Medication Summary
The goals of pharmacotherapy are to reduce inflammation, eliminate infection if present, reduce morbidity, and prevent complications.
Corticosteroids
Class Summary
These agents are used for their anti-inflammatory properties, but they must be used with caution because they have local and systemic side effects. In most cases pustular folliculitis respond to topical corticosteroids.
Triamcinolone (Kenalog-10, Kenalog-40, Aristospan)
Triamcinolone can be used topically or injected intralesionally. It decreases inflammation by suppressing the migration of PMN leukocytes and reversing capillary permeability.
Immunosuppressants
Class Summary
These agents interfere with processes that promote immune reactions resulting from diverse stimuli.
Mycophenolate (CellCept, Myfortic)
Mycophenolate is useful for both skin and muscle disease. It inhibits purine synthesis and proliferation of human lymphocytes.
Cyclosporine (Gengraf, Neoral, Sandimmune)
Cyclosporine is a cyclic polypeptide that suppresses some humoral immunity and, to a greater extent, cell-mediated immune reactions. It suppresses mRNA expression of T helper type 2 (Th2) cytokines (interleukins 4 and 13) in peripheral blood mononuclear cells.
Pimecrolimus cream (Elidel)
Pimecrolimus cream is used for short-term treatment or for intermittent, long-term treatment in unresponsive or intolerant cases. It is available in a 1% cream.
Retinoid-like Agents
Class Summary
These agents stimulate cellular retinoid receptors and help normalize keratinocyte differentiation and are comedolytic. In addition, they have anti-inflammatory properties. Oral isotretinoin also reduces sebum production in the skin.
Isotretinoin (Claravis, Amnesteem, Sotret, Myorisan)
Isotretinoin is an oral retinoid indicated for recalcitrant, nodulocystic acne. It addresses all four pathogenic factors involved the development of acne: follicular hyperkeratinization, inflammation, sebum production, and Propionibacterium acnes growth. Treatment is weight-based, usually dosed initially 0.5 mg/kg and increased to 1 mg/kg in 2 divided doses for 15-20 weeks. Once-daily dosing is not recommended. One may adjust the dose to administer up to 2 mg/kg/day. Patients must be registered into the government-regulated iPledge program in order to receive the medication.
Acitretin (Soriatane)
Acitretin is a retinoic acid analog, like etretinate and isotretinoin. Etretinate is the main metabolite and has demonstrated clinical effects close to those seen with etretinate. Its mechanism of action is unknown.
Antimalarials
Class Summary
Antimalarial agents may be used as steroid-sparing agents to treat skin disease. Hydroxychloroquine is preferred; chloroquine and quinacrine (100 mg/day) are second-line agents. Quinacrine may suppress bone marrow and is distributed by the Centers for Disease Control and Prevention (CDC); blood cell counts should be obtained regularly.
Hydroxychloroquine (Plaquenil)
Hydroxychloroquine may allow partial or complete control of the disease. Anecdotal evidence has suggested that morbilliform drug reactions are more common in patients with dermatomyositis than in those with other collagen vascular diseases. Hydroxychloroquine inhibits chemotaxis of eosinophils and locomotion of neutrophils and impairs complement-dependent antigen-antibody reactions.
Antibiotics, Other
Class Summary
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of this clinical setting. Antibiotic treatment for rosacea include tetracyclines and metronidazole. Dapsone is used in the treatment of eosinophilic pustular folliculitis.
Dapsone (Aczone)
Dapsone prevents bacterial use of para-aminobenzoic acid (PABA) for folic acid synthesis by acting as a competitive inhibitor.
Tetracycline
Tetracycline inhibits bacterial protein synthesis by binding with 30S and, possibly, 50S ribosomal subunit(s). Tetracycline has anti-inflammatory activity. One may administer 250-500 mg orally twice daily.
Doxycycline (Doryx, Adoxa, Monodox, Vibramycin)
Doxycycline is a broad-spectrum antibiotic with excellent gram-positive coverage, including most resistant staphylococcal organisms. It inhibits protein synthesis and, thus, bacterial growth, by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. It may block dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Clidamycin (Cleocin)
Clidamycin is a lincosamide for the treatment of serious skin and soft tissue staphylococcal infections. It is also effective against aerobic and anaerobic streptococci (except enterococci). It inhibits bacterial growth, possibly by blocking dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest. Clidamycin is commonly used topically, but it can be given orally. Oral monotherapy administration should be avoided to reduce the risk of antibiotic resistance. One may administer 150-300 mg twice daily.
Rifampin (Rifadin)
Rifampin is for use in combination with at least one other antituberculosis drug. It inhibits DNA-dependent bacterial RNA polymerase but not mammalian RNA polymerase. Cross-resistance may occur. One may administer 600 mg twice daily.
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Traction alopecia.
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Alopecia due to primary cutaneous follicular center cell lymphoma. Used with permission, rights retained, courtesy of Rashid M. Rashid, MD, PhD, Morzak Research Collaborative.
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Recalcitrant scarring pressure alopecia several years after an ICU stay. Used with permission, rights retained, courtesy of Rashid M. Rashid, MD, PhD, Morzak Research Collaborative.
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End-stage scarring alopecia (ESSA) with prior history of itching and burning, along with a receding hairline. Started as the lichen planopilaris variant, frontal fibrosing alopecia. Used with permission, rights retained, courtesy of Rashid M. Rashid, MD, PhD, Morzak Research Collaborative.
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Dissecting scalp cellulitis. Used with permission, rights retained, courtesy of Rashid M. Rashid, MD, PhD, Morzak Research Collaborative.
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Armpit scarring alopecia in lichen planopilaris variant. Patient presented with frontal fibrosing alopecia. Used with permission, rights retained, courtesy of Rashid M. Rashid, MD, PhD, Morzak Research Collaborative.
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Acne keloidalis. A misnomer term based on clinical examination findings. Used with permission, rights retained, courtesy of Rashid M. Rashid, MD, PhD, Morzak Research Collaborative.
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Lichen planopilaris in its active stage presenting in a lighter-skinned patient. Courtesy of Rashid M Rashid, MD, PhD, and Ronald Rapini, MD.
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Alopecic and aseptic nodules of the scalp (AANS) is a new entity reported first in Japan as "pseudocyst of the scalp." The main location of the nodules was the occiput. The associated alopecia was nonscarring. Histology is nonspecific but often shows deep granulomas. AANS reponds to tetracyclines. Photo courtesy of Sami Abdennader, MD (rights retained).
