should also be applied inside the nostrils. If such treatment gives rise to discomfort it can be combined with local corticosteroid therapy. The shaving tackle should be cleaned carefully and if possible sterilized after every use ; and when shaving the strokes should be made only with the grain of the hair.
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