1984: Dermatologically revisited

By Warren R. Heymann, MD
Aug. 22, 2018

George Orwell published Nineteen Eighty-Four in 1949. I started my dermatopathology fellowship at the University of Pennsylvania in 1984. I decided to review Archives of Dermatology (now JAMA Dermatology), looking back 34 years to see how the dermatologic world has changed as depicted in a major dermatology journal.

It was an enlightening exercise. On one level there have been fantastic advances, yet in other circumstances, plus ca change plus que la meme chose (the more things change the more they stay the same).

Journals have changed dramatically, as has dermatology. The growth of subspecialization (dermatologic surgery, cosmetic dermatology, pediatric dermatology, genodermatology, occupational dermatology, dermatopathology, dermatoepidemiology, basic/translational research, and bioethics) had been breathtaking. Statistical analysis has become paramount in the realm of evidence based medicine. There are vastly more articles on the burden of skin disease, cost analysis, quality of life, and other topics that are certainly important to the discipline, although not necessarily of immediate relevance to the practicing dermatologist. The reality is that today, I can skip several manuscripts in a given issue without sacrificing my ability to practice good dermatology.
 
Compare that to Archives of Dermatology from July 1984 (volume 120, number 7, pages 834-972). Every article was worth reading (for a general, medically-oriented dermatologist), bar none. If the journal was structured the same way today, its impact factor would drop dramatically. It may be high time to reassess what the impact factor should really be — how much real world impact it has on physicians and patients, not how often it is cited by other researchers.

I have briefly summarized each article from the issue, and provide commentary immediately afterward in italics. My only valid conclusion is that any dermatologist must make a real commitment to stay abreast of developments in the field. The pace of change will only quicken!

---

Metronidazole in the Treatment of Rosacea

Nazi̇f Kürkçüoǧlu, MD; Ni̇lgün Atakan, MD

Arch Dermatol. 1984;120(7):837. doi:10.1001/archderm.1984.01650430023002

Ten women with papulopustular rosacea were successfully treated with a 10 day course of oral metronidazole.
 
It is hard to remember when, if ever during my career, that I have not been using metronidazole for rosacea in one form or another. In 2018 this article would not have been accepted for lack of quantification of lesions and the absence of a control.

---

Drug Eruption Following Ketoconazole Therapy

Michael Kahana, MD; Aharon Levy, MD; Ora Yaron-Shiffer, MD; et al.

Arch Dermatol. 1984;120(7):837. doi:10.1001/archderm.1984.01650430023003

A 24 year old with recalcitrant tinea versicolor was treated with oral ketoconazole and developed an extensive drug eruption within a day.

If you’re not aware of the black box warning for oral ketoconazole regarding hepatotoxicity and QT prolongation, and you still prescribe oral ketoconazole, I have one word for you – STOP!

---

Granuloma Annulare Caused by Injectable Collagen

Marvin J. Rapaport, MD

Arch Dermatol. 1984;120(7):837-838. doi:10.1001/archderm.1984.01650430023004

An injection of bovine collagen caused granuloma annulare – was it the trauma or the collagen?
 
Gone are the days of injecting collagen, but the fillers have proliferated as have the reports of granulomas.

---

A Memorial to Marion Baldur Sulzberger, MD

Arch Dermatol. 1984;120(7):857-858. doi:10.1001/archderm.1984.01650430043006

A brilliant tribute to one of the greatest dermatologists of the 20th century. “Throughout his life Dr. Sulzberger was always looking for things to learn and obstacles to surmount. He was a proud, ambitious man whose intellect and unfettered intellectual curiosity allowed him to make innumerable contributions to medicine, dermatology, and clinical science. His brilliance was a constant source of inspiration and stimulation to creative activity.”

Ask your residents if they know of Dr. Sulzberger. I don’t think I want to know the answer.

---

Papillomavirus Common AntigensPapillomavirus Antigen in Verruca, Benign Papillomatous Lesions, Trichilemmoma, and Bowenoid Papulosis: An Immunoperoxidase Study

Neal S. Penneys, MD, PhD; Rafaella J. Mogollon, MD; Mehrdad Nadji, MD; et al.
 
Arch Dermatol. 1984;120(7):859-861. doi:10.1001/archderm.1984.01650430045007

Thirteen of 18 lesions of Bowenoid Papulosis demonstrated HPV infection by immunoperoxidase stain, suggesting the pathogenicity of the virus in these lesions.

Immunoperoxidase stains were in their infancy in the early 1980s. Now, they are indispensable, of course – you can’t keep track of them without a scorecard!

---

Polymorphous Light EruptionA Seven-Year Follow-up Evaluation of 114 Patients

Christer T. Jansén, MD; Jaakko Karvonen, MD

Arch Dermatol. 1984;120(7):862-865. doi:10.1001/archderm.1984.01650430048008

Sixty-four of 138 patients with PMLE had diminution of their lesions when contacted 7 years later.

Interesting and encouraging. I’ll quote that study to my very frustrated patients with PMLE.

---

Papular Polymorphous Light Eruption: Fibrin, Complement, and Immunoglobulin Deposition

Jan E. Muhlbauer, MD; Martin C. Mihm Jr, MD; Terence J. Harrist, MD

Arch Dermatol. 1984;120(7):866-868. doi:10.1001/archderm.1984.01650430052009

DIF was performed on 8 patients with PMLE. The lupus band test was negative in all; 5 demonstrated vascular C3; 2 had vascular IgM. The authors proposed that vascular injury may be pathogenic.

In 2018, PMLE is considered as a delayed hypersensitivity response to ultraviolet light, with an unidentified antigen. Bottom line – we still don’t know what causes PMLE.

---

Skin Typing for Assessment of Skin Cancer Risk and Acute Response to UV-B and Oral Methoxsalen Photochemotherapy

Robert S. Stern, MD; Khosrow Momtaz, MD

Arch Dermatol. 1984;120(7):869-873. doi:10.1001/archderm.1984.01650430055010

Among PUVA patients, cutaneous carcinomas are significantly more frequent in those with skin types I and II than skin type IV.

Even though PUVA is used much less frequently, this remains an important observation.

---

Human Absorption of Crude Coal Tar Products

James Sellers Storer, MD; Ildefonso DeLeon; Larry E. Millikan, MD; et al.

Arch Dermatol. 1984;120(7):874-877. doi:10.1001/archderm.1984.01650430060011

Phenanthrene, anthracene, pyrene, and fluoranthene were found in 4 of 5 volunteers, and have been shown to be tumor initiators or cocarcinogens.

I still recommend popular tar emulsions and otc tar products. I’ll just ignore this study. Pardon me.

---

Anti-inflammatory Adrenal Steroids That Neither Inhibit Skin Collagen Synthesis nor Cause Dermal Atrophy

Thomas DiPetrillo; Henry Lee, PhD; Kenneth R. Cutroneo, PhD

Arch Dermatol. 1984;120(7):878-883. doi:10.1001/archderm.1984.01650430064012

Two prednisolone derivatives failed to cause dermal atrophy in rats.

Thank goodness in this steroid-phobic age, alternatives such as calcineurin inhibitors and phosphodiesterase inhibitors, that do not cause atrophy, exist.

---

Keratosis Punctata and Atopy Report of 31 Cases With a Prospective Study of Prevalence

William A. Anderson, MD; Moses D. Elam, MD; W. Clark Lambert, MD, PhD

Arch Dermatol. 1984;120(7):884-890. doi:10.1001/archderm.1984.01650430070013

The authors detail the punctate keratoderma that occurs in the creases of African-American patients, possibly associating it with atopy.

We still don’t understand this common, painful, chronic disorder. We still use the same keratolytics and pare the lesions down, just as in 1984.

---

Gianotti-Crosti SyndromeA Review of Ten Cases Not Associated With Hepatitis B

Kim L. Spear, MD; R. K. Winkelmann, MD, PhD

Arch Dermatol. 1984;120(7):891-896. doi:10.1001/archderm.1984.01650430077014

In the 8 cases presented, none were due to hepatitis B (although 2 had elevated LFTs.

The list of etiologic agents for Gianotti-Crosti has grown exponentially. Is it my imagination, or is mollucum the most common cause in 2018?

---

T Cells and T-Cell Subsets in Mycosis Fungoides and Parapsoriasis A Study of 18 Cases With Anti-Human T-Cell Monoclonal Antibodies and Histochemical Techniques

A. Buechner, MD; R. K. Winkelmann, MD, PhD; Peter M. Banks, MD

Arch Dermatol. 1984;120(7):897-905. doi:10.1001/archderm.1984.01650430083015

The predominance of helper cells was demonstrated by immunoperoxidase.

How wonderful it is to get molecular studies off the original paraffin block!

---

Topical Vitamin E as a Cause of Erythema Multiforme-like Eruption

Harry Saperstein, MD; Marvin Rapaport, MD; Robert L. Rietschel, MD

Arch Dermatol. 1984;120(7):906-908. doi:10.1001/archderm.1984.01650430092016

Two patients had extensive EM-like reactions to topical vitamin E, confirmed by patch testing.

The reaction is just as frightening in 2018 as it was in 1984.

---

Anaphylaxis Following the Use of Bacitracin OintmentReport of a Case and Review of the Literature

Jay F. Schechter, MD; Ralph D. Wilkinson, MD, FRCP(C); Jaime Del Carpio, MD, FRCP(C)

Arch Dermatol. 1984;120(7):909-911. doi:10.1001/archderm.1984.01650430095017

A 52 year-old woman had concurrent type I and IV reactions to topical bacitracin.

Bacitracin is readily available over the counter – fortunately anaphylaxis is rare!

---

Generalized Staphylococcal Scalded Skin Syndrome in an Anephric Boy Undergoing Hemodialysis

Stephen L. Borchers, MD; Edward C. Gomez, MD, PhD; R. Rivkah Isseroff, MD

Arch Dermatol. 1984;120(7):912-918. doi:10.1001/archderm.1984.01650430098018

A case of SSSS is presented in a boy with chronic renal insufficiency who lost his kidneys due to persistent hydronephrosis.

The predisposing factors of renal insufficiency and immunosuppression are still paramount in adult-type SSSS

---

Bypass Phrynoderma: Vitamin A Deficiency Associated With Bowel-Bypass Surgery

Donald J. Barr, MD; Robert J. Riley, MD; Donald J. Greco, MD

Arch Dermatol. 1984;120(7):919-921. doi:10.1001/archderm.1984.01650430105019

A woman underwent bowel bypass surgery for obesity and developed phryonoderma and perforating folliculitis.

America has increased its girth and the number of bariatric procedures over the past 3.5 decades. The complications of subsequent nutritional deficiencies still exist.

---

Progressive Cutaneous Herpes Simplex Infection in Acute Myeloblastic Leukemia Successful Treatment With Interferon and Cytarabine

Yoseph Shalev, MD; Alain Berrebi, MD; Leslie Green, MB, BCh; et al.

Arch Dermatol. 1984;120(7):922-926. doi:10.1001/archderm.1984.01650430108020

Self-explanatory from the title.

Cidofovir anyone?

---

Late-Onset, Warfarin-Caused Necrosis Occurring in a Patient With Infectious Mononucleosis

Timothy R. Franson, MD; Harold D. Rose, MD; Michael R. Spivey, MD; et al.

Arch Dermatol. 1984;120(7):927-931. doi:10.1001/archderm.1984.01650430113021

This 25 year-old man with Klinefelter syndrome recurrent thrombophlebitis developed warfarin necrosis with his EBV infection.

There were no studies about protein C or protein S deficiency, which was first being recognized as a major predisposing factor for warfarin necrosis in the early 1980s.

---

Localized Cicatricial Pemphigoid (Brunsting-Perry) A Transplantation Experiment

Razzaque Ahmed, MD; Martin Salm, MD; Ruth Larson, MD; et al.

Arch Dermatol. 1984;120(7):932-935. doi:10.1001/archderm.1984.01650430118022

Normal skin was transplanted into an area of cicatricial pemphigoid and was demonstrated to have a positive DIF develop 8 weeks later.

Very cool in any decade!

---

Protease-Inhibitor Deficiencies in a Patient With Weber-Christian Panniculitis

Eric Bleumink, PhD; Hans A. Klokke, MD

Arch Dermatol. 1984;120(7):936-940. doi:10.1001/archderm.1984.01650430122023

A case of Weber-Christian disease was shown to be due to alpha-1 antitrypsin deficiency, PiZZ phenotype

Articles like this lead to the demise of the concept of Weber-Christian disease. You can qualify as a “dinosaur” dermatologist if you learned about Weber-Christian disease as relapsing febrile nodular nonsuppurative panniculitis.

---

Adjuvant Therapy of Pemphigus

Jean-Claude Bystryn

Arch Dermatol. 1984;120(7):941-951. doi:10.1001/archderm.1984.01650430127024

A wonderful review of other immunosuppressive agents such as azathioprine, methotrexate, and cyclophosphamide by the late Dr. Bystryn.

Rituximab –need I say more?

---

Angioimmunoblastic Lymphadenopathy Followed by Kaposi’s Sarcoma

Hanneke C. Kluin-Nelemans, MD; Hans R. J. Elbers, MD; Cees G. Ramselaar, MD

Arch Dermatol. 1984;120(7):958-959. doi:10.1001/archderm.1984.01650430148025

A case of Kaposi sarcoma was observed in a patient with angioimmunoblastic lymphadenopathy with dysproteinemia.

Kaposi sarcoma was a “dormant” disease until the AIDS epidemic. We have learned so much about the HHV-8 lesion, that thinking about its presentation in older Middle Eastern men almost seems quaint.

---

Pyoderma Gangrenosum and Sarcoidosis

Frank C. Powell, MB, MRCPI; Arnold L. Schroeter, MD; W. P. Daniel Su, MD; et al.

Arch Dermatol. 1984;120(7):959-960. doi:10.1001/archderm.1984.01650430149026

The authors present the first two cases of pyoderma gangrenosum associated with sarcoidosis.

The authors from the Mayo Clinic were surprised that this association had not been previously reported (me too!)

---

Linear IgA Bullous Dermatosis Successful Treatment With Colchicine

Homayoun Aram, MD

Arch Dermatol. 1984;120(7):960-961. doi:10.1001/archderm.1984.01650430150027

A 25 year-old woman with linear IgA disease could not tolerate dapsone because of hemolysis, but responded well to colchicine.

Neutrophiic disorders respond just as well to colchicine in 2018 as in 1984. The only difference is that in 1984 the drug was affordable.

---

Chronic Urticaria Secondary to Aminobenzoic Acid

Danny R. Thomas, MD; Terry V. Pursley, MD; Joseph L. Jorizzo, MD

Arch Dermatol. 1984;120(7):961-962. doi:10.1001/archderm.1984.01650430151028

The aminobenzoic acid was in a multivitamin.

Where does it lurk in today’s supplements?

---

Pediatric Pemphigus Vulgaris Treatment With Topical Adrenal Steroids

Richard W. Hempstead, MC; James G. Marks Jr, MD

Arch Dermatol. 1984;120(7):962-963. doi:10.1001/archderm.1984.01650430152029

A 13 year-old with intraoral pemphigus was controlled with triamcinolone in dental paste.

Still relevant today!

---

Nail Dystrophy Following Intralesional Injections of Bleomycin for a Periungual Wart

Robert A. W. Miller, MD, FACP

Arch Dermatol. 1984;120(7):963-964. doi:10.1001/archderm.1984.01650430153030

Self-explanatory title.

I never got into using bleomycin for perigunal warts. I don’t recall, but this article may have been one of the reasons why.

---

Infectious Mononucleosis—like Manifestations An Adverse Reaction to Sulfasalazine

Keiji Iwatsuki, MD; Minoru Tsugiki, MD; Hachiro Tagami, MD; et al.

Abstract Full Text

Arch Dermatol. 1984;120(7):964-965. doi:10.1001/archderm.1984.01650430154031

This 36 year-old man developed fever, rash, lymphadenopathy, and displayed atypical lymphocytes following administration of sulfasalazine.

This is clearly a case of DRESS before DRESS was a known entity.

---