ACNE -------------------------------------------- 1) accutane 2) tetracyclines 3) phototherapy 4) Nadifloxacin cream 5) Seijo-bohuto 6) Adaplaene 7) antibiotics plus NSAID 8) Cleocin p.o. 9) x-ray and Grenz ray therapy 10) vitamin therapy 11) spironolactone 12) Benzamycin 13) Oral Contraceptives 14) Miscellaneous 15) Bactrim 16) Comedone extraction 17) Post-inflammatory pigmentation Does anyone know of any published suggestions or reccomendations on how long to wait to start a second Accutane course. I have a 16 y.o. male who is developing large cystic lesions 6 weeks off a 6 month course at 1 mg/kg/d. Does anyone have any experience on cross reactivity of minocyline with doxycycline, tetracycline. I have a 16 y.o. female patient with quite inflammatory acne who developed urticaria while taking generic minocycline and would like to consider doxycycline or tetracyline in the future. A brief not on cost of therapy from my local OSCO drug: minocyline generic 100 mg #60 $81.00 (they also told me they would sell the generic for $50.00 to "compete with Walmart") Dynacin 100 mg #60 $148.00 Minocin pellets 100 mg #60 $170.00 Although I feel that both Dynacin and Minocin are superior, it is hard to convince the patients to spend the extra money. I find that with Dynacin patients clear better but also get more dizziness (? better absorbtion) Previousely I did not think there was not much difference in cost between Dynacin and the generic, but at some pharmacies apparently it is significant. Mike Crowe, M.D. ---------------- 1) It has been my understanding that it is recommended to "rest" for 3 months before starting a 2nd course of Accutane. This has been my practice and has worked fine for me. 2) I personally discovered that I have a fixed drug eruption to TCN while I was an intern. When Doxcycline came out, I took some with me on a trip to Mexico and when I took it with the onset of the 'touristas', I again developed a fixed drug eruption. I would never come near a TCN derived drug. 3) I have had a fair number of patients whose acne was controlled on a fixed dosage of Minocin (Lederle) or Dynacin who were substituted another generic by their pharmacist. They subsequently began to break out and I had to increase there dosage of the generic to control them.. I then convinced them that by taking 1 1/2-2 pills of the generic vs. 1 pill of Dynacin or Minocin (Lederle), the cost was the same. I just don't think the generics are absorbed as well so the full dosage doesn't reach the target organ. Jeff Marmelzat, M.D. -------------------- (see also ACCUTANE, TETRACYCLINES) -------------- PHOTOTHERAPY ? -------------- A few studies have shown that propionibacterium acnes produces porphyrins. Blue Light Or Red light which are the action spectra of porphyrins are able to destroy propionibactria in vitro. Does anybody have experience with clinical use of blue or red light for acne? Yoram Harth MD -------------- That's a very interesting idea, but does visible light penetrate far enough down into the follicle? Yelva Lynfield, MD ------------------ I have a patient, a 39 yo white male, whom I have been following for about three years for acne. He also had some trouble with boils in the axillary areas, but on examination they did not show the typical scar and tract formation seen in hidradenitis suppurativa. He had both cystic and pustular lesions on the face and to a much lesser extent on the chest. He says that he has had acne, as he calls it, for years, including his teenage years. He has seen other doctors for this problem before me, and no one has really been able to help him much. Treatment that I have given him includes: 1. Erythromycin 500 mg bid x 4 months--no change 2. Minocin 100 mg qd x 6 months--initially helpful, but he became tolerant. Increasing the dose to 200 qd didin't help. 3. Septra DS bid x 3 months--didn't help very much. 4. Accutane 40 mg bid (wt was 197)--excessive elevation of triglycerides (497--500 is where I balk), and side effects that he was not able to tolerate--arthralgias, dry everything, nosebleeds, etc. He finally was able to tolerate 40 -50 mg per day, and finished a full 20 week course. He was unwilling to take it for an extra month. Unfortunately he started to relapse within 1 month of discontinuing the Accutane. He has repeatedly said that he will not take another course of it because he was so uncomfortable with the side effects and it didn't help him that much anyway, except it did help quiet the axilllary boils. 5. Cipro 500 bid x 2 months while on Accutane--no perceptible difference. 6. Retin-A--all strengths--some improvement with the pustular part of the acne. 7. Dapsone--up to 200 mg daily--no help. 8. Cleocin-T soln--some superficial improvement 9. Glycolic acid peels--helpd for a while, but the acne has recurred and become unresponsive to these. 10. Septra again--no benefit. 11. Zithromax x 3 or 4 months--some benefit, but not rally any good control. 12. Biaxin x 3 months--no benefit. 13. TCA peel (10 %)--no benefit--really no problem with it either. 14. Sulfacet-R lotion--plus-minus 15. Azelex--no benefit 16. Keflex--all the skin on his hands peeled off. 17. Minocin 200 mg bid again--no help. 18. TCN and Doxy in the past didn't help. 19. PCN--he is allergic (hives) As you can imagine, he usually was on a combination therapy, ie topical and oral. He is becoming quite frustrated and I don't really blame him. Any suggestions would be greatly appreciated. Heidi Cole, MD -------------- It seems that you have tried almost everything to treat his acne. In the 1980's (I forgot the year)my boss, Dra Jamora published in the JAAD a study which shows a very high correlation between Acne and pityrosporum yeasts. That is why we give our acne patients an additional antifungal regimen. You could confirm this by getting a comedone extractor to get a sample of sebum and doing KOH to it. If it is loaded with yeast you could give him Itraconazole 100mg OD for ten days. At the same time continuing his Tretinoin .05% but adding terbinafine or ketoconazole equal parts to it. May be at this point the fungal component is not being treated. Also I have read that adapalene from Galderma a analogue to tretinoin is starting to be available. I have no experience with this but may be others in the group do. They could advise you if it would help. Jonathan Yu, MD ---------------- ------------------ NADIFLOXACIN CREAM ------------------ I sometimes use Acuatim cream (1 % Nadifloxacin cream, OPC-7251 cream)(1) . Some colleagues like to use chinese medicine such as Seijo-bohuto for pustular acne. Yoshiki Taniguchi M.D., Ph.D. ----------------------------- --------- ADAPALENE --------- Adaplaene will be launched in the US in November. Great stuff - a selective retinoic acid receptor agonist. Very well tolerated . By the way, I had a woman with extensive flat warts on the face resistant to Retin-A, Efudex, ranitidine, and she cleared right up on Differin - great photos. I'm looking for more cases to see if this is real or just a fluke. For the deep stuff you'll need pills- Jim Rasmusson reported the combination of antibiotics plus NSAID about 10 years ago, and it really does work. Had another case recently resistant to Accutane, etc, clearing nicely on Biaxin 250 tid and Naprosyn 500 tid - again, great photos. I wonder if your guy has some immunologic problem eg. neutrophil dysfunction. KC Smith MD FRCPC ----------------- Maybe I am the only one who is feeling a bit uncomfortable with the diagnosis of acne in a 37 yo patient. Even with a history from puberty onwards, sounds to me like a rosacea after a typical acne, especially if you don't find any comedones. Might be one of the rare cases that this disease crosses the facial lines... Another suggestion: demodex folliculitis? Concerning the therapy, you really tried a lot, and I don't know all of these american brand names, but did you ever consider metronidazole either as gel or systemic treatment? Adapalene: seems to be a good alternative to topical isotretinoin, in Germany it is only cleared for acne of the face, can't find out why. As it has been available for just a few weeks, I only have a very restricted experience, but none of the ca. 10 patients I treated with it came back from the practitioners, so I assume a VERY good effect in mild to moderate papulopustolosa. Dr. med. Hans J. Kammler Dept. of Dermatology Friedrich-Schiller University ----------------------------- Cleocin p.o. and x-ray therapy were mentioned in my residency as treatments of desperation. You may be getting close. Beats suicide. Dan Mitchell, MD ----------------- Concerning the patient with intractable acne: A few suggestions to add to those good thoughts already posted. 1. Culture the pustules. A gram negative may be present...hard to permanently eradicate. 2. Consider hormone studies to rule out states of androgen over-secretion. Elliot Puritz ------------- Consider an endo workup & also a karyotype to r/o xyy syndrome even though the patient may not have the social-behavioral characteristics. Thomas F. Downham II, MD ------------------------ After all the stuff he's received, I wouldn't be surprised if you were to culture some peculiar organism, or a "regular one" resistant to everything. This is the same type of "biological cascade" which can occur in patients with hidradenitis who receive many increasingly broad spectrum antibiotics, until they're resistant to almost everything. I'd also seriously consider some other cause of acne/acneiform rashes such as occult drug ingestion, iodine ingestion, vitamin B (6, and 12), etc. I once had a young man resistant to therapy, until I found out he was a vegetarian, and ingesting large amounts of iodine containing foods, and giving himself megadoses of vitamin B6 and B12. His "acne" cleared with dietary modification. I can't imagine plain acne not responding to the therapeutic barrage your patient has had! Robert I. Rudolph, M.D., FACP ----------------------------- This may be politically incorrect to even suggest, but what about radiation therapy (i.e. Grenz Rays)? Warren Winkelman, MD, FRCPC --------------------------- -------- VITAMINS -------- Many of these patient's in my experience have a defect in processing the bacteria presented to their WBC's--They will sometimes respond suprisingly well to a multiple vitamine and extra vit. C 1000mg/d--Certainly won't hurt to try. W H Burrow ---------- -------------- SPIRONOLACTONE -------------- I've got lots of women who have pre-menstrual acne doing well on Aldactone (spironolactone) 100 mg qam (and a few on 200 mg qam) from the start of pre-menstrual symptoms until the end of menses (usually a total of 7-10 days each cycle.) Spironolactone works mainly by competing with dihydrotesterone (DHT) at receptor sites; and also works by blocing 5-alpha-reductase, which converts circulating testosterone to DHT. I give spironolactone peri-menstrually because this is when the sum of the adrenal plus the ovarian androgens is maximal. I know there are other androgens floating around making a nuisance of themselves, but as a practical matter spironolactone usually reduces the aggregate level of androgen effects by a useful degree, even though it only works on the DHT part of the problem. Most patients can tell a few days before their menses start, and can usually tell when the acne is going to start (it varies from woman to woman, but is usually at the same point in a given individual's cycle). Other standard acne treatments are usually used to control the rest of the acne, but by adding peri-menstrual Aldactone I am often able to reduce the intensity and expense of the pill and / or creams that are used every day of the month. Women who have fluid retention appreciate the diuretic effect of the Aldactone. On this note, be sure to tell them to take in IN THE MORNING or they'll be up all night going to the bathroom! Because it is only taken 7 - 10 days each cycle it does not seem to cause menometrorrhagia the way daily Aldactone can in women who are not taking birth control pills, which regulate the menstrual cycle and are essential in cases (eg. hirsutism) where Aldactone has to be taken every day of the month. Because its only taken 7 - 10 days each cycle I don't get lab tests, and potassium supplimentation is not necessary. I warn them all not to take it if they are pregnant because it could feminize a male fetus if taken later on in pregnancy. (But its only supposed to be taken peri-menstrually anyway, so that is kind of self-limiting.) I used to use quite a lot of Decadron 0.5 mg hs from the start of pre-menstrual symptoms until the end of menses but over the past few years most of this group of patients have wound up on Aldactone. Seems to work a bit better, and the diuretic effect is a bonus. Kevin C. Smith MD FRCPC ----------------------- ditto for aldactone, I find myself using it more and more. Great for the accompanying oily skin many women have and hate. I haven't used it in a "pulse" fashion so something else to try. One point, it's hyperkalemia that's the concern, not hypokalemia, so the comment about K+ supplementation may mislead those who haven't used the drug before. Mark Ling, M.D., Ph.D. ---------------------- I use spironolactone too but I am somewhat concerned about the alleged increased risk of breast cancer when spironolactone is given to rats. Since I practice in California, the land of the plantiff, I am concerned that someone down the line might blame their breast cancer on the spironolactone. Is breast cancer a significant risk of spironolactione and do you mention this to your patients? Walter H. Wood, M.D. -------------------- THAT is exactly why I don't prescribe the drug for a cosmetic condition. The boxed warning in the PDR is enough to scare me. When you add up the percentage risk of women who are going to get breast cancer, I don't perceive the benefit to outweigh the risk: not in a jury's eyes. Patrick Carrington, M.D. ------------------------ No, I don't mention that "risk" - I recall seeing that refuted, but I'm at home now and don't have the reference. The original concern was raised in a study of beagles. KC Smith MD FRCPC ----------------- I have also found that adult women & even teenage females with strong histories of menstrual acne flares do better on Aldactone than on antibiotics or any topicals. I have used Aldactone to treat a two young women with severe cystic acne that rapidly recurred after 3 or more courses of Accutane - it worked beyond my wildest expectations - they are nearly clear all the time! I usually use 50 mg. bid -tid continously, and add an oral contraceptive if needed for birth control or for added effect vs. the acne. The intermittent dose schedule sounds like a great idea. I also worry about how long I can keep them on it. Any comments on the duration of Rx? GenadijS@aol.com ---------------- In the Philippines we have very good response using this. However we find that minocycline 100mg OD 7 days before menstruation helps minimize or prevent flares in women prone to pre-menstrual acne. (Being a very catholic country, women here hesitant to use OCP) Last year one of our consultants has been using spirinolactone topically in a special vehicle. Seems to work but we are still evaluating our data and this is purely anecdotal. Jonathan Yu, MD --------------- I've had some women on peri-menstrual Aldactone for 3-4 years now - I usually order 100 of the 100 mg tabs at a time (this would last about a year in most cases), and it works well just giving it qam, which enhances compliance and perhaps reduce problems with diuresis (though Aldactone is not a very powerful diuretic, and I've NEVER had anyone complain about this). I think intermittently Aldactone can be used safely for decades if need be. KC Smith MD FRCPC ----------------- ---------- BENZAMYCIN ---------- I don't use Benzamycin much because many patients find it drying and irritating. That may just be a northern climate effect, however. The other problem is that the manufacturer labels it to be kept in the refridgerator, which means that many teenagers forget about using it, and so don't use it much. The only argument for using it here is that it's the only benzoyl peroxide on the managed care formularies. Heidi Cole,MD ------------- It must be the climate. None of my patients tolerate it either. Not one! It may be because Retin A is the mainstay of my non Accutane practice. Diane Thaler ------------- I use it regularly here in the NW and find it very useful and generally well tolerated. Better tolerated than Retin-A which I also use as first line Rx. Often, I use them together, Benza in AM and Retin-a in eve. Jerry Eisner ------------ I recommend it starting on an every other day basis depending upon the oiliness of the complexion to be increased more frequently as their skin 'hardens.' Also, I don't recommend the refrigerator, as most will tell you that it retains its efficacy for at least 30 days at room temperature: and if the patient is using it like they should, one jar should last no longer than 30-40 days. Patrick Carrington, M.D. ------------------------ I have found that Neostrata - 15 Lotion or MDForte 20% glycolics combine well with Benzamycin therapy. I start the glycolic first, and after a few weeks when the skin has adapted & is less subject to irritation I add Benzamycin or Triaz 6%. Both are applied bid. This seems better tolerated that Benzamycin + RetinA, and works pretty well unless there are very severe comedones, in which case RetinA is absolutely necessary. Gene Sienkiewicz, M. D. ----------------------- The combination of a topical erythromycin and benzoyl peroxide improves the efficacy of both medications and reduces the possibility of developing resistance to either. The problem that my patient's have with Benzamycin is keeping it in the refrigerator(either inconvient or to cold). To get around this I give my patients T-Stat pads and Brevoxyl (my favorite) and have them blend the cream into the pad thus applying both at once. I still get a few complaints of dryness but it works well. W H Burrow ----------- I can't believe all these negative comments about Benzamycin. I practice in an extremely dry climate (Denver) and I rarely get any complaints of dryness and irritation. I hear these complaints much more with Retin-A than Benzamycin. Kip Cullimore ------------- I have my patients tack a pocket mirror onto the refrigerator door when they are using any topical that must be kept cold. Having said that , I will say that I do not think Benzamycin is any more efficatious than Benzoyl peroxide in a decent base for the simple reason that I think topical erythromycin no longer works in the mid - 1990's. I began seeing a lack of response to oral erythromycin about 5 years ago, and the last academy meeting James Leyden stated that most of the P. acnes he tested was resistant to it as well. John Uhlemann ------------- Have had good results from Benzamycin with good patient acceptance, but it is fairly expensive. In our climate, very little dryness; much less irritating than Retin A. I agree that Erythromycin ,topical or systemic, doesn't seem as effective for acne than 5-10 years ago. You mentioned Jim Leyden - he gave a talk to our local Derms recently and got the attention of all of us when he mentioned that the youngest patient he has treated was 4 months! Showed many slides of patients under 10 years old with severe acne which responded to Accutane. He also believes that Accutane does not lead to increased scarring from dermabrasion and sends patients that want it for dermabrasion immediately after they finish Accutane. I'm glad I don't see the severe acnes he does. Harold Rehbein -------------- ------------------- ORAL CONTRACEPTIVES ------------------- Speaking of OCPs in acne patients, do any of you have favorites? Diane Thaler ------------ My favorite is Marvelon (also sold in the States under a different name). There was a flurry of negative publicity about it in the British medical press a few months ago, then that was refuted a month or two ago. Can't recall the exact details. Bottom line is that it actually HELPS acne somewhat, but it takes about 6 months to reach its maximum effect - also good for hirsutism, but not good enough as a single agent. I've got several women with idiopathic hirsutism doing well on Marvelon + Aldactone 100 - 200 mg qam. KC Smith MD FRCPC ----------------- There was a nice review article in Fitzpatrick's Journal on oral contraceptives. I usually recommend Desogen or Ortho-cyclen. Gene Sienkiewicz, M. D. ----------------------- Desogen may sometimes cause breakthrough bleeding for several months, so warn people of the trade off. One of my patients stopped due to this problem. Otherwise, everyone had liked it. I t does seem to cut down on the grease load as well after a while. Diane Thaler ------------ The newer antiandrogenic pills (OrthoCept, Desogen, etc) which held so much promise as the answer to acne management because of their supposed minimal acnegenic properties have been a disappointment in practice. Lots of breakthru bleeding, weight gain, bitchiness. My friends in the business tell me that their favorites for acne patients are Demulen, Modicon, Brevicon. Stay away from Ovral and Lo-Ovral. Barbara R. Reed, MD ------------------- Demulen 50 with lots of estrogen might help acne a bit, but I think Demulen 30 is useless for acne. Recently the triphasic BCP were reported to increase libido, so they may be the most popular (with the patients) over the long run. Kevin C. Smith MD FRCPC ----------------------- Because of the up and down hormone rushes with the triphasics, I discourage their use. I can't imagine the subtle or not so subtle mood changes accompanying the peaks and troughs. And, who says anyone would want to have an increased libido?????Unless its their significant other. Diane Thaler ------------- ------------- MISCELLANEOUS ------------- I use HCTZ 25-50 mg daily for one week before menses. Works about 50-66% of the time. James R. (Jay) McCarty, M.D. ----------------------------- I've heard that HCTZ can work - glad to hear from someone who's used it. There is a HCTZ-Aldactone combo called Aldactazide - maybe I'll start to Rx that as see if it gives an extra increment of improvement. Thanks for the tip! Kevin C. Smith MD FRCPC ----------------------- Even though its not supposed to kick in for weeks, prozac can be used in the same way as spironolactone, HCTZ, Minocin, etc. For people who get very grouchy. Diane Thaler ------------ I worked with a dermatologist a few years ago who would give Vitamin B6, 100 mg/day, to his patients that complain of pre-menstrual flares. It usually takes 2-3 months, but does seem to help. Can increase this to 100 mg BID if no improvement in 3 months. I Have personally tried this on several patients myself with good success. Bryan Sands ----------- For those of you who know more about asa and nsaid's...I always develop acne on my face when i take aspirin for more than a day. Does this tell us wonderful things about the sebaceous gland that will make for better drugs?. Something is clearly going on. Steve Emmet ----------- ------- BACTRIM ------- Received a call from a well-read pediatrician regarding my prescribing of Bactrim DS - bid for acne in a 13 yo who failed courses of tcn, mino, erythromycin, usual topicals, and even a 5 month course of accutane. He expressed concern regading dose of DS strength and the lack of monitoring of WBC. I advised him that I have been using it in this dose without monitoring of lab studies for years with no problems even with long-term > 6month use. He stated that the pediatric literature demands regular monitoring of WBC. Robert M. Peppercorn, M.D. Inc ------------------------------ Bactrim because of its high rash rate ( wasn't it 51/1000 in the old Boston study) and severe rash types is on my list of never use unless push comes to shove-and it hasn't yet. Sulfa drugs make me sleepless. It amazes me how some of the young docs who have no memory of the old sulfa hospitalizations use it so liberally. Diane Thaler ------------ When I was a resident the first 2 hospital cases I saw were both severe Stevens Johnson Syndrome secondary to Bactrim given for acne. One patient had long-term sequelae. I have since never given it. Recently however I learned that another good reason to avoid it was neutropenia, and that periodic bloodwork was advisable. Barbara R. Reed, MD ------------------- I share your nightmares concerning sulfas. But it's the best and easiest to apply as prophylaxis in people with HIV or AIDS against toxoplasmosis and PCP, and I hope every day that these patients don't get a rash. So I never consider an application in comparatively mild diseases such as acne or cystitis. Fortunately these drugs are no longer *en vogue*. Hans J. Kammler -------------- Please remember that there are many mechanisms responsible for the induction of Drug Eruption. Synergistic actions with viruses, decreased levels of free-radical quenchers and other anti-oxidants, decreased levels of glutathione, etc. In the "Private Practice" of Dermatology, most of these outpatients with moderately severe acne are adolescent teenagers in excellent shape. Most cases of TEN/EM occur in patients with secondary infections, patients on multiple medications, and patients with just poor protoplasm. Interesting that you comment on this. Today a pharmacist wouldn't refill one of my patients BactrimDS for acne: said it wasn't used for that. Well, guess again. I've used BactrimDS for 13 years for moderately severe inflammatory papulopustular acne in place of Accutane. If they failed it: I used Accutane. Never had any problem. Never had the first case of TEN or S-J Syndrome. Just haven't had problems. And it works great! Patrick R. Carrington --------------------- A good friend of mine was sued (and settled) because of agranulocytosis attributed to Bactrim for acne; this case required marrow transplantation with all of its associated costs and problems. This was coincidentally just after a pharmacist's daughter came in with severe E. Nodosum from her Bactrim, and then of course there is the worry about toxic epidermal necrolysis. Since then I have only prescribed cotrimoxazole for acne when patients came to me already on it long-term and doing well. I think oral Cleocin is probably safer than cotrimoxazole, and most of us are too timid to use Cleocin........ This is anecdotal, of course, and I do not presume to voice a standard of care; I'm merely pointing out that I'm sufficiently frightened of this drug that I would rather not use it for acne myself. Accutane is probably a safer alternative, even in a 13 year old. Mark Valentine -------------- I use a fair amount of Septra DS for acne. It often yields great results when everything else has failed. No severe reactions in 6 years, but I do warn every patient about what can rarely happen. I see more typical allergic reactions to it about every 30-40 patients with a red itchy eruption. I monitor CBC once or twice a year, and have had a handful of low WBC's, including a patient last week who was at a WBC of 2.5, from a baseline of 4. I too worry about TEN and have seen TEN to Septra, but I feel the benefits outweigh the risks. Bill Liss --------- I had a middle-aged male pt recently who was put on Septra by one of our Navy corpsmen for a cold. He came to see me a week later for an unrelated nail problem. I asked him, "How long have you had yellow eyes?" News to him. LFT's sky high. D/C'd Septra, with total resolution of his drug-induced hepatitis. I have a healthy fear of the drug. Dan Mitchell, MD ---------------- Bactrim won't give a long-term drug-free remission the way Accutane often does, so I go straight to Accutane, which is probably safer too. I've given Accutane to a 2 year old, and several 10 year olds -- no problem. I don't think age is a consideration when prescribing Accutane, and in fact I'd rather give it early than late, when the patient has suffered for a few extra years and got some scarring of the skin (and maybe the psyche). Kevin C. Smith MD FRCPC ----------------------- Does anyone know the incidence of this adverse reaction? Is it idiosyncratic or is it dose and duration of treatment dependent? What is the mortality if fluids and electrolytes are managed early by expert burn docs? Walter H. Wood, M.D. -------------------- All these reports of disasters from Septra DS are starting to make me nervous about its use in acne(from one who seldom uses Methotrexate and never has prescribed Cyclosporin). It's too bad because it works really well. Do many have success with just using the trimethoprim? Thought I remembered an article years ago saying that was the effective drug rather than the sulfa. Harold Rehbein -------------- There are reports documenting bactrim for acne. I believe that I mentioned it in my chapter in Conn's Current Therapy a couple of years ago and also in the article on acne Rx in Drugs 1 year ago. I use it very successfully in a few who need it. Marrow failure is an idiosyncratic reaction based on aberrant metabolism of the hydroxylamine metabolite (N. Shear has published on this over several years) it is very rare. Ongoing monitoring is not sensible since the reaction is quite rare. A WBC after a few weeks seems mnore than adequate to me. Guy Webster ----------- I believe that the answer is "A", yet there is no rush to avoid amoxicillin. Our fear/respect for sulfa is rather limited to our specialty because we see all of the problems from the drug. We use many more fearsome drugs pretty cavalierly. For example, Dapsone frequently appears on this list used as Rx for very benign diseases, yet it has a high rate of marrow toxicity, much higher than the 1 in 40, 000 for chloramphenicol, a notorious "bad drug". Food for thought. Guy Webster ----------- Certainly you raise some interesting thoughts. I guess if we worried about the side effects of all the drugs we use we would be paralyzed by inactivity. Elliot Puritz ------------- I've used lots of TM/sulfa over the years for URI's in kids and UTI's in grownups and haven't had a problem except in HIV patients being Rx for pneumocystis; there I have seen a S-J syndrome. I have had patients tell me of sulfa drug allergy, of course. I rarely use it for acne, but that is for fear of contributing to development of bacterial resistance by more serious pathogens. Michael Fetterman ------------------ Since there have been so many negatives about this drug, I felt compelled to write in its defense. Septra is currently my third line drug for acne. I have many patients on it and have had no serious problems, aside from the occasional rashes. Every patient I place on it I tell them if they get fatigued, flu-like or develop a rash in about a week, to stop the drug immediately and call me. My personal feeling is that it is only the patients who continue to take the drug despite their body's warning them of an impending reaction, will get into trouble with a serious reaction like TEN. Quantity is more important than quality in this case. Jere J. Mammino, D.O. --------------------- Just thinking about the 'free-floating' fear about using a sulfa drug for acne. Some have proposed trimethoprim alone as a drug, but most haven't found it worthwhile. Somebody help me with this. I consider trimethoprim essentially as a weak 'poor-man's substitute' chemotherapy agent. I think this is where the agranulocytosis and leukopenia may originate when it is seen whereas the TEN originates from the SMX. Maybe that is why the combination TMP/SMX works so well. Possibly we could use TMP in conjunction with something like doxycycline or minocycline and achieve somewhat of a synergistic effect allowing us to discontinue one of them when the patient clears. Patrick R. Carrington ---------------------- Sulfa/Trimethoprim was the worst offender in this review: Roujeau, JC et al.: Medication use and the Risk of Stevens-Johnson Syndrome or Toxic Epidermal Necrolysis. NEJM 1995;333:1600-7. I'd call this a "must-read" for everyone, so I won't try to summarize it here. Gene Sienkiewicz, M. D. ----------------------- As with the anticonvulsants, some of the most serious reactions to sulfa (as in trimethoprim/sulfa) are related to inherited metabolism. A family history of a drug reaction to sulfa in a first-degree blood relative may be a warning that the risk of an adverse reaction is higher than otherwise. John Melski MD -------------- Does anyone have access to that original Boston study where tmp-sulfa had 51/l000 or so risk of rash. Were any of these TEN? Diane Thaler ------------- I have the reference: Arndt and Jick JAMA 235:918-925, 1976 was the original paper and there were a couple of follow-ups - it's all well described in Dermatology in General Medicine - Chapter 142 - for any of you who are interested, the Fifth Edition of Dermatology in General Medicine is currently being written for 1998 publication Irwin Freedberg --------------- How can anyone know the incidence of any drug reaction? Given enough individual anecdotes (observations) such as yours and others on this program, we may learn more. The pharmaceutical companies (package inserts) give just a few of those incidents, and only after a few trials. In Bruinsma's Drug Eruption Guide, he lists rare, common, uncommon, etc. Again, there are no percentages. In the Archives of Dermatology (1995: Volume 131, 544 ff), P. Wolkenstein and others reported seven cases of TEN from cotrimoxazole (Bactrin, Septra). Can one extrapolate from these figures? If every one on this server would send in an observation about cotrimoxazole and TEN, we may get a different "handle" on incidence. Jerry Litt ---------- If you are interested in the literature about frequency of TEN: I have it from Arzneimittelbrief 27 (1993):9-11, Editor D. von Herrath. This is a review article, the source mentioned is a personal communication of B. Rzany, M. Mockenhaupt and E. Schöpf (University of Freiburg, Germany), who led a multicenter study about frequency of TEN in germany. Andreas Eisenmann ----------------- There is a documentation center for cutaneous drug reactions, run by the Dept. of Dermatology, University of Freiburg. If any doc sees a Stevens Johnson or even TEN, the colleagues there should be informed immediately (via e-mail, phone or whatever). They usually send someone to the patient to verify the findings and to document it. If anyone is interested, I'll give you the URL. Concerning non-cutaneous side effects, there is a reporting form printed in the official physician's journal and collected by a federal institution. It should be written by the doc who saw the drug reaction first. Surely, there is no fine if you simply forget it or if you are too lazy to do the paper work. Normally, we just report severe cases and not all the stomach pains... Hans Juergen Kammler -------------------- Years ago - at the urging of Al Kligman - a bunch of us used Motrin for acne. As I recall the med (then only prescription was given TID or QID. It seemed to help some patients, especially females with premenstrual flares. I really wasn't too impressed, and haven't used it (even as adjunctive therapy) for a long time. But it is something to consider "if all else has failed". Robert I. Rudolph, M.D., FACP --------------------------------------- On a related topic, I was amazed to see an ad in the British Journal of Dermatology for a 4% nicotinamide preparation for topical therapy of acne, claiming that it was at least as effective as available topical antibiotics. I don't recall ever hearing or reading anything about this as an acne remedy. Are our Canadian colleagues using this treatment yet??? Mark Valentine ------------------ A recent suit brought against a dermatologist and Roche for having prescribed both minocycline and Accutane in a female patient in 1982. After about 7 weeks the patient developed "vision problems and headaches." Referred to ophthalmologist. Ophthalmologist diagnosed papilledema. Referred to neurologist. Neurologist diagnosed Pseudotumor Cerebri (PTC). Steroids were prescribed. "As a result of the steroid therapy, [patient] experienced avascular necrosis, which involved diminished blood flow to the heads of bones [sic], eventually leading to destruction of the bone ends. [Patient] underwent several surgeries to replace both hip joints and a shoulder joint." Moral: Don't prescribe minocycline and Accutane together! For whatever the above is worth. Jerry Litt ----------- Where I work we have had two patients with pseudotumor cerebri. One was on Minocin, one was on Doxycycline. Around here I warn patients that if they get Lyme while on Accutane to inform their physician that they should not be rx'd with the tetracycline derivatives-and that even if they stop Accutane it is still hanging around if they chose the tetracyclines. Diane Thaler --------------- ----------- Pseudotumor ----------- I have a 26 yo female with severe nodular acne and history of severe pseudotumor cerebri (PC) after use of Oral contraceptives. She is allergic to penicillin, sulfas. Her free and total testosterone, DHEA-S, Thyroid function, etc. are within normal limit. Because of this well established history of PC I have been reluctant to use Isotretinoin. I have used numerous topical acne preparations with oral several oral antibiotics (Erythromycin, Azithromycin, Dapsone) over the last two months. In addition, because a slight upper normal DHEA-S, I used Aldactone for 2 months up to 200mg/day with mild improvement of her acne. Dapsone was used for 2 weeks but patient developed nausea, vomiting and headaches and it was discontinued. I have been injecting the larger cysts with kenalog with good results but her problem persists. I am considering an attempt of low dose isotretinoin, but I am concerned with this history of severe pseudotumor cerebri. Any suggestions ? J. Cruz, MD ---------- I had a 24 y/o female patient witha history of pseudotumor cerebri on minocyline who was also on lithium, effexor, trazadone etc. for manic-depression. We tried many antibiotics like you did. She could not use spironolactone because it effects the lithium level. Glycolic peels with intralesional and topical glycolics helped some. Eventually she agreed to try 10mg of accutance a day and follow-up to check for signs of pseudotumor cerebri. She had a mild headache initially and then after 4 or 5 weeks we were slowly able to raise her dose and then complete an actual 20 week course at the recommended level. she did beautifully. I would consider low dose accutanne and work with an opthalmologist. Good luck. Brenda Dintiman ----------- Since increased intracranial pressure due to Accutane is not irreversible, it would not be unreasonable to consider a cautious trial of its' use if the patient understands the potential risks and is willing to sign a release form to that effect. You could try the low-dose, long term regimen that has been advocated by Kligman and others, but I think I would put her on full dose and monitor her closely for the development of progressive headaches and papilledema, probably with weekly visits. Mark Naylor, M.D. ------------- ----------------- Comeone extraction ----------------- The Skin Therapy Letter of aug 96, vol 1 # 6 brings a short note (pg 2),that questions the effectiveness of comedo extraction, concluding it is not effective,leading to even clinically non evident inflamatory reaction and scarring, almost always.What is your position regarding this technique - also condemn it ? You just give tretinoin or azelaic acid for the closed comedones? and the milia? George Leal ----------- We have seen a lot of acne patients and performed thousands of comedo removal on each of them and found results superior as compared to just applying topicals. We have not seen a patient develop any scarring. We have been using the Robbins extractor 1.5 and 2.5. Marked improvement just after one visit and our patients are very happy. We actually give both tretinoin and azelaic at the same time. Tretinoin has better results in treating acne but we are basically using the azelaic to minimize the post inflammatory hyperpigmentation which develops while the comedones are healing.(bleaching effect). Comedo extraction with topicals I believe work hand in hand in treating acne. Jonathan Nevin Yu, MD --------------- I don't do a lot of acne surgery(comedone extraction) but at times it is necessary and desirable. I usually give the topical meds a try for a few months. For the inflamed cysts, there is nothing faster than intralesional kenalog 10mg/cc. Gary Salenger M.D. ------------ I have always been of the opposite opinion as far as open comedos ("blackheads") are concerned, e.g., physical extraction done properly is better than drug therapy (certainly faster). The opening of the comedo has to be large enough to easily deliver the plug; if you do it on small ones, you will see a lot of inflammation and probably won't be able to get them out anyway. Drug therapy with retinoids is probably the treatment of choice for closed comedos due to acne. Milial cysts usually have to be removed surgically (even if it is just extraction with an 18 gauge needle for a scalpel and a comedo extractor. Mark Naylor, M.D. --------------- For intralesional injection of acne cysts, I have seen a fairly high incidence of atrophy with Kenalog 10 mgm/cc. I personally dilute Aristospan to 1.7 mgm/cc and have never experienced atrophy, and it works. Philip Hughes, M.D. -------------- According to Ortho, sunlight inactivates tretinoin. That is the reason for night application. Though if people are very sensitive and are determined to use it (and of course *all* of them use sunscreens) they might tolerate it with fewer side effects using AM application. In contrast, adapalene gel is not subject to inactivation by sunlight. The sun warnings for both tretinoin and adapalene are similar. Both thin the strateum corneum and thus modify ultraviolet absorption. Barbara R. Reed, MD ----------------- ------------------------------ Post Inflammatory Pigmentation ------------------------------ I hope this leads to a discussion on treatments for post-inflammatory hyperpigmentation in general. Any ideas? Diane Thaler ----------- For PIP(post-inflammatory hyperpigmentation), I recommend the following: 1)hs application of tretinoin(Retin-A cr 0.025) 2)a.m. application of a steroid cream(triamcinolone 0.1 ) 3)finally bid application of a hydroquinon product(Melanex, or Solaquin or Viquin-forte) .I've sometimes used Azelex rather than hydroquinone if there is sensitivity.Sunscreens are recommended for daily application.Dr. Ike Willis had recommended a version of the above in a single compounded mix-but pts complained of the cost,so I've had them mix it in their skin as outlined.It works. Requires 3-6 months. Pierre Jaffe, MD ----------- I've tx'd adults with c/o pip(postinflammatory hyperpigmentation) who note the persistance of these sites on their legs from childhood(?noseeums;?skeeters). Those pts with more recently acquired pigmentation,such as post acne note some clearing during the winter and worsening with summer sun.I'm guessing, but I'm pretty sure that by the time these pts present with their complaint they've given the problem a fair chance to dwindle spontaneously. Pierre Jaffe, MD ---------- (see also ACCUTANE, TETRACYCLINES) ------ 12.16.96