FURUNCULOSIS ------------------------------------------ I periodically see a patient with this problem and I have not found a satisfactory treatment. 27 yo female patient with cystic facial acne and similar lesions on her buttocks. Both exacerbate around her periods but the buttocke lesions never improve much despite all acne treatments. I tried various acne antibiotics and all topicals to no avail. A course of accutane cleared her face completely but did not affect her buttocks problem. Now she is getting boil like lesions on her upper thighs as well. I had also tried dicloxicillin to no avail as well. Questions: Is this a type of acne,furunculosis, hidradinitis or a completely differen condition? Will spironolactone or proscar help? Would a higher dose of accutane or a differen retinoid help? Do we try the full court press for recurrent furunculosis?(despite her assurance that all antibiotics were useless so far) Martin H. Kay Ph.D.,M.D. ----------------------- Perhaps. Gary Peck has shown that long-term high dose accutane will help some hidradinitis. I haven't had much luck with it in well established hidradinitis. You might consider culturing for staph in the groin etc as well as the lesion. Guy Webster ----------- As an additional point of interest, cephalexin suspension tastes pretty good and is a whole bunch cheaper than Duricef. Mark Ling, M.D., Ph.D. ---------------------- Is that generic? By the way, Duricef suspension is half the price of the pills, or used to be. I always have tons of samples around to use. The cephalexin is a great hint. Most important is not to use dicloxicillan. Diane Thaler ------------- Though I culture for staph in both furuncles and nares, I treat nares with Bactroban regardless. The most recent technique I use for the nasal carrier state is to apply nasal Bactroban BID for 1 week. Then BID for the first 5 days of each month for about four months. I tell the patient the rationale is that the staph can hide in the nose and return to cause infection as soon as oral antibiotics are done. The monthly dose has been more successful than my prior attempt just to treat for 5 to 7 days. Jerry Eisner ------------ I have seen similar patients and treated them as hidradenitis suppurativa, which I believe them to be. My staple treatment is intralesional triamcinolone, 5 mg/ml up to 15 mg/ml usually mixed in 1% lidocaine with epinephrine to keep it localized. Needs to be put in deep, where the lesions are. The more acutely inflammed the lesion, the better this treatment works. A 4 month course of Accutane at or above 1 mg/kg is also worth a try (sounds like you got a partial response, which would not be unusual). Might try a second course if the first was well-tolerated. I am trying an androgen blocker (Eulexin [flutamide] 125 mg tid--half the dose for prostate cancer) in one really bad case I am following, too early to say, but I haven't heard from this patient wanting more IL injections in several weeks, so maybe it's working. By the way this is a woman, so side effects have been negligible. The British literature gave me the idea for this approach (see refs). 1. Ebling FJ: Hidradenitis suppurativa: an androgen-dependent disorder [editorial]. Br J Dermatol 115(3):259-62, 1986. 2. Mortimer PS, Dawber RP, Gales MA, et al.: A double-blind controlled cross-over trial of cyproterone acetate in females with hidradenitis suppurativa. Br J Dermatol 115(3):263-8, 1986. 3. Mortimer PS, Dawber RP, Gales MA, et al.: Mediation of hidradenitis suppurativa by androgens. Br Med J (Clin Res Ed) 292(6515):245-8, 1986. 4. Sawers RS, Randall VA, Ebling FJ: Control of hidradenitis suppurativa in women using combined antiandrogen (cyproterone acetate) and oestrogen therapy. Br J Dermatol 115(3):269-74, 1986. 5. Goldsmith PC, Dowd PM: Successful therapy of the follicular occlusion triad in a young woman with high dose oral antiandrogens and minocycline. J R Soc Med 86(12):729-30, 1993.^A Mark Naylor, M.D. ----------------- >Naprosyn is an anti-inflammatory - maybe it is synergistic with the >anti-inflammatory effects of tetracycline, erythromycin and clarithromycin; >and the anti-inflammatory effect may also make it easier for the antibiotic >to get to where its needed. > > This makes sense. I think that most of the symptoms from an infection are due to the host response. Look at how few bugs will grow from cellulitis, yet how symptomatic it is. Likewise, a neutropenic will not evidence infection until his wbcs return. It makes sense that a NSAID would help relieve symptoms of an infection, especially if antibiotics are also on board. Nsaids probably do not help the macrolides and azalides get to an infection. Erythro et al are actively concentrated in the cytoplasm of PMN and this is thought by the mavens to account for their high levels in infected tissue. Guy Webster ----------- Speaking of nsaids, a doc at work just returned from a conference where an Intensive Carist (?????) warned of fatal strep symptoms obscured by nsaids until too late. 3 deaths. Diane Thaler ------------ Perhaps it is also worth reminding the group of the utility of Xerac AC in treatment of folliculitis of the buttocks and/or thighs....... Mark Valentine -------------- recurrent "boils" of the buttocks a) culture the lesions and culture the nose as a source of pathogenic bacteria. Treat with appropriate antibiotics. b) have patient wash buttocks with Hibiclens, Phisohex, or BP wash on a regular basis Jeff Marmelzat, M.D. -------------------- Spironolactone ought to be helpful. I've got a similar Accutane resistant case doing great on Biaxin (clarithromycin) 250 mg bid together with Naprosyn 500 mg bid. Kevin C. Smith MD FRCPC A patient of mine with chronic "boils" on her legs and hidradenitis like lesions in her groin and axillae on a prn basis has been controlled by Centrum vitamines and zinc. I have not investigated her immune status but Ibelieve she has a defect in processing her exposure to bacteria that the vitamines have helped control.--She could not afford the work-up to further define her problem-- She was also helped by Tetracycline up to 500mg qid but no longer needs them after starting the vitamines--Give it a try before spending alot on her work-up. W H Burrow ----------- What is the role of naproxen in treatment of the boils? Are you worried at all about worsening of the lesions with the addition of this NSAID? Barbara R. Reed, MD ------------------- You might also want to culture the ant. nares. If + for staph aureus, I would be inclined to treat with Bactroban bid to the nares, plus Diclox 250mg qid f10d plus Rifampin 500mg bid f10d. This is my full-court-press for recurrent furunculosis. Dan Mitchell, MD ---------------- Naprosyn is an anti-inflammatory - maybe it is synergistic with the anti-inflammatory effects of tetracycline, erythromycin and clarithromycin; and the anti-inflammatory effect may also make it easier for the antibiotic to get to where its needed. Jim Rasmussen wrote a good paper about this ~10 years ago. Kevin C. Smith MD FRCPC ----------------------- Point of information. Does everyone know that Dicloxicillan Liquid for kids tastes so bad that they spit it out? So, go for good tasting anti-staph in kids if needed. I use Duricef, for taste. Diane Thaler ------------ -----------