Dermatological diseases

Rheumatic disorders and coUagen diseases Ophthalmic, otic, and nasal disorders Dermatologic diseases Respiratory diseases... 

Lupus erythematosus, acute rheumatic carditis, systemic dermatomyositis DERMATOLOGIC DISEASES... 

Porphyrins 21 are the backbone of major players in life cycles—cytochromes (Scheme 8). There are three types of cytochromes, classified by their color, or more precisely by their long-wavelength absorption band, as a (600 mn), b (563 nm), and c (550 nm). They are protein conjugates of a porphyrin complex with iron(II), which is a coenzyme called heme (22). In plants, porphyrins form a complex with magnesium-(II) chlorophylls a and b (23), vital in photosynthesis. Porphyrin derivatives are used in photodynamic therapy for dermatological diseases such as psoriasis, and for skin or subcutaneous cancer.5c-e... 

Dermatologic diseases Pemphigus bullous dermatitis herpetiformis severe erythema multiforme (Stevens-Johnson syndrome) mycosis fungoides severe psoriasis angioedema or urticaria exfoliative, severe seborrheic, contact, or atopic dermatitis. 

There are many retinol containing preparations to treat vitamin deficiency states. Retinoids are also used to treat dermatological diseases like acne, psoriasis, Darier s disease, and ichthyosis. Tretinoin, all-trans-retinoic acid, is a topical preparation while isotretinoin or 13-cis-retinoic acid, and etretinate are available for oral administration. 

Legitimate clinical research is being conducted with vitamins in many areas including heart disease, ophthal-mological disease, neurocognitive function, and dermatological diseases. It is important for physicians to be aware of scientific information that either supports or refutes a role for vitamins in the maintenance of health or in the avoidance of disease. 

Vitamin A and its retinoid analogues have gained popularity in the treatment of acne and other dermatological diseases (see Chapter 41). 

Because of the effectiveness of systemic tacrolimus in some dermatologic diseases, a topical preparation is now available. Tacrolimus ointment is currently used in the therapy of atopic dermatitis and psoriasis. 

Diseases of the skin offer special opportunities to the clinician. In particular, the topical administration route is especially appropriate for skin diseases, although some dermatologic diseases respond as well or better to drugs administered systemically. 

The remarkable efficacy of topical corticosteroids in the treatment of inflammatory dermatoses was noted soon after the introduction of hydrocortisone in 1952. Numerous analogs are now available that offer extensive choices of potencies, concentrations, and vehicles. The therapeutic effectiveness of topical corticosteroids is based primarily on their antiinflammatory activity. Definitive explanations of the effects of corticosteroids on endogenous mediators of inflammation await further experimental clarification. The antimitotic effects of corticosteroids on human epidermis may account for an additional mechanism of action in psoriasis and other dermatologic diseases associated with increased cell turnover. The general pharmacology of these endocrine agents is discussed in Chapter 39. 

Table 61-1 groups topical corticosteroid formulations according to approximate relative efficacy. Table 61-2 lists major dermatologic diseases in order of their responsiveness to these drugs. In the first group of diseases, low- to medium-efficacy corticosteroid preparations often produce clinical remission. In the second group, it is often necessary to use high-efficacy preparations, occlusion therapy, or both. Once a remission has been achieved, every effort should be made to maintain the improvement with a low-efficacy corticosteroid. 

Metze, D., Reimann, S., Beissert, S., and Luger, T. Efficacy and safety of naltrexone, an oral opiate receptor antagonist, in the treatment of pruritus in internal and dermatological diseases. J. Am. Acad. Dermatol. 41, 533-539 (1999). 

Topical glucocorticoids are used extensively for the treatment of a variety of inflammatory diseases such as rhinitis, inflammatory bowel disease, asthma, and several dermatological diseases. 

Dermatologic disease and its related ocular complications are commonly encoimtered entities in general ophthalmic practice. The conjimctiva frequently is affected with ocular involvement. Although numerous dermatologic conditions can affect the eye, this section focuses on the three conditions that are most often encountered acne rosacea, psoriasis, and atopic dermatitis. 

The possibility of autoimmune disorders during interferon alfa treatment has been addressed by many authors. The spectrum of interferon alfa-induced immune diseases includes organ-specific and systemic autoimmune diseases, such as thyroiditis, diabetes, hematological disorders, systemic lupus erythematosus, rheumatoid arthritis, dermatological disease, and myasthenia gravis (156). Several have been discussed in appropriate sections elsewhere in this monograph. The exact role of interferon alfa is usually difficult to ascertain, because the underlying disease, that is chronic hepatitis C, can also be associated with immune-mediated disease. 

Dalekos GN, Hatzis J, Tsianos EV. Dermatologic disease during interferon-alpha therapy for chronic viral hepatitis. Ann Intern Med 1998 128(5) 409-10. 

Some patients consider drugs to treat a common dermatological disease such as acne vulgaris to be cosmetics rather than medications. Safer alternatives than minocy-cline should be considered in the treatment of acne. 

Although topical GCs usually have less side-effects than systemic GCs, and are successfully used to treat several inflammatory dermatological diseases, their major limitation remains the local side-effects they can cause. Furthermore, severe disease exacerbations often cannot be treated efficiently with compounds that work locally only. In such situations, systemic treatment is mandatory (e.g. in bullous skin diseases). In dermatological indications especially the main drawback of topical GCs is the development of skin atrophy after long-term use [11, 12],... 

CRA has been detected in humans [34] and was the first RAR-RXR pan-agonist discovered [35-37] and may be classified as a retinoid/rexinoid. It is the only retinoic acid isomer not approved for the common dermatological diseases. However, it has recently been launched in the US as adjuvant topical treatment of AIDS-associated Kaposi s sarcoma [38-41]. This agent is the first RXR ligand to be approved for the treatment of a dermatological disease. In a randomized study with 268 AIDS-associated Kaposi s sarcoma patients, 35% treated with alitretinoin (0.1% gel) had a positive response, compared with 18% treated with vehicle gel irrespective of the number of concurrent antiretroviral therapies [41], 9-CRA is in clinical trials for the treatment of various cancers, including breast cancer [42], renal cell carcinoma [43,44] and squamous cell carcinoma [45—47]. 

---