Venous leg ulceration affects 1% to 3% of the elderly population and represents a severe complication of lower-limb venous insufficiency. Therapeutic options focusing on reversing the effects of venous hypertension include compression therapy, wound care and debridement, and minimally invasive surgery. Low-cost and noninvasive therapeutic procedures are needed as alternative treatments. Cabrera et al undertook a retrospective analysis of 116 patients who underwent ultrasound-guided injection of polidocanol microfoam (UIPM) in the treatment of their venous leg ulcerations. The rationale for UIPM treatment was to selectively and progressively sclerose sources of incompetence and thus reduce venous incompetence in the involved limb. The use of UIPM was found to be highly effective in achieving ulcer healing, even in very elderly patients.
Lichen sclerosus (LS) is a chronic inflammatory dermatitis found predominantly in the anogenital area with long-term sequelae that include the potential development of squamous cell carcinoma. Potent topical steroids remain the mainstay of therapy, but it remains unclear whether such therapy may prevent malignant transformation in this condition. In this prospective study of 83 women with vulvar LS who were treated with potent topical steroids until complete clinical and histologic remission, Renaud-Vilmer et al demonstrate the long-term safety and efficacy of 0.05% clobetasol proprionate ointment in the treatment of vulvar LS, although the suggested protective effect against malignant transformation failed to reach the level of statistical significance.
Lichen planus is a mucocutaneous inflammatory disease that may affect the genital mucosa with a wide range of manifestations and cause significant discomfort. Management of this sometimes debilitating condition is challenging, and therapeutic options include corticosteroids, antifungal agents, retinoids, estrogens, cyclosporine, hydroxychloroquine, and dapsone. In this retrospective analysis of 16 patients, Byrd et al reviewed the response of vulvar lichen planus to topical tacrolimus, an agent that offered significant symptomatic relief in all but 1 of the patients studied.
Psoriasis is a chronic inflammatory skin disease for which only remittent rather than curative therapies are available. For patients with moderate to severe psoriasis, methotrexate and cyclosporine represent the mainstays of systemic therapy. Decision making regarding choices between these 2 modalities may be informed by many factors, among which might be the total costs associated with treatment. In this cost-minimization analysis performed in the setting of a randomized controlled trial, Opmeer et al demonstrate that clinical outcomes and quality of life were comparable between the 2 therapeutic modalities and that despite considerable difference in the medication costs, total treatment costs after 1 year were also comparable. These data suggest that economic considerations are not likely decisive for individual patient decisions or for the development of guidelines for systemic therapy.
Herbal supplements are widely used as natural promoters of good health, and many are touted for their immunomodulatory effects. As awareness grows regarding the prevalence of complementary medicine use, the adverse effects of these supplements has become more widely recognized. In this case series, Lee and Werth describe 3 patients whose autoimmune disease onset or flares correlated with ingestion of herbal supplements with immunostimulatory effects. The mechanism for this effect needs further study, although increased production of tumor necrosis factor α may play a role. These cases offer cautionary examples of how immunostimulatory herbal supplements may exacerbate preexisting autoimmune disease in persons genetically predisposed to such disorders.
Heliotrope rash in patient 3.
This Month in Archives of Dermatology. Arch Dermatol. 2004;140(6):655. doi:10.1001/archderm.140.6.655