Miscellaneous Topics

Miscellaneous Topics

Patients’ Opinions Regarding Direct Access to Dermatologic Specialty Care

Introduction.—The premise of HMOs and preferred provider organizations is that care delivered by generalists instead of physician specialists is one means of reducing the overall costs of medical care. Patients’ opinions on this practice, however, have not been analyzed. An anonymous survey administered to patients seen at an outpatient dermatology clinic sought to determine patient opinion on the efficacy, costs, and desirability of gatekeeper vs. direct access to dermatology specialty care.

Patients and Methods.—All 150 patients who were approached agreed to complete the skin care survey; 77% returned the questionnaires. More than half (61%) had already been seen by the dermatologist on 1 or more previous visits. The mean age of the patients was 53 years; 51% were women and 95% were white. Insurance coverage was private for 53%, managed care for 13%, and Medicare for 33%; 2 patients (1.8%) had no insurance coverage.

Miscellaneous TopicsResults.—Most patients (65%) had self-referred to the dermatologist, 30% were referred by another physician, and 5% were referred by other individuals. Half had seen another physician for their skin condition. Two third of respondents who had received treatment from a previous physician believed they had gained little benefit from that physician. Eleven patients reported more than 5 visits to the other physician before they saw the dermatologist. When asked about their satisfaction with treatment, only 24% were “very satisfied” with the previous physician, compared with 89% for the dermatologist’s care. Few (6%) believed that a generalist could adequately treat their skin disease, and almost all (89%) viewed direct access to dermatology as “very important” to their health care.

Conclusion.—Significant skin disease is estimated to occur in 31.2% of the American population, and patients included in this survey were found to prefer dermatologic specialists over generalists for the treatment of skin disorders. Health care systems that respond to this preference may enhance their marketability.

Increasing Utilization of Dermatologists by Managed Care: An Analysis of the National Ambulatory Medical Care Survey, 1990-1994

Introduction.—For care of skin disease, a 1989 study found a much greater use of nondermatologists by patients in HMOs or preferred provider organizations. Dermatologists are concerned that they will receive fewer patient referrals in the growing managed care environment. Using data from the National Ambulatory Medical Care Survey (NAMCS), investigators sought to assess the impact of the managed care market on overall demand for dermatologists’ services.

Methods.—Sampling by the NAMCS was limited to non-federally employed physicians principally engaged in outpatient care. The resulting estimates describe the nationwide use of ambulatory services. Skin disease visits were analyzed for the years 1990 through 1994. Items recorded for each visit sampled included demographic data, reasons for patient visits, physicians’ diagnoses, services provided, and referral practices.

Results.—Visits to dermatologists for all payers was near an all-time high in 1992, despite the growth in managed care. And although the demand for treatment of skin conditions did not rise between 1992 and 1994, the demand for services of dermatologists more than doubled within the managed care sector. In 1994, patients with HMO/prepaid insurance who required treatment of skin diseases were just as likely as patients with commercial insurance to see a dermatologist. During the entire study period, the weighted average mean visit duration was 14.5 minutes for dermatologists vs. 17.2 minutes for nondermatologists (a 19% longer duration).

Conclusion.—Several studies have reported lower utilization of dermatologists in gate-keeper-managed care plans, and there were predictions of further decreases in demand for the services of this specialty. Data from the NAMCS study, however; indicate an increasing proportion of first visits and referral visits to dermatologists.

► The managed care landscape appears to be changing. At least when it comes to skin problems, patients have a strong preference for dermatologists over primary care givers, and this preference is being recognized by an increasing number of health care plans. These plans understand that removing the gatekeeper can enhance a plan’s marketability and decrease its costs. More studies like these two (Abstracts 17-1 and 17-2) are needed to keep the momentum rolling in this direction.

Teledermatology in the Nursing Home

Background.—Recent advances in affordable technology and the need to reduce health care costs have led to renewed interest in telemedicine. Teledermatology, a subset of telemedicine, could be of value when there is a physical barrier between the dermatologist and the patient or primary caregiver. The dermatologic care of nursing home residents presents such a situation. Elderly patients have a higher incidence of significant cutaneous diseases than the general population, and it is often difficult for these patients to leave the nursing home.

Methods.—Twenty-nine nursing home residents with 30 cutaneous disorders were enrolled in the study. A nurse completed a medical history form for each patient and used a videocamera to collect images of the cutaneous findings at the patients bedside. Two to 4 still images selected from the videotape were sent via a still-image telephone to the dermatologist. After viewing the images and reading the faxed histories, alone and in combination, 2 or 3 dermatologists independently made a diagnosis and treatment plan. Results of the teledermatology system were compared with those of on-site dermatologic examination.

Results.—Using the history alone, correct diagnoses of the dermatologic conditions were made in 67% of cases. Viewing of the image alone yielded correct diagnoses in 85% of cases; having both history and image available increased the rate of correct diagnoses to 88%. The correct treatment plan was formulated in 70% of cases given the history alone, 87% given the image alone, and 90% given both history and image. Patients or their guardians who returned a survey were satisfied with the teledermatology care, and 4 of 5 preferred this method to traveling to a dermatologist’s office for diagnosis.

Discussion.—This small pilot study suggests that teledermatology consults can be both accurate and cost-effective. More than 85% of cases were diagnosed and treated correctly with the teledermatology system. Skin lesions proved to be more easily diagnosed and treated than inflammatory skin eruptions.

The Substitution of Digital Images for Dermatologic Physical Examination

Introduction.—Telemedicine interventions can involve the capturing of still digital images to be viewed by consultants at a later date, or real-time interactions, as in videoconferencing or interactive television. A group of patients with dermatologic symptoms took part in a study to compare the diagnostic accuracy of clinicians viewing a history and static digital image set with that of clinicians who conducted office-based physical examinations.

Methods.—Study participants were 116 adults seen at a dermatology clinic. Excluded were patients with acne or warts, conditions that present no diagnostic challenge. Staff dermatologists took a history, examined the patient, and recorded the most likely diagnosis and up to 5 alternate diagnoses. Patients were then photographed, using a digital camera equipped with a macro lens. The office-based dermatologists’ diagnoses were compared with those of 2 remote clinicians who used still digital images (resolution, 92 dots per inch) and the medical history data to reach a diagnosis.

Results.—Evaluations were performed using 121 image sets gathered for the 116 patients. Remote clinicians did not appear to order tests any more frequently than face-to-face clinicians. The 2 remote clinicians had a lower mean certainty of their diagnoses than the office-based dermatologists (7.0 and 7.6 vs. 8.5). There was high agreement, however, between office-based and remote clinicians (61% to 64% for all cases; more than 75% when photographic quality and office-based clinician certainty were high). No disease group appeared to be more difficult to photograph, and agreement between office-based and remote physicians did not vary remarkably in any disease group. Office-based clinician certainty was the variable with the greatest impact on agreement.

Discussion.—The findings of this pilot study suggest that teledermatology may be an efficient and cost-effective means of providing diagnoses. Diagnostic agreement between office-based and remote clinicians was approximately 80% in this series of patients when patient history and a high quality image set were available to the remote clinician.

► Although still digital images can substitute for the hands-on physical examination in the majority of cases, the “personal touch” of direct patient contact cannot be replicated (Abstracts 17-3 and 17-4). Clearly, telemedicine has a place in modern medicine, especially as an aid in the examination of home-bound or institution-bound patients or those who live in underserved areas. Telemedicine should be accepted as an option for these individuals, but it will never provide the direct physician-patient interaction that so many of our patients require.

Psychiatric Illness in Patients Referred to a Dermatology-Psychiatry Clinic

Introduction.—The incidence of psychiatric illness among patients attending dermatology clinics ranges from 30% to 40%. There are the rare instances of patient with a psychiatric illness that leads to a dermatology referral (e.g., dermatitis artefacta, delusional parasitosis). The more common manifestation is psychological problems coincident with eczema or psoriasis. Earlier investigations have determined psychiatric morbidity using self-report questionnaires, which could mean overestimation of morbidity. Information derived from a full psychiatric interview was used to estimate the pattern of psychiatric disorders in 149 consecutive patients.

Methods.—Data from the psychiatric and dermatologic assessments were assessed, along with detailed social, life event, and follow-up data. Skin conditions were classified. Patients were treated for psychiatric disorders.

Result.—The most frequent psychiatric diagnoses were mild to moderate depression (28%), mild generalized anxiety (25%), and severe depression (14%). The incidence of mild to moderate depression and somatization disorder was more frequent in women. There was a history of psychiatric disorder in 40%, family history in 29%, and concurrent physical illness in 29%. At least 1 social difficulty (mean number, 1.66) was present in 78% overall (84% women, 68% men). Skin diagnoses were exacerbation of skin disease (13), dermatologic nondisease (12), scratching without cause (3), delusional parasitosis (2), dermatitis artefacta (1), and disproportionate symptoms (1).

Conclusion.—Of the patients evaluated, only 5% either denied having or had no psychiatric problems. Noteworthy were the significant levels of severe depression, particularly in patients with symptoms out of proportion to any physical cause. These patients had the most need for drug treatment and follow-up care. Important, but less common, diagnoses were delusional parasitosis, phobias, obsessive-compulsive disorder, and posttraumatic stress disorder. The psychiatric symptoms were long-standing and were related to severe, chronic social difficulties, particularly problems with close relationships. Most patients responded to psychiatric intervention.

► This article cites a high incidence of psychiatric illness in a selected group of patients—those referred to a liaison psychiatrist within a dermatology clinic. All but 5% merited a psychiatric diagnosis, with depression and anxiety disorders being most common. The most common skin diseases were so-called “dermatologic nondisease” and exacerbation of chronic skin disease. The physician should be alert to the possibility of underlying psychological problems in any patient with symptoms out of proportion to the skin disease.

The Cutaneous-Vulvar Clinic Revisited: A 5-Year Experience of the Columbia Presbyterian Medical Center Cutaneous-Vulvar Service

Introduction.—Vulvar vestibulitis is clinically difficult to manage. It has received considerable attention recently because it is now a common condition. It occurs primarily in white women, ages 18-35 years, of higher socioeconomic background. A psychological component is suspected but has not been well elucidated. A variety of treatment approaches have been used, some of which are controversial. Described is the 5-year experience of the Cutaneous-Vulvar Service of the Columbia Presbyterial Medical Center (CPMC).

Methods.—A total of 500 randomly chosen charts, representing about 10% of patients evaluated in 5 years, were reviewed for data regarding history, symptomatology, therapies, responses, dermatologic and allergic histories, and use of irritants. Patients were divided into diagnostic subgroups.

Results.—The most common subgroup was vestibulitis (36.2%), then lichen sclerosus (19.2%), and vaginitis or vaginosis (14.8%). Only 3.4% of patients had sexually transmitted diseases. No pathologic diagnosis or clinical findings that could explain their symptomatology were detected in 58 patients (11.6%). Before referral to the CPMC, most patients were treated for moniliasis in the absence of clinical evidence. Most patients responded well to conservative therapy such as colloidal oatmeal solution and oral hydroxyzine or amitriptyline.

TABLE 1.—Diagnoses of 500 Patients Seen at the Columbia Presbyterian Medical Center Cutaneous-Vulvar Clinic
Diagnosis Numberof cases Percent of cases
Vestibulitis 181 36.2
Lichen sclerosus 96 19.2
Vaginitis/vaginosis 78 14.8
Essential vulvodynia 58 11.6
Atopy/eczema 32 6.4
Squamous cell hyperplasia 24 4.8
Condyloma acuminata 12 2.4
Tinea/intertrigo 9 1.8
Psoriasis 9 1.8
Herpes 5 1
Total 500

Conclusion.—Vestibulitis is difficult to treat, but symptoms can be relieved. Consultation between gynecology, dermatology, and pathology can be beneficial in treating patients with cutaneous vulvar disorders that have been difficult to manage.

► Vulvar vestibulitis presents with a wide range of symptoms and exhibits varying degrees of severity. Burning, soreness, irritation, and swelling are common. Dyspareunia is a frequent complaint. Symptoms may be triggered by tight or confining clothing, strenuous exercise, and the use of tampons. Vulvar vestibulitis is extremely difficult to treat, and a multidisciplinary approach is often beneficial.

Short-term Effects of Topical Testosterone in Vulvar Lichen Sclerosus

Objective.—Several studies have examined the use of topical testosterone for lichen sclerosus; most, but not all, suggest that it is efficacious. There is also disagreement regarding the systemic effects of topical testos¬terone. A prospective study of topical testosterone for vulvar lichen sclerosus was reported.

Methods.—The study included 10 consecutive postmenopausal women with vulvar lichen sclerosus. In each case, this diagnosis was confirmed by histopathologic examination. The women’s mean age was 62 years, and their mean duration of symptoms was 21 months. Patients who were taking any medication; who had recently used hormone replacement therapy; or who had cancer, cardiovascular disease, or diabetes were excluded. All patients received 2% testosterone propionate in petrolatum and were instructed to apply 1 g in a thin layer twice daily. Venous blood was obtained for testosterone and other hormone measurements before and after 4 weeks of treatment. Vulvodynia before and after treatment was rated by the patient on a visual analogue scale. Evidence of hirsutism and clitoral enlargement was sought by gynecologic examination, including vulvar and cervical cytologic studies.

Results.—Serum total and free testosterone levels were increased during therapy, exceeding the normal range in most patients. All patients but 1 had significantly reduced vulvodynia during therapy. By 4 weeks, 4 patients had 1 or more clinical symptoms of hyperandrogenism, including clitoral enlargement, deepening of the voice, and increased libido. None had hirsutism. All of these changes resolved after the end of testosterone therapy. There were no changes in serum dehydroepiandrosterone sulfate, androstenedione, or sex hormone-binding globulin levels during treatment, nor were there any changes in electrolyte levels, hepatic or renal function, or blood cell count.

Conclusion.—Women treated with topical testosterone for vulvar lichen sclerosus have significant percutaneous absorption of the steroid. At the commonly recommended dosage used in this study, most patients have elevated serum testosterone levels within 4 weeks. Severe side effects may occur in women receiving long-term topical testosterone therapy. It is important to assess the patient’s androgen status before treatment and to keep the steroid dose as low as possible.

► These results show a marked systemic effect from topical testosterone treatment of lichen sclerosus et atrophicus. The authors recommend this treatment specifically for patients with normal or low serum androgen levels; moreover, the 1 patient in this study with slight symptoms of hyperandro- genism did not respond to therapy. Close monitoring—including clinical examination and determination of serum androgens—is necessary to individualize the dosage and to avoid symptoms of virilization.

Lichen Amyioidosus: A Consequence of Scratching

Background.—Lichen amyioidosus is currently described as a papular, intensely pruritic type of amyloidosis of unknown cause. It is characterized histopathologically by epidermal changes of lichen simplex chronicus and deposits of amyloid in the papillary dermis that stem from keratin peptides of necrotic keratinocytes.

Methods.—Evaluations were performed in 8 patients with lichen amyloidosus and 1 patient with macular amyloidosis, a variant of lichen amyloidosus. All patients were between the ages of 60 and 90. Of the 9 patients, 6 were male. Histopathologic features, onset of pruritus, associated diseases, and response to treatment were analyzed. Biopsy specimens showed deposits of homogeneous eosinophilic globules in the papillary dermis that showed greenish birefringence on Congo red staining under polarized light.

Results.—In most patients, the pruritus had occurred before the skin lesions appeared. Of the 9 patients, 8 had other diseases that may be associated with pruritus. Histopathologic examination showed amyloid restricted to areas with signs of lichen simplex chronicus. Systemic treatment with sedating antihistamines was moderately effective, as was intense local treatment with corticosteroids. The most effective treatment was a combination of these two treatments plus appropriate treatment for associated pruritic diseases.

Discussion.—Lichen amyloidosus is believed to be a variant of lichen simplex chronicus, in which scratching causes necrosis of keratinocytes and formation of amyloid in the papillary dermis. Treatment of lichen amyloidosus is very difficult. There is a greater chance of success if the treatment is adjusted to the pathophysiology of the disease. The aim of treatment should be to improve the pruritus because scratching appears to be the cause and not the result of amyloid deposits.

► The authors’ suggestion that lichen amyloidosus is a variant of lichen simplex chronicus rather than a true form of amyloidosis is certainly logical from a clinical point of view. As they indicate, the amyloid in this condition is derived not from immunoglobulins or serum proteins, as it is in the systemic amyloidoses, but from keratin peptides of necrotic keratinocytes. Such necrosis may be induced by prolonged scratching. Hence, the treatment of this condition should be directed at alleviating its most prominent system, pruritus.

Oral Naltrexone Treatment for Cholestatic Pruritus: A Double-blind, Placebo-controlled Study

Introduction.—Recent findings suggest that endogenous opiate substances of the enkephalin class may be potential mediators of cholestatic itching. Naltrexone is an opiate receptor antagonist that may be given orally. It is mainly excreted by the kidneys. The antipruritic effects and tolerance of naltrexone were assessed in a randomized, double-blind, placebo-controlled trial of 16 patients with chronic cholestatic liver disease.

Methods.—Of the 16 patients, 13 had primary biliary cirrhosis (PBC), 2 had primary sclerosing cholangitis (PSC), and 1 had features suggestive of PSC but refused further diagnostic testing. Patients were randomized to receive either 50 mg naltrexone or placebo for 3 weeks. Visual analog scales were used to determine the severity of pruritus, quality of sleep, and fatigue. Separate scales were used to evaluate daytime and nighttime itching. Patients also were assessed every 2 weeks for serum naltrexone and 6β-naltrexol concentrations, side effects, and liver function.

Results.—Daytime itching (-54% vs. 8%) and nighttime itching (—44% vs. 7%) were significantly diminished in the naltrexone group, compared with the placebo group. Deterioration of the underlying disease was not detected. Four patients in the naltrexone group had side effects consistent with opiate withdrawal syndrome. The effects were transient in 3 patients. There were no significant between-group differences in naltrexone and 6β-naltrexol levels. There was no significant association of these levels with treatment response.

Conclusion.—Treatment with naltrexone relieved daytime and nighttime itching in patients with cholestatic liver disease. Itching was considerably decreased in 5 of 8 treated patients. Treatment with naltrexone is an effective alternative for patients with cholestatic pruritus refractory to conservative measures. It does not appear that the lack of response to naltrexone in some patients is caused by impaired gastrointestinal absorption or metabolism of naltrexone. The long-term benefit-risk ratio of opiate receptor antagonist treatment needs to be determined.

► Pruritus can be a disabling symptom among patients with chronic cholestatic liver disease. Past treatments have included bile salt-binding resins and rifampicin. The efficacy of these agents is variable and side effects are common. Antihistamines and ursodeoxycholic have not been proven effective. Other therapeutic modalities, including plasmapheresis, hemoperfusion, biliary drainage, and even liver transplantation, have been advocated. The oral opiate receptor antagonist, naltrexone, may be an effective, well- tolerated alternative for patients with cholestatic liver disease and severe pruritus refractory to more traditional therapies.

Pain in Multiple Leiomyomas Alleviated by Nifedipine

Introduction.—Multiple cutaneous leiomyomas can be painful and difficult to treat. The patient reported here achieved remarkable relief from pain and itching with the administration of nifedipine.

Case Report.—Women, 28, had a 19-year history of skin nodules and had undergone excision of leiomyoma of the uterus a year previously. Her nodules had gradually increased in number and extent, and pain had become severe—particularly on exposure to cold. The cutaneous swellings, which were most prominent on the trunk and extremities, were confirmed at biopsy as cutaneous leiomyomas. Treatment with nifedipine (10 mg 3 times daily) brought remarkable relief from pain, but mild itching persisted after 3 months. The dose was increased to 10 mg 4 times a day when necessary during the winter. The patient continues to be free from pain 2 years later but experiences recurrence when the drug is stopped.

Discussion.—Leiomyomas of the skin are often quite painful, and the pain may be paroxysmal with stabbing, burning, or pinching sensations. The source of pain appears to be tumor pressure on cutaneous nerves. In cases of multiple and extensive lesions, surgery is not feasible. Nifedipine, a calcium-channel blocker which works to retard smooth muscle contraction, was highly effective in alleviating the severe pain experienced by this patient with multiple cutaneous leiomyomas.

► Nifedipine, a calcium-channel blocker, retards smooth muscle contraction by selectively inhibiting the transmembrane influx of calcium ions into smooth muscle. Phenoxybenzamine and, perhaps, sublingual nitroglycerin have also been reported to alleviate the pain in patients with multiple cutaneous leiomyomas.

Subcutaneous Granuloma Annulare: A Review of 47 Cases

Background.—Granuloma annulare (GA) is a common, benign, inflammatory skin lesion of unknown cause. There are 4 clinically distinct types—localized, generalized, perforating, and subcutaneous GA (SGA). The subcutaneous type occurs in children, and is associated with deep dermal or subcutaneous nodules lying near or on the periosteum and affecting the extremities or head. A 26-year experience with SGA was reviewed.

Patients.—A total of 47 children with histologically confirmed SGA were studied. Their mean age was 4 years. All patients had single or multiple painless, soft tissue nodules of the extremities or scalp. Nearly two thirds of the lesions measured 2.5 X 2.5 cm. The diagnosis of SGA was made by biopsy, which was performed a mean of 6 months after the lesion was identified.. Few patients underwent diagnostic studies more advanced than radiography and complete blood cell count.

Outcomes.—Nineteen percent of patients had recurrent SGA after incisional or excisional biopsy, with 2 patients having 2 recurrences each. Most of the recurrences developed at the same site as the initial lesion, with a mean time to recurrence of 10 months. None of the patients exhibited progression to systemic illness or connective tissue disease.

Conclusions.—A long-term experience with SGA is reviewed. These benign inflammatory skin lesions should be considered in any otherwise healthy child with one or more subcutaneous nodules of the scalp or distal extremities. Some patients have recurrences, but the nodules are benign. Aside from reassurance, no treatment is needed.

► The key points of this article are (1) to recognize the usual location of SGA (on the scalp or distal extremities), (2) to recognize the propensity of the lesions to recur after excision, and (3) to understand that treatment is unnecessary because spontaneous resolution is to be expected. Unfortunately, the authors did not indicate the duration of time the lesions were present before they resolved.

Calciphylaxis in Patients on Hemodialysis: A Prevalence Study

Background.—Calciphylaxis is a rare condition occurring in patients with end-stage renal disease and secondary hyperparathyroidism. It is characterized by painful, violaceous, mottled skin lesions that can result in necrosis, nonhealing ulcers, gangrene, amputation, sepsis, or death. The incidence of calciphyiaxis and the characteristics of individuals with calciphylaxis need to be determined in order to identify patients on dialysis who may benefit from close monitoring or early surgical intervention.

Methods.—The medical records of 242 patients being treated for end- stage renal disease were reviewed. Patient characteristics and clinical variables were analyzed.

Results.—Of the 242 patients, 10 had calciphylaxis. These 10 patients were significantly younger; had been on hemodialysis longer; and had higher median serum calcium, phosphate, calcium phosphate product, parathyroid hormone, and alkaline phosphate levels than the other patients. Bone surveys were positive in the 10 patients with calciphyiaxis and in 49 of the 232 patients without calciphyiaxis. Dramatic healing of ulcers was seen in all patients who had parathyroidectomy for calciphyiaxis.

Discussion.—The incidence of calciphylaxis is higher in younger patients who have been undergoing hemodialysis for longer periods. Such patients should be closely monitored and treated promptly for complications of secondary hyperparathyroidism. Calciphyiaxis may be encoun¬tered more frequently than in the past because of the increasing numbers of patients receiving long-term hemodialysis.

► Calciphylaxis is a potentially fatal disorder and careful follow-up of high-risk patients is essential. Although considered rare, the condition is likely to be encountered more frequently with increasing numbers of patients under¬going long-term hemodialysis. Angelis et al. found subtotal parathyroidectomy to be a highly effective treatment for this condition.

Crohn’s Disease of the Leg: A New Case and a Review of the Literature

Introduction.—Metastatic Crohn’s disease—that occurring distant from the intestinal tract—is very rare. There have been only 22 reported cases of metastatic Crohn’s disease in extragenital sites. A new case of Crohn’s disease affecting the leg is reported.

Case Report.—Woman, 30, underwent subtotal colectomy with ileostomy for colorectal Crohn’s disease. She later underwent surgery for an enterovaginal fistula. Five years later, she was seen with an infiltrated, red-purple plaque on her left leg. The lesion measured 10 X 17 cm with central ulceration and inflammatory pustules. Antibiotic treatment had no effect. A biopsy specimen revealed numerous noncaseating granulomas with dermal epithelioid and giant cells, confirming the diagnosis of cutaneous Crohn’s disease. Stains and culture studies for acid-fast bacilli and fungi were negative. Treatment was with oral prednisone, 0.5 mg/kg/day for 3 weeks. Steroid therapy continued for 2 months after the lesion. went into complete remission, but a new local recurrence followed.
The lesion finally healed with 4 months of prednisone at 5 mg/day. There were no recurrences at 1 year’s follow-up.

Discussion.—Extragenital metastatic Crohn’s disease is a very rare lesion. Its most frequent characteristics are ulcerations, painful subcutaneous nodules, and lichenoid papules of the limbs. Because of the clinical polymorphism of Crohn’s disease, unusual skin lesions in affected patients must receive due attention. Systemic steroid therapy is usually effective.

► Metastatic Crohn’s disease is most often observed in the genital area; however, less commonly, it is observed in extragenital sites. Histologic examination reveals noncaseating epithelioid and giant cell granulomas in the dermis. Skin lesions generally occur in patients with known Crohn’s disease, although they rarely can precede the onset of gastrointestinal symptoms.

Fournier’s Gangrene: Therapeutic Impact of Hyperbaric Oxygen

Objective.—Fournier’s gangrene, necrotizing fasciitis of the genital and perineal tissues, is a life-threatening disease originally characterized by abrupt onset in healthy young males, rapid progression, and lack of a specific cause. Recently, urologic and colorectal disorders and immuno- suppressed states have been identified in affected patients. A retrospective analysis focused on disease prevention, comorbid factors, hospital man-agement, treatment modalities, and overall mortality.

Methods.—Since 1990, 26 male patients, aged 26-87, with Fournier’s gangrene have received treatment at the University of Tennessee Medical Center. Average hospital stay was 21 days. Treatment included surgery and broad-spectrum antibiotic therapy, and 14 patients received adjuvant hyperbaric oxygen. Patients had 2 dives per day for 7 days, and daily dives for the remainder of the treatment period. Average total treatment period was 12 days. Twenty patients survived. During follow-up, large perineal wounds were treated as follows: delayed surgical closure in 15, with split-thickness skin grafts in 11, local advancement flaps in 2, and a combination of both in 2. Five wounds were allowed to heal by secondary intention.

Results.—Ten patients had diabetes mellitus, 9 abused alcohol, 3 were receiving systemic immunosuppression, and 1 was undergoing localized pelvic radiation therapy. Fifteen patients had identifiable causes for the disease: 8 had urethral stricture disease or trauma, 5 had colorectal disease, and 2 had penile prostheses. Mortality was 23%, including 1 patient with known cardiac disease who received hyperbaric oxygen therapy. Survival was significantly higher in the group receiving hyperbaric oxygen than in the other group (93% vs. 58%).

Conclusion.—Early recognition and intervention, along with aggressive surgical debridement, antibiotic therapy, and hyperbaric oxygen therapy improve the survival of patients with Fournier’s gangrene.

► Today most cases of Fournier’s gangrene are thought to be associated with inflammatory disease of the urologic or gastrointestinal tract. Hyperbaric oxygen may be a useful adjunct to prompt medical and surgical management.