Israel Medical Association Journal

Lower extremity ulcers are a late complication of connective tissue diseases and occur more commonly in patients with this disease than in the general population. Although these lesions have historically been attributed to vasculitis, it is now recognized that inflammatory vessel injury accounts for fewer than 20% of ulcers in connective tissue disease. The pathogenesis of these lesions is complex, and often several processes act synergistically to initiate and perpetuate tissue injury. We review the evidence for antiphospholipid antibodies and prothrombotic states contributing to a vasculopathy in patients with connective tissue disease, precipitating ulceration and impairing healing.

Research in the acquisition of patient interviewing skills by medical students has dealt mostly with the evaluation of the effectiveness of various teaching programs and techniques. The educational approaches (i.e., the tutor-learner relationship and learning atmosphere) have rarely been discussed. These approaches may be grouped into: a) "teacher-centered" (didactic), in which the students are passive recipients of instruction; b) "learner-centered," in which the tutor functions as a facilitator of small group learning, whose task is not to teach but rather to ensure that all students participate in the discussions and share knowledge with other students; and c) "integrated learner-and teacher-centered" or "experiential learning," which consists of an ongoing dialogue between the tutor and the students. In this paper, we review the strengths and weaknesses of these educational approaches and attempt to identify the current trends in their use in the teaching of interviewing skills. It would appear to us that, until the 1960s, medical students acquired interviewing skills without any expert guidance. On the other hand, since the 1970s, there has been a tendency to offer and upgrade undergraduate programs aimed at imparting communication skills to medical students. Initially, these programs were didactic; however, during the last decade, there has been an increasing shift to teaching interviewing skills by promoting experiential learning.

Background: Acute generalized exanthematous pustulosis is a rare pustular severe cutaneous adverse reaction characterized by a rapid clinical course and unique histological findings. It is usually attributed to drugs, although other factors have also been implicated.

Objectives: To analyze demographic, clinical and laboratory data of AGEP[1] cases in Israel, based on the RegisCAR study, a multinational European study.

Methods: Patients included in the present study were actively recruited by the Israeli RegiSCAR network, which comprised 10 dermatology departments and units. The cases were validated by a multinational expert committee of dermatologists based on a standardized scoring system.

Results: Overall, 11 potential cases of AGEP were collected in Israel: 9 (81.8%) definite and 2 (19.2%) possible. The adjusted annual incidence of AGEP in Israel was 0.35/million/year. The nine definite cases that entered the analyses showed a male/female ratio of 0.28 with an age range of 10–60 years. Most cases were reported during the summer months. The clinical course and laboratory findings in most of our patients were in accordance with previous reports. A drug etiology was suspected in the majority of cases and consisted of analgesics (66.7%), antibiotics (22.2%) and non-steroidal anti-inflammatory drugs (11.1%) as the main culprit drugs.

Conclusions: Whereas the clinical and laboratory findings of AGEP in Israel corresponded to the reported features of AGEP in the literature, unique findings consisting of marked female predominance, seasonality and a profile of culprit drugs were noted.

7.4.10.6.04

Background: Atopic dermatitis or atopic eczema is an itchy inflammatory skin condition with a predilection of the skin flexures. Most cases start in children although some have been reported in adults. Patients with moderate to severe disease refractory to topical corticosteroid or calcineurin inhibitors may require second-line treatment such as phototherapy or systemic immunosuppressants. Methotrexate therapy has been suggested to be a useful immunosuppressant in adult atopic dermatitis.

Objectives: To further determine the efficacy of low dose methotrexate therapy in adults with new-onset atopic dermatitis or with idiopathic eczema.

Methods: All adult patients with new-onset atopic dermatitis or idiopathic eczema treated by methotrexate in our clinics from 2004 to 2006 were included in the study. All had failed prolonged therapy with oral antihistamines and local corticosteroid creams. Methotrexate, 10–20 mg, was given orally once a week along with folic acid supplements 5 days a week. Additional therapies included predominantly emollients. During the entire treatment period the investigators made global assessments of the clinical response.

Results: Nine patients diagnosed with late-onset atopic dermatitis (n=6) or idiopathic eczema (n=3) were treated with methotrexate. All patients responded to the drug. The initial response was noted after 3–7 weeks. Six patients achieved complete remission after 3 months of methotrexate therapy and three patients had significant improvement. One patient's the condition worsened after achieving a complete response while on methotrexate and it was withdrawn completely. No serious adverse events were noted during treatment.

Conclusions: Low dose methotrexate is an effective therapeutic alternative for late-onset atopic dermatitis or idiopathic eczema in patients unresponsive to local and other systemic therapies.
 

Background: Fungal infection of the nail affects millions of people worldwide and has an estimated prevalence of more than 10% of the general population.

Objectives To determinate the prevalence of fungal infection in toenails, in order to decide the treatment policy in onychomycosis.   

Methods: We evaluated 331 patients with suspected clinical toenail onychomycosis affecting at least two toenails. Mycological examination of the affected nails was performed, both the KOH test and fungal culture were used. 

Results: Of 331 patients with psoriasis, 78.2% of the patients had at least three infected nails. The first toenail was the most affected. Trichophyton rubrum was by far the most common dermatophyte cultured from all samples.

Conclusions: Most of the patients had at least three affected toenails. Topical treatment is not effective or practical, and systemic treatment should therefore be considered.
 

Background: Seborrheic dermatitis is a common chronic disease. Malassezia yeasts have been implicated in the pathogenesis of this disease. Antifungal agents are known to be effective in the treatment of Malassezia yeast infections.

Objectives To evaluate the efficacy of itraconazole in the treatment of mild to severe facial seborrheic dermatitis.

Methods: Sixty patients with moderate to severe seborrheic dermatitis were evaluated in an open non-comparative study. Patients were treated with oral itraconazole, initially 200 mg/day for a week, followed by a maintenance therapy of a single dose of 200 mg every 2 weeks. Four clinical parameters (erythema, scaling, burning, itching) were assessed using a 0–3 score. Mycological evaluation determined the presence of Malassezia spores in the scales using a direct smear.

Results: At the end of the initial treatment significant improvement was reported in three clinical parameters: erythema, scaling, itching. Maintenance therapy led to only slight further improvement. Burning sensation was only mildly improved during the treatment. The quantity of Malassezia spores present in the direct smear decreased throughout the treatment period. No blood test abnormalities were found during the treatment.

Conclusions: In this study initial treatment with itraconazole was beneficial in patients with moderate to severe seborrheic dermatitis.