eMedicine Specialties > Dermatology > Benign Neoplasms

Dupuytren Contracture: Treatment & Medication

Author: Felisa S Lewis, MD,, Staff Physician, Department of Dermatology, Madigan Army Medical Center
Coauthor(s): Theresa Dressler Conologue, DO, FAAD, Physician, Department of Dermatology, Geisinger Medical Center; Kristina Shaffer, MD, MPH, Consulting Staff, Department of Dermatology, Dermatology Consultants
Contributor Information and Disclosures

Updated: Feb 3, 2010

Treatment

Medical Care

In the early stages (<15° of contracture at the MCP joint and no PIP joint contractures), Dupuytren contracture can be treated medically.

Multiple therapies have been tried in small, uncontrolled reports. Many have been unsuccessful, including splinting, dimethylsulfoxide injection, vitamin E cream application, allopurinol and colchicine administration, physical therapy, and ultrasonic therapy. One case report also proposed the use of hyperbaric oxygen therapy for treatment during the early phase of Dupuytren contracture.20

Some promise has been shown using slow skeletal traction followed by surgery; in addition, calcium channel blockers, interferon-gamma injections, tamoxifen, and topical corticosteroids combined with topical retinoids have all been shown to have some efficacy. The following additional (and mostly experimental) treatments have also been proposed:

  • Triamcinolone acetonide: Intralesional triamcinolone acetonide (Kenalog-40) injections of 40 mg/mL have yielded subjective improvement of Dupuytren nodules in some patients.21
  • Collagenase enzymatic fasciotomy: This new treatment was approved by the FDA in February 2010.22,23,24 The phase 3 trial was a randomized, double-blind, placebo-controlled trial followed by an open-level extension. Patients were given a maximum of 3 injections at the primary joint at 4- to 6-week intervals. During the double-blind phase, 91% of patients treated with collagenase achieved clinical success (to normal 0° ±5°). In the open-label phase, 77% of joints achieved clinical success. Overall, 54 (87%) of 62 joints achieved success (90% MCP, 84% PIP). Five recurrences were recorded, occurring between 6 and 24 months and ranging from 20-40° regression. Adverse events included local injection reactions (most common) and skin lacerations at cord rupture.25
  • Ilomastat: This is an investigational drug that shows promise as a broad-spectrum matrix metalloproteinase inhibitor. Using the stress-release fibroblast-populated lattice as a contraction model, ilomastat led to decreased levels of MMP-1 and MMP-2 activity in nodule- and cord-derived fibroblasts.26
  • 5-Fluorouracil: This agent has been shown to cause a dose-dependent selective and specific decrease in collagen production by fibroblasts and inhibit fibroblast proliferation and myofibroblast differentiation.27,28 However, TGF-beta1 gene expression and procollagen types I and III mRNA are not affected. After undergoing clinical trials, this treatment may be useful as an adjuvant therapy to surgery in reducing extracellular matrix production and recurrence of Dupuytren contracture.
  • Radiation therapy: An uncontrolled study looked at radiation therapy in patients with established Dupuytren contracture. After the 1-year follow-up period, 53% of sites regressed, 38% were stable, and 9% progressed. The authors are awaiting a 5-year follow-up evaluation to determine long-term results. Local adverse effects developed in 38% of patients.
  • Imiquimod: Because it is an immune modulator that down-regulates TGF-beta and fibroblast growth factor-2, this medication has been proposed as a therapy.29 However, currently no reports describe experimental use of imiquimod for Dupuytren contracture.
  • Botulinum toxin: This has also been proposed as an intralesional therapy for Dupuytren contracture, based on its inhibition of Rho GTPase, which is necessary for activation of the IL-1 inflammation pathway.30 As with imiquimod, no reports currently describe clinical use of botulinum toxin for this condition.

Surgical Care

Surgery is indicated when contraction is 20° or more at the MCP joint and 30° or more at the PIP joint. As with all elective surgeries, the patient's age, comorbid conditions, and ability to comply with postoperative care and rehabilitation determine whether surgery is appropriate.

Skin overlying the contracture is closed either primarily (using skin grafts) or by secondary intent. The synthesis technique is a method of wound closure that incorporates the advantages of tissue rearrangement, the open-palm technique, and full-thickness skin grafting. One study showed a decreased healing time and recurrence rate using the synthesis technique versus the traditional open-palm technique.31

Finally, one study found that improvement in the PIP joint contracture has a greater correlation with hand function at 6 and 12 months after surgery than improvement in the MCP joint contracture. The results of another study revealed the severity of contracture preoperatively had a significant negative effect on hand power, and older patients experienced less functional benefit from selective fasciectomy.32

Surgical methods are as follows:

  • Fasciectomy
    • Radical fasciectomy involves excision of the entire palmar fascia. The procedure involves excision of healthy tissue in an effort to prevent recurrence. Dupuytren contracture has recurred following surgery, and this procedure is not commonly used. One study concluded that total aponeurectomy was most appropriate for stage 2 disease.33
    • In selective fasciectomy, clinically apparent disease is excised. Areas not treated still may develop disease. This method is commonly used to treat both primary and recurrent disease. Skin incisions may be transverse, longitudinal, or diagonal/zigzag (eg, Z-plasty, Y-V-plasty, Bruner-type zigzag incision). Local advancement flaps, including an ulnar-based skin flap34 and palmar intermetacarpal flap,35 have been described.
    • Segmental fasciectomy involves removal of one or more segments of diseased fascia through multiple small incisions.
    • Open-palm technique (McCash) involves a transverse skin incision and division of the aponeurosis; healing is by secondary intention.
    • In the surgical synthesis technique (dermofasciectomy), 2 incisions are made, one from the distal interphalangeal joint of the affected joint to the distal palmar flexion crease, and a transverse palmar incision, to form an L shape. A selective fasciectomy is performed, with partial closure of the incision site. A full-thickness skin graft is harvested from the hypothenar eminence during this surgery. A portion of the palm is left open, and an extension splint is applied. After 4 days, the splint is removed, the wound is cleaned, and the skin graft is applied to the palm. The palm is splinted again for 1 week.
    • A modification of the McCash technique called the Jacobsen flap uses the L -shaped incision of dermofasciectomy, but healing is by secondary intention.36
  • Fasciotomy
    • Limited open fasciotomy and percutaneous needle fasciotomy may be performed. Diseased tissue is not removed, but is incised.
    • In several studies, percutaneous needle fasciotomy resulted in short-term improvement (77% in one study), but the recurrence rate was high (65% at 32 mo in the same study).37 In addition, in a 6-week follow-up comparison of outcomes between limited open fasciotomy and percutaneous needle fasciotomy, the authors concluded that percutaneous needle fasciotomy was a good alternative to limited open fasciotomy in the short term in patients with early disease.38 A Chinese study found that percutaneous needle aponeurotomy was more effective in metacarpophalangeal joints than proximal interphalangeal joints (70% vs 41%).39 Overall, these techniques are best reserved for patients unable to comply with postfasciectomy care, for elderly patients who are debilitated, or for patients who are willing to accept primarily short-term improvement. One additional advantage is that the procedure may be safely repeated in the event of a recurrence.
    • Soft tissue reconstruction using various flaps may be performed after the fasciotomy to correct skin defects introduced as a result of the surgery.
  • Amputation: This may be an alternative for primary or recurrent severe disease when flexion contracture is greater than 90° or if the digit has vascular compromise. Some patients may prefer amputation to the postoperative care required for fascial surgery.

Consultations

Consult a hand surgeon for evaluation and possible treatment of patients who are symptomatic and have more than 15° of contracture.

Medication

The goals of pharmacotherapy are to reduce morbidity and to prevent complications.

Corticosteroids

These agents have anti-inflammatory properties and cause profound and varied metabolic effects. They modify the body's immune response to diverse stimuli.


Triamcinolone acetonide (Kenalog-40)

For inflammatory dermatosis responsive to steroids; decreases inflammation by suppressing migration of polymorphonuclear leukocytes and reversing capillary permeability.

Adult

40 mg/mL injected into nodule

Pediatric

Not established

Coadministration with barbiturates, phenytoin, or rifampin decreases effects

Documented hypersensitivity; fungal, viral, and bacterial skin infections; >3 prior injections 6 wk apart within last 6 mo

Pregnancy

C - Fetal risk revealed in studies in animals but not established or not studied in humans; may use if benefits outweigh risk to fetus

Precautions

Injection into flexor tendon has been associated with tendon rupture; ultrasonographic evaluation of nodule may be useful prior to injection; multiple complications (eg, severe infections, hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression) may occur; abrupt discontinuation may cause adrenal crisis

Enzyme

Collagenase clostridium histolyticum is now an approved drug for percutaneous needle fasciotomy.


Collagenase clostridium histolyticum (Xiaflex)

Proteinase that hydrolyzes collagen in its native triple-helical conformation, resulting in lysis of collagen deposits. Injection into a Dupuytren cord (composed mostly of collagen) may result in enzymatic disruption of the cord. Indicated for Dupuytren contracture with a palpable cord.

Adult

Inject 0.58 mg into palpable Dupuytren cord with a contracture of metacarpophalangeal (MP) or proximal interphalangeal (PIP) joint
If contracture persists 24 h following injection, perform finger extension procedure
May repeat injection and finger extension procedures up to 3 times per cord at 4-wk intervals
Inject only 1 cord at a time; if other cords with contractures exist, inject each cord in sequential order
Reconstitute lyophilized powder with supplied diluent prior to use (diluent volume depends on whether injecting MP or PIP joint)
Should only be administered by healthcare providers experienced with injection procedures of the hand

Pediatric

Not indicated

Data limited; safety and efficacy when coadministered with anticoagulants (other than low-dose aspirin up to 150 mg/d) within 7 d of administration is unknown

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Tendon rupture of other serious injury to the injected extremity reported in clinical trials; pruritus experienced in 15% (increased incidence after more injections); administration in patients with abnormal coagulation may result in ecchymosis/contusion or an injection site hemorrhage; common adverse effects (>25%) include edema of injected hand, contusion, injection site reaction, injection site hemorrhage, and/or pain in the extremity

More on Dupuytren Contracture

Overview: Dupuytren Contracture
Differential Diagnoses & Workup: Dupuytren Contracture
Treatment & Medication: Dupuytren Contracture
Follow-up: Dupuytren Contracture
References
Further Reading
[ CLOSE WINDOW ]

References

  1. Augoff K, Tabola R, Kula J, Gosk J, Rutowski R. Epidermal growth factor receptor (EGF-R) in Dupuytren's disease. J Hand Surg [Br]. Dec 2005;30(6):570-3. [Medline].

  2. Johnston P, Chojnowski AJ, Davidson RK, Riley GP, Donell ST, Clark IM. A complete expression profile of matrix-degrading metalloproteinases in Dupuytren's disease. J Hand Surg [Am]. Mar 2007;32(3):343-51. [Medline].

  3. Ulrich D, Ulrich F, Piatkowski A, Pallua N. Expression of matrix metalloproteinases and their inhibitors in cords and nodules of patients with Dupuytren's disease. Arch Orthop Trauma Surg. Aug 30 2008;[Medline].

  4. Kopp J, Seyhan H, Muller B, Lanczak J, Pausch E, Gressner AM. N-acetyl-L-cysteine abrogates fibrogenic properties of fibroblasts isolated from Dupuytren's disease by blunting TGF-beta signalling. J Cell Mol Med. Jan-Mar 2006;10(1):157-65. [Medline].

  5. Forsman M, Paakkonen V, Tjaderhane L, Vuoristo J, Kallioinen L, Salo T. The expression of myoglobin and ROR2 protein in Dupuytren's disease. J Surg Res. May 15 2008;146(2):271-5. [Medline].

  6. Gonzalez MH, Sobeski J, Grindel S, Chunprapaph B, Weinzweig N. Dupuytren's disease in African-Americans. J Hand Surg [Br]. Jun 1998;23(3):306-7. [Medline].

  7. Bebbington A, Savage R. Dupuytren's disease in an infant. J Bone Joint Surg Br. Jan 2005;87(1):111-3. [Medline].

  8. Wilbrand S, Ekbom A, Gerdin B. The sex ratio and rate of reoperation for Dupuytren's contracture in men and women. J Hand Surg [Br]. Aug 1999;24(4):456-9. [Medline].

  9. Habash A, Rinker B. Dupuytren's disease involving the wrist. J Hand Surg [Am]. Mar 2007;32(3):352-4. [Medline].

  10. Meathrel KE, Thoma A. Abductor digiti minimi involvement in Dupuytren's contracture of the small finger. J Hand Surg [Am]. May 2004;29(3):510-3. [Medline].

  11. Burge P. Genetics of Dupuytren's disease. Hand Clin. Feb 1999;15(1):63-71. [Medline].

  12. Hindocha S, John S, Stanley JK, Watson SJ, Bayat A. The heritability of Dupuytren's disease: familial aggregation and its clinical significance. J Hand Surg [Am]. Feb 2006;31(2):204-10. [Medline].

  13. Lee LC, Zhang AY, Chong AK, Pham H, Longaker MT, Chang J. Expression of a novel gene, MafB, in Dupuytren's disease. J Hand Surg [Am]. Feb 2006;31(2):211-8. [Medline].

  14. Hu FZ, Nystrom A, Ahmed A, et al. Mapping of an autosomal dominant gene for Dupuytren's contracture to chromosome 16q in a Swedish family. Clin Genet. Nov 2005;68(5):424-9. [Medline].

  15. Bayat A, Walter J, Lambe H, et al. Identification of a novel mitochondrial mutation in Dupuytren's disease using multiplex DHPLC. Plast Reconstr Surg. Jan 2005;115(1):134-41. [Medline].

  16. Gudmundsson KG, Arngrimsson R, Jonsson T. Dupuytren's disease, alcohol consumption and alcoholism. Scand J Prim Health Care. Sep 2001;19(3):186-90. [Medline].

  17. Brown JJ, Ollier W, Thomson W, Bayat A. Positive association of HLA-DRB1*15 with Dupuytren's disease in Caucasians. Tissue Antigens. Aug 2008;72(2):166-70. [Medline].

  18. Kuhn MA, Wang X, Payne WG, Ko F, Robson MC. Tamoxifen decreases fibroblast function and downregulates TGF(beta2) in dupuytren's affected palmar fascia. J Surg Res. Apr 2002;103(2):146-52. [Medline].

  19. Pagnotta A, Specchia N, Soccetti A, Manzotti S, Greco F. Responsiveness of Dupuytren's disease fibroblasts to 5 alpha-dihydrotestosterone. J Hand Surg [Am]. Nov 2003;28(6):1029-34. [Medline].

  20. Yildiz S, Karacaoglu E, Pehlivan O. Hyperbaric oxygen for the treatment of early-phase Dupuytren's contracture. Microsurgery. 2004;24(1):26-9. [Medline].

  21. Ketchum LD, Donahue TK. The injection of nodules of Dupuytren's disease with triamcinolone acetonide. J Hand Surg [Am]. Nov 2000;25(6):1157-62. [Medline].

  22. Badalamente MA, Hurst LC, Hentz VR. Collagen as a clinical target: nonoperative treatment of Dupuytren's disease. J Hand Surg [Am]. Sep 2002;27(5):788-98. [Medline].

  23. Hurst LC, Badalamente MA. Nonoperative treatment of Dupuytren's disease. Hand Clin. Feb 1999;15(1):97-107, vii. [Medline].

  24. Hurst LC, Badalamente MA, Hentz VR, Hotchkiss RN, Kaplan FT, Meals RA, et al. Injectable collagenase clostridium histolyticum for Dupuytren's contracture. N Engl J Med. Sep 3 2009;361(10):968-79. [Medline].

  25. Badalamente MA, Hurst LC. Efficacy and safety of injectable mixed collagenase subtypes in the treatment of Dupuytren's contracture. J Hand Surg [Am]. Jul-Aug 2007;32(6):767-74. [Medline].

  26. Townley WA, Cambrey AD, Khaw PT, Grobbelaar AO. Matrix metalloproteinase inhibition reduces contraction by dupuytren fibroblasts. J Hand Surg [Am]. Nov 2008;33(9):1608-16. [Medline].

  27. Bulstrode NW, Mudera V, McGrouther DA, Grobbelaar AO, Cambrey AD. 5-fluorouracil selectively inhibits collagen synthesis. Plast Reconstr Surg. Jul 2005;116(1):209-21; discussion 222-3. [Medline].

  28. Jemec B, Linge C, Grobbelaar AO, Smith PJ, Sanders R, McGrouther DA. The effect of 5-fluorouracil on Dupuytren fibroblast proliferation and differentiation. Chir Main. Feb 2000;19(1):15-22. [Medline].

  29. Namazi H. Imiquimod: a potential weapon against Dupuytren contracture. Med Hypotheses. 2006;66(5):991-2. [Medline].

  30. Namazi H, Abdinejad F. Botulinum Toxin as a novel addition to the antidupuytren armamentarium. Med Hypotheses. 2007;68(1):240-1. [Medline].

  31. Skoff HD. The surgical treatment of Dupuytren's contracture: a synthesis of techniques. Plast Reconstr Surg. Feb 2004;113(2):540-4. [Medline].

  32. Zyluk A, Jagielski W. The effect of the severity of the Dupuytren's contracture on the function of the hand before and after surgery. J Hand Surg Eur Vol. Jun 2007;32(3):326-9. [Medline].

  33. Hogemann A, Wolfhard U, Kendoff D, Board TN, Olivier LC. Results of total aponeurectomy for Dupuytren's contracture in 61 patients: a retrospective clinical study. Arch Orthop Trauma Surg. May 31 2008;[Medline].

  34. Ali SN, McMurtrie A, Rayatt S, Roberts JO. Ulnar-based skin flap for Dupuytren's fasciectomy. Scand J Plast Reconstr Surg Hand Surg. 2006;40(5):307-10. [Medline].

  35. Pelissier P, Gardet H, Pinsolle V. The palmar intermetacarpal flap in Dupuytren's contracture. J Hand Surg Eur Vol. Feb 2007;32(1):113. [Medline].

  36. Tripoli M, Merle M. The "Jacobsen Flap" for the Treatment of Stages III-IV Dupuytren's Disease: A Review of 98 Cases. J Hand Surg Eur Vol. Dec 2008;33(6):779-82. [Medline].

  37. van Rijssen AL, Werker PM. Percutaneous needle fasciotomy in dupuytren's disease. J Hand Surg [Br]. Oct 2006;31(5):498-501. [Medline].

  38. van Rijssen AL, Gerbrandy FS, Ter Linden H, Klip H, Werker PM. A comparison of the direct outcomes of percutaneous needle fasciotomy and limited fasciectomy for Dupuytren's disease: a 6-week follow-up study. J Hand Surg [Am]. May-Jun 2006;31(5):717-25. [Medline].

  39. Cheng HS, Hung LK, Tse WL, Ho PC. Needle aponeurotomy for Dupuytren's contracture. J Orthop Surg (Hong Kong). Apr 2008;16(1):88-90. [Medline].

  40. Jerosch-Herold C, Shepstone L, Chojnowski AJ, Larson D. Splinting after contracture release for Dupuytren's contracture (SCoRD): protocol of a pragmatic, multi-centre, randomized controlled trial. BMC Musculoskelet Disord. Apr 30 2008;9:62. [Medline].

  41. Evans RB, Dell PC, Fiolkowski P. A clinical report of the effect of mechanical stress on functional results after fasciectomy for Dupuytren's contracture. J Hand Ther. Oct-Dec 2002;15(4):331-9. [Medline].

  42. Misra A, Jain A, Ghazanfar R, Johnston T, Nanchahal J. Predicting the outcome of surgery for the proximal interphalangeal joint in Dupuytren's disease. J Hand Surg [Am]. Feb 2007;32(2):240-5. [Medline].

  43. Symes T, Stothard J. Two significant complications following percutaneous needle fasciotomy in a patient on anticoagulants. J Hand Surg [Br]. Dec 2006;31(6):606-7. [Medline].

  44. Reuben SS, Pristas R, Dixon D, Faruqi S, Madabhushi L, Wenner S. The incidence of complex regional pain syndrome after fasciectomy for Dupuytren's contracture: a prospective observational study of four anesthetic techniques. Anesth Analg. Feb 2006;102(2):499-503. [Medline].

  45. Abe Y, Rokkaku T, Ofuchi S, Tokunaga S, Takahashi K, Moriya H. An objective method to evaluate the risk of recurrence and extension of Dupuytren's disease. J Hand Surg [Br]. Oct 2004;29(5):427-30. [Medline].

  46. Al-Qattan MM. Factors in the pathogenesis of Dupuytren's contracture. J Hand Surg [Am]. Nov 2006;31(9):1527-34. [Medline].

  47. Benson LS, Williams CS, Kahle M. Dupuytren's contracture. J Am Acad Orthop Surg. Jan-Feb 1998;6(1):24-35. [Medline].

  48. Bulstrode NW, Jemec B, Smith PJ. The complications of Dupuytren's contracture surgery. J Hand Surg [Am]. Sep 2005;30(5):1021-5. [Medline].

  49. Draviaraj KP, Chakrabarti I. Functional outcome after surgery for Dupuytren's contracture: a prospective study. J Hand Surg [Am]. Sep 2004;29(5):804-8. [Medline].

  50. Fitzgerald AM, Kirkpatrick JJ, Naylor IL. Dupuytren's disease. The way forward?. J Hand Surg [Br]. Aug 1999;24(4):395-9. [Medline].

  51. Hindocha S, Stanley JK, Watson S, Bayat A. Dupuytren's diathesis revisited: Evaluation of prognostic indicators for risk of disease recurrence. J Hand Surg [Am]. Dec 2006;31(10):1626-34. [Medline].

  52. Lubahn JD, Pollard M, Cooney T. Immunohistochemical evidence of nerve growth factor in Dupuytren's diseased palmar fascia. J Hand Surg [Am]. Mar 2007;32(3):337-42. [Medline].

  53. Rayan GM. Clinical presentation and types of Dupuytren's disease. Hand Clin. Feb 1999;15(1):87-96, vii. [Medline].

  54. Ross DC. Epidemiology of Dupuytren's disease. Hand Clin. Feb 1999;15(1):53-62, vi. [Medline].

  55. Roush TF, Stern PJ. Results following surgery for recurrent Dupuytren's disease. J Hand Surg [Am]. Mar 2000;25(2):291-6. [Medline].

  56. Saar JD, Grothaus PC. Dupuytren's disease: an overview. Plast Reconstr Surg. Jul 2000;106(1):125-34; quiz 135-6. [Medline].

  57. Shaw RB Jr, Chong AK, Zhang A, Hentz VR, Chang J. Dupuytren's disease: history, diagnosis, and treatment. Plast Reconstr Surg. Sep 2007;120(3):44e-54e. [Medline].

  58. Thurston AJ. Dupuytren's disease. J Bone Joint Surg Br. May 2003;85(4):469-77. [Medline].

  59. Yi IS, Johnson G, Moneim MS. Etiology of Dupuytren's disease. Hand Clin. Feb 1999;15(1):43-51, vi. [Medline].

[ CLOSE WINDOW ]

Keywords

Dupuytren contracture, Dupuytren's disease, Dupuytren disease, Dupuytren's contracture, palmar fibromatosis, fibrosis of the palmar fascia, flexure contraction of the digits, proximal interphalangeal joint contracture, PIP joint contracture, PIP contracture, metacarpophalangeal joint contracture, MCP joint contracture, MCP contracture, palmar contracture

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Felisa S Lewis, MD,, Staff Physician, Department of Dermatology, Madigan Army Medical Center
Felisa S Lewis, MD, is a member of the following medical societies: American Academy of Dermatology, International Society of Dermatology, and Women's Dermatologic Society
Disclosure: Nothing to disclose.

Coauthor(s)

Theresa Dressler Conologue, DO, FAAD, Physician, Department of Dermatology, Geisinger Medical Center
Theresa Dressler Conologue, DO, FAAD is a member of the following medical societies: American Academy of Cosmetic Surgery, American Academy of Dermatology, and American Society for Laser Medicine and Surgery
Disclosure: Nothing to disclose.

Kristina Shaffer, MD, MPH, Consulting Staff, Department of Dermatology, Dermatology Consultants
Kristina Shaffer, MD, MPH is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

Medical Editor

Evan R Farmer, MD, Clinical Professor of Pathology and Dermatology, Department of Pathology, Virginia Commonwealth University School of Medicine
Evan R Farmer, MD is a member of the following medical societies: American Academy of Dermatology, American Dermatological Association, American Medical Association, American Society of Dermatopathology, and International Society of Dermatology
Disclosure: Nothing to disclose.

Pharmacy Editor

David F Butler, MD, Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic
David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa
Disclosure: Nothing to disclose.

Managing Editor

Jeffrey J Miller, MD, Associate Professor of Dermatology, Penn State University College of Medicine; Staff Dermatologist, Penn State Milton S Hershey Medical Center
Jeffrey J Miller, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, Association of Professors of Dermatology, North American Hair Research Society, and Society for Investigative Dermatology
Disclosure: Nothing to disclose.

CME Editor

Catherine M Quirk, MD, Clinical Assistant Professor, Department of Dermatology, University of Pennsylvania
Catherine M Quirk, MD is a member of the following medical societies: Alpha Omega Alpha and American Academy of Dermatology
Disclosure: Nothing to disclose.

Chief Editor

Dirk M Elston, MD, Director, Department of Dermatology, Geisinger Medical Center
Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology
Disclosure: Nothing to disclose.

 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.