Faculty Bibliography

BACKGROUND AND DESIGN--Cutaneous T-cell lymphoma (CTCL) is a slowly advancing disease that initially presents in the skin and may later progress to involve the lymph nodes and viscera. Since CTCL most often presents on non-sunlight-exposed regions of the body, a possible protective role for UVB irradiation has been suggested. Recent observations have also found that UVB irradiation serves an immunoregulatory role. Given that limited data are available regarding the use of UVB phototherapy in treating CTCL, a retrospective nonrandomized study of 37 nonconsecutive patients with early CTCL was performed to assess the efficacy of UVB phototherapy in the treatment of CTCL. RESULTS--Twenty-five (71%) of the 35 patients treated with UVB phototherapy (two were unavailable for follow-up) achieved a total clinical remission. Median time to remission was 5 months, and median duration of the remission was 22 months. Twenty-five (83%) of 30 patients with disease limited to patches achieved remission, whereas none of the patients with plaque-level disease achieved a remission. Of the 25 patients who achieved complete remission, five (20%) had a recurrence of CTCL. CONCLUSIONS--Phototherapy with UVB appears to be effective in patients with early patch-stage CTCL

One hundred seventeen patients with mycosis fungoides were treated with topical mechlorethamine hydrochloride. The probability of achieving a clinically apparent remission within 2 years of therapy was 75.8% in patients with stage I disease, 44.6% in patients with stage II disease, and 48.6% in patients with stage III disease. Patients with stage I disease achieved complete remission sooner (median, 6.5 months) than patients with stage II (median, 41.1 months) or stage III (median, 39.1 months) disease. The median time to relapse was 44.5 months. Sixty-eight patients (58.1%) developed a delayed hypersensitivity reaction, but only one patient had to discontinue therapy as a consequence. No appreciable differences were seen in the probability to achieve complete remission or time to complete remission as stratified by gender, substage, or the development of a delayed hypersensitivity reaction. Survival analysis revealed that the probability of surviving at 5 years was 89% for all patients. These findings compare favorably with results with other treatments for early stage mycosis fungoides

The authors describe two patients with clinically and histopathologically documented advanced (tumor) stage mycosis fungoides. In each case the large, pleomorphic neoplastic cells lacked the monoclonal antibody-defined cell surface antigens commonly associated with immature and mature T-cells, i.e., T11, Leu-1, T3, T4, T6, T8, and T10, but expressed various T-cell-associated activation antigens, such as HLA-DR, Tac, and T21. Leu-M1, a monocyte-associated antigen, was not expressed by the small, cerebriform neoplastic cells in the plaque stage lesions of either patient. However, Leu-M1 was expressed by most of the large, pleomorphic neoplastic cells present in the nodular lesions of both patients. The pattern of Leu-M1 antigen expression was identical to that previously reported in the Reed-Sternberg cells of Hodgkin's disease. Identification of these two patients suggests using caution in the interpretation of the results of immunophenotypic analysis of cutaneous lymphoid neoplasms and that Leu-M1 should not be used as a diagnostic indicator of Hodgkin's disease or a histiocytic-derived neoplasm. These studies also suggest that Leu-M1 may be preferentially expressed on a subpopulation of activated, rapidly proliferating, and/or dedifferentiated neoplastic T-cells that proliferate in the advanced (tumor) stages of mycosis fungoides.

Sexually transmitted diseases have increased in both prevalence and public concern over recent years; however, current treatment of sexually transmitted diseases remains fragmented among several specialty groups. In this study, dermatologists, who historically were the leaders in the treatment of sexually transmitted disease, were surveyed to assess their training, practice activity, and attitudes toward sexually transmitted disease. An overwhelming majority of dermatologists and training program directors stated that most sexually transmitted diseases should be treated primarily by dermatologists. Factors that restricted dermatologists' involvement in sexually transmitted diseases included inadequate public awareness of dermatology's role in treating these diseases, the limited number of direct patient visits, and limited physician referrals. This study indicates that dermatologists want to increase their role in sexually transmitted disease and favor making the public aware of their interest and ability

A survey of dermatology department or section chairmen was conducted to investigate the extent of undergraduate dermatologic training in US medical schools. The median number of required hours of dermatologic training was 14, which represents 0.24% of the overall medical school curriculum time. Required dermatologic training time varied greatly among schools, but most such training occurred in the fourth year of school. Students in 53% of the schools that responded to the survey were not involved in either clinical or basic dermatologic investigative activities

Seventy-six patients with mycosis fungoides (MF) were given topical mechlorethamine hydrochloride therapy. Allergic contact hypersensitivity reactions to the drug developed in 51 patients (67.1%). Sixty-four patients of the original 76 continued therapy, with 43 (67.2%) achieving a complete remission and 12 (18.8%) achieving a partial remission. Stage I disease responded significantly better than did subsequent, more severe disease stages. The median times to complete remission were 5.6 months, 32.3 months, and 22.3 months for stage I, II, and III disease, respectively. The conditions of patients with contact sensitivity did not respond better than those of patients without contact sensitivity. Patients with substage A disease did not respond better patients with substage B disease. These findings are encouraging and indicate that the use of topically applied mechlorethamine for early-stage MF should be continued, despite the development of contact dermatitis to the drug

Since an oversupply of physician specialists leads to a waste of professional resources, planning of the number of physicians may be desirable. A model projecting the future supply of dermatologists was formulated on the basis of current residency capacity, which produces about 270 dermatologists per year, and on experience regarding the average length of active clinical practice. How changes in the training capacity affect the future supply of dermatologists was also examined. The model projects an equilibrium supply of about 9,500 dermatologists, or 3.2 per 100,000 population early in the 21st century, provided the number of new graduates remains at its present level. Assuming no economic barriers to access, 2.8 to three dermatologists per 100,000 population should be adequate to meet demand. Because of many unpredictable factors, periodic reassessment of dermatology training capacity is necessary

Although the balance between the number of primary care physicians and the number of specialists has been the subject of much attention, there has been little investigation of the quality and cost-effectiveness of various provider groups. To a large extent, dermatologic care is rendered by primary care physicians. In this study, the ability of primary care physicians to recognize the 20 most frequently encountered dermatoses was examined. Results indicate that, in comparison to dermatologists, primary care physicians are deficient in their ability to recognize common dermatoses. This study emphasizes the need for reevaluation of the training and, possibly, manner in which health care is delegated to personnel who deal with cutaneous disease.

Thirty consecutive patients with biopsy-proved mycosis fungoides were examined ophthalmologically. Specific ocular changes, judged directly related to the mycosis fungoides, were found in 11 of the 30 subjects, usually in the late plaque or tumor stages of the disease. Tumors, especially involving the lids, were the most common ophthalmic finding. Keratitis, uveitis, and optic atrophy were also described. A review of the literature is given, and changes found in patients in this series correlate well with ophthalmic findings presented in diverse isolated case reports. It seems that the frequency of ophthalmic pathologic findings in mycosis fungoides is much more common than previously assumed