eMedicine Specialties > Dermatology > Bacterial Infections
Acrodermatitis Chronica Atrophicans: Treatment & Medication
Updated: Mar 23, 2009
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
- Multimedia
Treatment
Medical Care
The choice of treatment depends on the coexistence of other signs or symptoms of Lyme borreliosis with acrodermatitis chronica atrophicans. The authors also consider the value of the titer of serologic tests.
- If the extracutaneous Lyme borreliosis signs are absent and the level of specific antibodies is low, the authors usually recommend oral doxycycline or oral amoxicillin, over 3 weeks.
- If organic or systemic physical or laboratory signs of Lyme borreliosis are present or if the antibody titer is high, the appropriate treatment should be introduced mainly with ceftriaxone or cefotaxime or aqueous penicillin G given intravenously for 21-28 days.
Consultations
Seek the appropriate consultations (ie, neurologist, ophthalmologist, rheumatologist, cardiologist) if extracutaneous signs and symptoms exist.
Medication
The goals of pharmacotherapy are to eradicate the infection, to reduce morbidity, and to prevent complications.
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of this clinical setting.
Amoxicillin (Amoxil, Trimox)
Bactericidal against Borrelia species. Semisynthetic penicillin of aminopenicillins group demonstrating wide spectrum of bactericidal activity related to gram-positive and gram-negative bacteria. Mechanism of action involves bacterial cell wall synthesis inhibition.
Adult
500 mg PO q6h or 1000 mg PO q12h for 21-28 d
Pediatric
2-3 years: 40-60 mg/kg/d PO bid/tid
>4 years: 375-750 mg/d PO tid
Neomycin decreases its absorption; allopurinol increases rash development; reduces efficacy of oral contraceptives
Documented hypersensitivity; infectious mononucleosis; lymphatic leukemia
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; may cause dyspepsia or rash
Doxycycline (Vibramycin)
Tetracycline antibiotic that inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. Used for antibacterial and anti-inflammatory effect and for concern about possible coexistent infection.
Adult
100-200 mg PO qd for 21-28 d
Pediatric
<8 years: Not recommended
>8 years: Administer as in adults
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Ceftriaxone (Rocephin)
Bactericidal against Borrelia species. Third-generation cephalosporin with broad-spectrum, gram-negative activity. Lower efficacy against gram-positive organisms and higher efficacy against resistant organisms. Arrests bacterial growth by binding to 1 or more penicillin-binding proteins.
Adult
2 g IV q24h for 14-21 d
1-2 g IV/IM q12-24h
Pediatric
50-100 mg/kg IV/IM; not to exceed 4 g/d
High doses of probenecid may increase clearance by blocking biliary secretion and displacement of ceftriaxone; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in renal impairment; caution in women who are breastfeeding and allergy to penicillin; caution in children who are hyperbilirubinemic because of its ability to displace bilirubin; adverse effects include headaches, dizziness, pseudomembranous colitis, nausea, vomiting, and diarrhea
Cefotaxime (Claforan)
Third-generation of semisynthetic cephalosporin with board-spectrum bactericidal activity against gram-negative bacteria and Staphylococcus and Streptococcus species. Resistant to beta-lactamases. Mechanism of action is related to inhibition of bacteria cellular wall component synthesis.
Adult
1-2 g IV q8h for 14-21d
Pediatric
<12 years: 50-100 mg/kg/d IV tid
>12 years: Administer as in adults
Synergic with aminoglycosides, vancomycin, and anticoagulants; may cause false-positive Coombs reaction
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
May cause hypersensitivity reaction, headaches, dizziness, pseudomembranous colitis, nausea, and vomiting; neutropenia and biochemical signs of liver injury are seldom
Penicillin G (Pfizerpen)
Beta-lactam antibiotic. The mechanism of action is related to bacterial cell wall synthesis inhibition in the growth phase as a result of penicillin and bacterial transpeptidase binding.
Adult
4.5-6 million U IV q6h or 3-4 million U IV q4h (18-24 million U/d) for 21 d
Pediatric
50,000-80,000 U/kg/d IV divided q6h
Probenecid and NSAIDs increase blood concentration and extend time of action; penicillin benzathine demonstrates in vivo synergism with aminoglycoside antibiotics, but, in vitro, it causes their inactivation; not to be administered in the same syringe with vancomycin, cephalothin, amphotericin B, or metronidazole; antagonism toward tetracycline, chloramphenicol, and mucolytic drugs; high doses given with digoxin increase toxicity; combination with beta-adrenergic blocking drugs increases risk of anaphylaxis
Documented hypersensitivity; caution in patients with bronchial asthma, renal insufficiency, or circulatory insufficiency; caution in those receiving potassium and diuretics
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Not contraindicated in pregnancy but can lead to fetal hypersensitization, particularly in the second or third trimester; can induce anaphylactic shock, hypersensitivity reactions, arthralgia, fever, eosinophilia, lymphadenopathy, and kidney interstitial inflammation; high doses can lead to hemolytic anemia, leukopenia, and electrolytic disturbances; neurotoxicity; can induce Jarisch-Herxheimer reaction in patients with spirochetosis
More on Acrodermatitis Chronica Atrophicans |
| Overview: Acrodermatitis Chronica Atrophicans |
| Differential Diagnoses & Workup: Acrodermatitis Chronica Atrophicans |
Treatment & Medication: Acrodermatitis Chronica Atrophicans |
| Follow-up: Acrodermatitis Chronica Atrophicans |
| Multimedia: Acrodermatitis Chronica Atrophicans |
| References |
| « Previous Page | Next Page » |
References
Buchwald A. Ein Fall von diffuser idiopathischer Haut-Atrophie. Vrtljschr Derm. 1883;10:553-6.
Herxheimer K, Hartmann K. Ueber Acrodermatitis chronica atrophicans. Arch f Dermatol u Syph (Wien). 1902;61:57-76.
Aberer E. Country report - Austria. Report of WHO Workshop on Lyme Borreliosis Diagnosis and Surveillance, Warsaw. Warsaw, Poland: World Health Organization; 1995.
Christova I, Komitova R. Clinical and epidemiological features of Lyme borreliosis in Bulgaria. Wien Klin Wochenschr. Jan 31 2004;116(1-2):42-6. [Medline].
Flisiak I, Schwartz RA, Chodynicka B. Clinical features and specific immunological response to Borrelia afzelii in patients with acrodermatitis chronica atrophicans. J Med. 1999;30(3-4):267-78. [Medline].
Zalaudek I, Leinweber B, Kerl H, Mullegger RR. Acrodermatitis chronica atrophicans in a 15-year-old girl misdiagnosed as venous insufficiency for 6 years. J Am Acad Dermatol. 2005;52:1091-4. [Medline].
Danz B, Kreft B, Radant K, Marsch WCh, Fiedler E. Skin-coloured facial oedema as an initial manifestation of acrodermatitis chronica atrophicans. J Eur Acad Dermatol Venereol. Jun 2008;22(6):751-3. [Medline].
Mullegger RR, Glatz M. Skin manifestations of lyme borreliosis: diagnosis and management. Am J Clin Dermatol. 2008;9(6):355-68. [Medline].
Leverkus M, Finner AM, Pokrywka A, Franke I, Gollnick H. Metastatic squamous cell carcinoma of the ankle in long-standing untreated acrodermatitis chronica atrophicans. Dermatology. 2008;217(3):215-8. [Medline].
Aberer E, Breier F, Stanek G, Schmidt B. Success and failure in the treatment of acrodermatitis chronica atrophicans. Infection. Jan-Feb 1996;24(1):85-7. [Medline].
Aberer E, Kersten A, Klade H, Poitschek C, Jurecka W. Heterogeneity of Borrelia burgdorferi in the skin. Am J Dermatopathol. Dec 1996;18(6):571-9. [Medline].
Asbrink E. Cutaneous manifestations of Lyme borreliosis. Clinical definitions anddifferential diagnoses. Scand J Infect Dis Suppl. 1991;77:44-50. [Medline].
Asbrink E, Hovmark A. Comments on the course and classification of Lyme borreliosis. Scand J Infect Dis Suppl. 1991;77:41-3. [Medline].
Baumann M, Tebbe B, Arnold M, Krengel S, Goerdt S, Orfanos CE. [Livedo racemosa: an unusual late manifestation of borreliosis?]. Hautarzt. Aug 2000;51(8):593-6. [Medline].
Braun-Falco O, Plewig G, Wolff HH. Dermatology. 2nd ed. Berlin, Germany: Springer-Verlag; 2000:188-90.
Brehmer-Andersson E, Hovmark A, Asbrink E. Acrodermatitis chronica atrophicans: histopathologic findings and clinical correlations in 111 cases. Acta Derm Venereol. 78(3):207-13. [Medline].
Brzonova I, Wollenberg A, Prinz JC. Acrodermatitis chronica atrophicans affecting all four limbs in an 11-year-old girl. Br J Dermatol. Aug 2002;147(2):375-8. [Medline].
Chodynicka B, Flisiak I. Treatment and prophylaxis of Lyme disease. Postepy Dermatol (Poznan). 2000;17:43-52.
Chodynicka B, Flisiak I, Lukaszuk C, Bulhak V. [Late consequences of untreated lyme borreliosis]. Przegl Epidemiol. 1997;51(4):445-9. [Medline].
Chodynicka B, Lukaszuk C, Pucilo K. Studies on the value of IFA and ELISA in the screening and diagnosing of Lyme borreliosis. Przegl Dermatol. 1996;83:159-161.
de Koning J, Tazelaar DJ, Hoogkamp-Korstanje JA, Elema JD. Acrodermatitis chronica atrophicans: a light and electron microscopic study. J Cutan Pathol. Feb 1995;22(1):23-32. [Medline].
Dh te R, Basse-Guerineau AL, Beaumesnil V, Christoforov B, Assous MV. Full spectrum of clinical, serological, and epidemiological features of complicated forms of Lyme borreliosis in the Paris, France, area. Eur J Clin Microbiol Infect Dis. Nov 2000;19(11):809-15. [Medline].
DiCaudo DJ, Su WP, Marshall WF, Malawista SE, Barthold S, Persing DH. Acrodermatitis chronica atrophicans in the United States: clinical and histopathologic features of six cases. Cutis. Aug 1994;54(2):81-4. [Medline].
Fingerle V, Wilske B. Stage-oriented treatment of Lyme borreliosis. MMW Fortschr Med. 2006;148:39-41. [Medline].
Gerster JC, Peter O. Rheumatic manifestations related to acrodermatitis chronica atrophicans. A review of four cases. Rev Rhum Engl Ed. Oct 1998;65(10):567-70. [Medline].
Hodl S, Soyer HP. Dermatopathology of Lyme disease. Acta Derm Venerol (Ljubljana). 1994;3:89-98.
Houtman PM, Tazelaar DJ. Joint and bone involvement in Dutch patients with Lyme borreliosis presenting with acrodermatitis chronica atrophicans. Neth J Med. Jan 1999;54(1):5-9. [Medline].
Kansky A. Lyme disease is spreading to the South-East. Skin manifestations in Croatia 1988-1990. Acta Derm Venerol (Ljubljana). 1992;1:93-95.
Kindstrand E, Nilsson BY, Hovmark A, et al. Peripheral neuropathy in acrodermatitis chronica atrophicans - a late Borrelia manifestation. Acta Neurol Scand. 95(6):338-45. [Medline].
Kindstrand E, Nilsson BY, Hovmark A, et al. Polyneuropathy in late Lyme borreliosis - a clinical, neurophysiological and morphological description. Acta Neurol Scand. Jan 2000;101(1):47-52. [Medline].
Maraspin V, Ruzic-Sabljic E, Strle F. Isolation of Borrelia burgdorferi sensu lato from a fibrous nodule in apatient with acrodermatitis chronica atrophicans. Wien Klin Wochenschr. Jul 31 2002;114(13-14):533-4. [Medline].
Mullegger RR, McHugh G, Ruthazer R, Binder B, Kerl H, Steere AC. Differential expression of cytokine mRNA in skin specimens from patients with erythema migrans or acrodermatitis chronica atrophicans. J Invest Dermatol. Dec 2000;115(6):1115-23. [Medline].
Oschmann P. Lyme borreliosis and tick-borne encephalitis. In: Oschmann P, Kraiczy P, Halperin J, Brade V, eds. UNI-MED. Bremen, Germany: Verlag AG; 1999.
Philipson A. Antibiotic treatment in Lyme borreliosis. Scand J Infect Dis Suppl. 1991;77:145-50. [Medline].
Picken RN, Strle F, Picken MM, et al. Identification of three species of Borrelia burgdorferi sensu lato (B. burgdorferi sensu stricto, B. garinii, and B. afzelii) among isolates from acrodermatitis chronica atrophicans lesions. J Invest Dermatol. Mar 1998;110(3):211-4. [Medline].
Ruzic-Sabljic E, Podreka T, Maraspin V, Strle F. Susceptibility of Borrelia afzelii strains to antimicrobial agents. Int J Antimicrob Agents. 2005;25:474-8. [Medline].
Schmidt BL, Aberer E, Stockenhuber C, Klade H, Breier F, Luger A. Detection of Borrelia burgdorferi DNA by polymerase chain reaction in the urine and breast milk of patients with Lyme borreliosis. Diagn Microbiol Infect Dis. Mar 1995;21(3):121-8. [Medline].
Stanek G, Strle F. Lyme disease: European perspective. Infect Dis Clin North Am. Jun 2008;22(2):327-39, vii. [Medline].
Further Reading
Keywords
acrodermatitis chronica atrophicans, Herxheimer disease, ACA, European Lyme borreliosis, LB, Lyme disease, borreliosis, Borrelia afzelii, B afzelii, Borrelia garinii, B garinii, Borrelia burgdorferi, B burgdorferi, Ixodes ricinus, I ricinus, Ixodes hexagonus, I hexagonus, Ixodes persulcatus, I persulcatus, Ixodes scapularis, I scapularis, Ixodes pacificus, I pacificus, cutaneous atrophy, erythema migrans, EM, tick bite, tick vector
Treatment & Medication: Acrodermatitis Chronica Atrophicans