Chapter 17 Review 17.1 : Psychoanalysis At his friends’ urging, Barney has decided to seek help for the depression he has been struggling with ever since moving away from home and starting college two months ago. He’s heard a lot about Sigmund (1) Freud’s therapy, called (2) psychoanalysis , in which patients use (3) free association to express whatever comes to mind in order to un
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08cu.pabbyCombination Therapy of Tetracycline andTacrolimus Resulting in Rapid Resolutionof Steroid-Induced Periocular RosaceaAnju Pabby, MD; Kathy P. An, MD; Richard A. Laws, MD Standard treatment of steroid-induced rosacea The patient reported improvement several days includes discontinuation of steroids and use of after starting therapy. At the 3-week follow-up an oral tetracycline. A temporar y decrease to a visit, we noted marked improvement in the patient’s lower-potency steroid prior to discontinuation dermatitis except for faint infraorbital erythema remains optional. The limitations of standard (Figure 2). The patient was advised to continue the therapy include a prolonged course of treat- tacrolimus ointment on an as-needed basis.
m e n t w i t h e x a c e r b a t i o n s p r i o r t o p e r m a n e n timprovement. Our challenge was to identify a treatment regimen to resolve steroid-induced Topical steroids are paramount in treating many der- periocular rosacea quickly and with minimal matologic diseases; however, their prolonged use has multiple side effects, most notably atrophy. Another side effect that may result from improper use issteroid-induced rosacea.
Several theories exist as to the pathogenesis of Case Report
steroid-induced rosacea. Topical steroids may inhibit A 55-year-old man with an unremarkable medical collagen synthesis, eventually causing dermal atro- history was referred to us by his physician for a phy. The decrease in supporting connective tissuepersistent facial rash. The patient had a long-term allows for passive dilation of the blood vessels and history of seborrheic dermatitis that had been easier visualization of dermal capillaries, clinically treated for approximately the previous 12 months resulting in prominent telangiectasias and back- ground erythema.1 Additionally, inflammatory Results of the patient’s physical examination papules and pustules may be caused by a reaction to revealed background erythema and telangiectasias increased colonization of pilosebaceous bacterial or with 1- to 3-mm discrete erythematous papules fungal flora, though specific organisms have not(Figure 1). The history and physical examination of the facial rash was most consistent with steroid- The rebound phenomenon of steroid-induced periocular dermatitis also is unclear. The vasocon- The use of the fluticasone cream was discontin- strictive action of corticosteroids may lead to ued, and the patient was started on tacrolimus 0.1% the buildup of potent vasodilators such as nitric ointment twice a day for 3 weeks and oral tetracy- oxide. After the corticosteroid is discontinued, vessels dilate beyond their original diameterbecause of the accumulation of such vasodilators.3Additionally, the immunosuppressive effect ofcorticosteroids may facilitate the overgrowth of Accepted for publication March 27, 2003.
microorganisms that may then act as super- Drs. Pabby and Laws are from the Department of Dermatologyand Skin Surgery, Roger Williams Medical Center, Providence, antigens. Withdrawal of immunosuppression may Rhode Island. Dr. An is from the Department of Internal Medicine, lead to an immunologic response and a heightened Reprints: Richard A. Laws, MD, Boston University School of Tacrolimus is a topical immunomodulator that Medicine, Department of Dermatology and Skin Surgery, Roger mediates its effects through inhibition of cal- Williams Medical Center, Elmhurst Bldg, 50 Maude St, Providence,RI 08908 (e-mail: email@example.com).
cineurin. Tacrolimus inhibits release of inflammatory Figure 1. A patient with periocular dermatitis resulting
Figure 2. Minimal erythema at the infraorbital region of
from approximately 12 months of topical steroid use.
the face following a 3-week course of tacrolimus and Note the erythematous papules on a background of cytokines, most notably interleukin 2, and thus rosacea with combination therapy of topical inhibits subsequent T-cell activation.5 Although tacrolimus and corticosteroids are comparable topi-cal immunomodulators, they differ considerably in REFERENCES
their side effect profile. Unlike topical corticoste- 1. Sibenge S, Gawkrodger DJ. Rosacea: a study of clinical pat- roids, tacrolimus is minimally absorbed into the terns, blood flow, and the role of Demodex folliculorum. J Am systemic circulation, does not accumulate in tissue, Acad Dermatol. 1992;26:590-593.
and does not cause decreased collagen synthesis and 2. Egan CA, Rallis TM, Meadows KP, et al. Rosacea induced resultant atrophy. In addition, tacrolimus does not by beclomethasone dipropionate nasal spray. Int J Dermatol. cause vasoconstriction and the subsequent rebound phenomenon seen with topical corticosteroid ther- 3. Rapaport MJ, Rapaport V. Eyelid dermatitis to red face apy. The most common side effects of tacrolimus are syndrome to cure: clinical experience in 100 cases. J Am transient pruritus and burning on application.6 Acad Dermatol. 1999;41:435-442.
Tacrolimus recently has been approved by the 4. Leung DYM. Atopic dermatitis: new insights and opportu- US Food and Drug Administration for use in atopic nities for therapeutic intervention. J Allergy Clin Immunol. dermatitis. A previous study of 3 patients with steroid-induced rosacea found that patients treated 5. Ruzicka T, Assmann T, Homey B. Tacrolimus: the drug for the with tacrolimus ointment twice daily for 7 to turn of the millennium? Arch Dermatol. 1999;135:574-580.
10 days experienced a mild rebound flare when the 6. Berkersy I, Fitzsimmons W, Tanase A, et al. Nonclinical and tacrolimus was discontinued. These patients subse- early clinical development of tacrolimus ointment for the quently had to be treated with oral doxycycline, treatment of atopic dermatitis. J Am Acad Dermatol. topical clindamycin 1%, and sulfacetamide sodium 10% and sulfur 5% lotions for complete resolu- 7. Goldman D. Tacrolimus ointment for the treatment of tion.7 Our patient showed a rapid response and steroid-induced rosacea: a preliminary report. J Am Acad experienced no exacerbations of his periocular
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