Systemic Glucocorticosteroid Therapy Research Articles

Deverji's disease after COVID-19: Case report

Deverji's disease is a rare idiopathic skin disease characterized by keratinization disorder and manifested in follicular hyperkeratosis, orange-red peeling plaques, palmar-plantar keratodermia with the possible development of erythroderma. The etiopathogenesis of this dermatosis is still unknown. There are such possible trigger factors as traumatization, ultraviolet radiation, taking certain medications, autoimmune and oncological diseases, bacterial or viral infection, vaccination. The presence of familial cases is due to a mutation in the CARD14 gene. Diagnosis of the disease is based on characteristic clinical symptoms. The histological picture has no pathognomonic features; however, a biopsy is necessary for differential diagnosis with other papulosquamous dermatoses. Treatment of Deverji's disease remains a difficult task, since the disease pathogenesis has not been fully studied.
 The article describes a clinical case of Deverji's disease manifestation in a 64-year-old woman who had suffered COVID-19 infection twice. She was admitted to the Department of Dermatology and Venerology (Sechenov University) with complaints of skin rashes on her face, trunk, upper and lower extremities, accompanied by severe itching. The absence of any distinctive clinical and histological changes, the torpidity of the skin process and resistance to the therapy made it difficult to make a diagnosis. After the emergence of characteristic clinical symptoms (palmar-plantar keratodermia, salmon-tinged rashes with islands of healthy skin), as well as the results of repeated histological examination (alternating areas of ortho- and parakeratosis; uneven granular layer; vacuolization of basal cells; uneven broad acantholytic strands; loosened dermo-epidermal junction; small perivascular lymph-macrophage infiltrates) Deverji's disease was diagnosed.
 The use of standard therapies (systemic glucocorticosteroid therapy, methotrexate, topical therapy) did not give any results, and therefore it was decided to initiate the netakimab. After 5 injections, the first positive results were obtained in the form of the color paling and a decrease in the number of rashes, palmar-plantar keratodermia regression and improvement of the patient psychoemotional state. After 11 injections, almost complete remission was achieved, and treatment was continued until all symptoms disappeared completely.
 The article provides a literature review of the etiopathogenesis, clinical manifestations and treatment methods of Deverji's disease. The described clinical case is the fifth example in the world of the Deverji's disease manifestation after a COVID-19 infection, and is also the first case of the IL-17 inhibitor netakimab successful use for the disease treatment.

Can Methotrexate Be Employed as Monotherapy for Bullous Pemphigoid? Analysis of Efficiency and Tolerance of Methotrexate Treatment in Patients with Bullous Pemphigoid.

The European Academy of Dermatology and Venerology (EADV) consensus states that the treatment of choice for bullous pemphigoid is systemic glucocorticosteroid therapy. Bearing in mind that long-term steroid therapy is associated with numerous side effects, an effective and safer treatment regimen for these patients is still being sought. A retrospective analysis was performed of the medical reports of patients with diagnosed bullous pemphigoid. The study included 40 patients with moderate or severe disease, and who had continued ambulatory treatment for at least six months. The patients were divided into two groups: one treated with methotrexate in monotherapy, or with combined methotrexate and systemic steroid therapy. A slightly better survival rate was noted in the methotrexate group. No significant differences were observed between the groups in time to achieve clinical remission. The combination therapy group demonstrated more frequent disease recurrence and exacerbations during treatment, and a higher mortality rate. None of the patients in either group presented with severe side effects related to methotrexate treatment. The treatment of bullous pemphigoid with methotrexate in monotherapy is an effective and safe therapeutic method for elderly patients.

Целесообразность радикальных методов эндоскопических хирургических вмешательств на околоносовых пазухах при полипозном риносинусите

Treatment of chronic rhinosinusitis with nasal polyps (CRSwNP) is a complex problem for physicians. There is basic therapy with topical glucocorticosteroids, in case of ineffectiveness of which a short course of systemic glucocorticosteroid therapy is carried out, or the question of using biological therapy with monoclonal antibodies is considered. Surgical approaches for CRSwNP have evolved over the years, ranging from simple nasal polyps to nasalization procedures. Since the introduction of functional endoscopic sinus surgery (FESS) into widespread practice, there has been a principle that surgery for CRSwNP should only be considered in patients who are refractory to pharmacological therapy. The analysis of surgical treatment of patients with CRSwNP in the departments of otorhinolaryngology of the Vladimirsky Moscow Regional Research Clinical Institute (MONIKI) and Clinical Hospital No. 1 of Department for Presidential Affairs of the Russian Federation (Volynsk Hospital) for the period 2015–2022 was carried out. In the department of the Volynsk Hospital, from 2017 to 2022, 595 people were treated with CRSwNP, of which 440 patients received surgical care, 36 patients in 2021 and 119 patients in 2022 were treated with dupilumab. The index of surgical activity in 2021 was 0.695 (30.51% of patients received conservative treatment, 69.49% of patients received surgical treatment) and 0.27 in 2022 (63% of patients received conservative treatment, 27% of patients were operated). In the department of otorhinolaryngology of MONIKI, in 2015, 144 surgeries were performed for PRS; in 2016, 94 surgeries; in 2017, 31 surgeries; in 2018, 28 surgeries; in 2019, 26 surgeries. All surgical interventions in both departments were performed in the scope of endoscopic polysinusotomy or maxillary ethmoidotomy. In parallel, since September 2015, on the basis of the surgical department with a day hospital, specialized care has been organized for patients with CRSwNP, where diagnostic measures are carried out jointly with an allergist-immunologist, treatment is carried out according to a stepwise therapy scheme for various CRSwNP phenotypes with an assessment of the dynamics of the course of the disease every 3 months. This made it possible to reduce the number of these operations in the department of otorhinolaryngology of MONIKI by almost 5 times. Surgical treatment for CRSwNP is not a panacea. Mechanical removal of pathologically altered tissue does not eliminate the etiological factors of this disease, nor does it affect any link in the development of pathogenesis. Any operation is associated with a surgical and anesthetic risk for the patient and costs. Therefore, reducing their number due to the complex treatment of patients, considering comorbid pathology, the use of biological therapy drugs along with economic efficiency and reducing the load on a round-the-clock hospital allows avoiding invasive interventions. Radical endoscopic surgery with a reboot approach, full-house functional endoscopic sinus surgery (FESS), and Draf III (frontal drillout) operations should always have strict indications since they are rather a «rescue operation» and can never become a routine surgical intervention for CRSwNP, especially since in 96.3% of patients with CRSwNP relapse occurs within 3 years after surgery. Schemes for the management of patients with CRSwNP in the departments of otorhinolaryngology of MONIKI and the Volynsk Hospital can improve the quality of life of these patients, achieve drug control of the disease, and reduce the number of surgical interventions while increasing the total number of patients with CRSwNP treated in these institutions.

Cases of mucormycosis in the Kazan Republican Clinical Hospital

Mucormycosis is a rare fungal infection with high morbidity and mortality in immunocompromised patients. Eight cases of mucormycosis were detected in the Kazan Republican Clinical Hospital of the Ministry of Health of the Republic of Tatarstan: 5 men and 3 women, aged 22 to 70. Given the presence of patient risk factors, such as diabetes mellitus, recent novel coronavirus infection, and systemic glucocorticosteroid therapy, one can assume their influence on the development of mucormycosis in these patients.

Optimization of the treatment of moderate to severe and active thyroid orbitopathy considering the recommendations of the European Group on Graves' Orbitopathy (EUGOGO) [Optymalizacja leczenia umiarkowanej do ciężkiej i aktywnej orbitopatii tarczycowej z uwzględnieniem zaleceń European Group on Graves' Orbitopathy (EUGOGO)]

Graves' disease (GB), also known as Basedow's disease, is the most common cause of hyperthyroidism, and thyroid orbitopathy (TO) is its most common non-thyroid manifestation with an incidence of 42.2/million people/year. Based on the guidelines of the European Graves' Orbitopathy Group (EUGOGO), certain management standards presented in our publication should be used to optimize and improve the efficacy of TO treatment. Deciding on the optimal treatment for both hyperthyroidism and TO requires a cooperative team of specialists: endocrinologist, ophthalmologist, radiation therapist, and surgeon, as well as consideration of the risk of relapse and possible complications of the treatment method. The inflammatory activity and severity of TO should be diagnosed based on the investigator's own experience and according to standard diagnostic criteria. Assessment of the inflammatory activity of TO can be performed using the clinical activity score (CAS) and using imaging methods - mainly MRI. The severity of TO is assessed using a seven-grade NOSPECS classification and a three-grade EUGOGO scale. In moderate to severe and active TO, i.v. methylprednisolone pulses are the treatment of choice. It is important to maintain the standard and regimen of treatment. The recommended standard as first-line treatment in most patients with moderate to severe and active TO is the combined use of methylprednisolone i.v. (cumulative dose of 4.5 g over 12 weeks) with concurrent administration of mycophenolate sodium 0.72 g per day for 24 weeks. In more severe forms of moderate to severe and active TO, a higher cumulative dose of methylprednisolone i.v. is recommended as an alternative first-line treatment (7.5 g) as monotherapy starting with a dose of 0.75 g once a week for 6 weeks and 0.5 g for a further 6 weeks. EUGOGO guidelines recommend that in cases of no clinical response after 6 weeks of first-line treatment with i.v. methylprednisolone and mycophenolate, after 3-4 weeks, a second course of i.v. methylprednisolone monotherapy should be started with a higher cumulative dose of 7.5 g. Other second-line treatment options are orbital radiotherapy with or without oral or i.v. systemic glucocorticosteroid therapy, cyclosporine, or azathioprine in combination with p.o. glucocorticosteroid, methotrexate monotherapy, and a group of biologic drugs rituximab, tocilizumab, teprotumumab). Keeping in mind that TO is a sight-threatening disease, we expect, through the treatment applied, to maintain full visual acuity, pain relief, single vision in the useful part of the visual field, and a positive cosmetic effect.

Treatment of moderate to severe and active thyroid orbitopathy during SARS-CoV-2 pandemic.

Thyroid orbitopathy (TO) is the most common non-thyroid manifestation of Graves’ and Basedow disease. Assessment of the inflammatory activity of TO can be performed using the clinical activity score (CAS) and using imaging methods — mainly magnetic resonance imaging (MRI). The severity of TO is assessed using a seven-grade NOSPECS classification and a three grade scale proposed by the European Group on Graves’ Orbitopathy (EUGOGO). In moderate to severe and active TO, the recommended standard as first-line treatment is the combined use of methylprednisolone intravenously ( i.v. ) with concurrent oral ( p.o. ) administration of mycophenolate sodium. Second-line treatment options are orbital radiotherapy with or without oral or i.v. systemic glucocorticosteroid therapy, cyclosporine, or azathioprine in combination with p.o. glucocorticosteroid, methotrexate monotherapy, and a group of biologic drugs (riuximad, tocilizumab, teprotumumab). All recommended therapies for moderate to severe and active TO involve immunosuppressive and immunomodulatory drugs, which are a risk for the unfavorable course of COVID-19. There are no available recommendations for treating TO in Graves’ and Basedow disease patients during the SARS-CoV-2 pandemic. Moderate to severe and active TO patients present a serious dilemma during SARS-CoV-2 pandemic. It seems reasonable that in patients with moderate to severe TO, who are not at risk of sight deterioration, i.v. glucocorticosteroids should be avoided, and an observational strategy should be used, whereas in patients with more severe TO and at risk of sight worsening, i.v. glucocorticosteroids are the therapeutic choice regardless of SARS-CoV-2 infection or clinical signs of COVID-19.

Особливості перебігу негоспітальної пневмонії етіології (COVID-19) у пацієнтів з бронхіальною астмою

Abstract. Materials and methods. Analyzed in the dynamics CT OGK in 70 patients with community-acquired pneumonia of viral etiology (COVID-19), who were treated at the State Institution “National Institute of Tuberculosis and Pulmonology named after F. G. Yanovsky NAMS of Ukraine» in the acute period of the disease, including patients with concomitant asthma. CT OGK was performed on a scanner Aquilion TSX101A «Tochiba» (Japan). Spirography with analysis of the «flow-volume» curve of forced exhalation was performed on the «Master Screen Pneumo» and «Master Screen PFT», «Cardinal Health» (Germany). Results and discussion. Among the 70 patients with community-acquired pneumonia of viral etiology (COVID-19) who were hospitalized during the acute period of the disease and needed oxygen support, the proportion of patients with concomitant asthma was 2.9 %. Severe viral pneumonia (COVID-19) occurred mainly in patients with uncontrolled asthma, comorbidities, or long-term use of systemic glucocorticosteroids. Prior to treatment, CT OGC revealed CT signs of bilateral polysegmental viral pneumonia with symptoms of «frosted glass» and consolidation. Lesions of the lung parenchyma ranged from 50 % to 60 %. In addition to the basic asthma therapy and the standard therapy according to the national protocol “Provision of medical care for the treatment of coronavirus disease (COVID-19)”, which included – oxygen therapy, anticoagulant, antibacterial, systemic glucocorticosteroid therapy, 10 days infusion therapy was prescribed: rheosorbilact 200 ml / day, xavron (edaravon) 30 mg, dissolved in 100 ml of saline, tivorel (L-arginine with L-carnitine) 100 ml / day. After 3 weeks, control CT scan of OGK was performed, on which regression of the pathological process was observed in patients with concomitant asthma – recovery of pneumatization of the lung parenchyma, absence of additional emphysematous changes. There were no symptoms of asthma exacerbation. Complications, such as toxic-allergic dermatitis, occurred after the acute period of COVID-19 and accounted for 1.4 % of all 70 subjects, and 50 % of patients with concomitant asthma. Conclusions. Peculiarities of community-acquired pneumonia of viral etiology (COVID-19) in patients with concomitant asthma, needed in oxygen support are: almost complete resorbtion or pathologic signs in lungs during first 3 weeks (according CT) of adequate therapy, lack of development of additional emphysematous changes in lungs and signes of asthma exacerbation.

Features of polymorbid pathology in patients with autoimmune bullous dermatosis

Autoimmune bullous dermatosis (ABD) is a group of inherited and acquired skin diseases, the main morphological elements of which are the bullas, developed as a result of autoantibody production directed against protein structures of the epidermis and dermo-epidermal junction, leading to epidermal detachment and blistering on the skin and mucous membranes. The aim of the research is to analyze the detection rate and structure of polymorbid pathology in patients with autoimmune bullous dermatoses and to determine the Charlson index and 10-year viability in patients before and after prescription of glucocorticosteroid therapy. Materials and methods. The research included retrospective and prospective stages. At the first stage, the analysis of primary medical records was carried out, and histories of 70 patients over 18 years old, before the onset of autoimmune bullous dermatosis were analyzed. Clinical and epidemiological data were taken into account, the main and concomitant diagnoses were determined in accordance with ICD X. The Charlson index was calculated for all patients, the 10-year viability rate of patients with autoimmune bullous dermatoses was determined. Results. Polymorbid pathology was recorded in 81.4% of patients, before the onset of autoimmune bullous dermatosis. 48.6% of patients had two or more concomitant diseases. Among patients with diseases of internal organs, those with cardiovascular pathology (52.8%) occupied the first place, patients with gastroenteric pathology (41.4%) occupied the second place, patients with endocrinopathy held the third place (20.0%). The Charlson index median in patients of this group was 2.5 (1–3), the risk of fatal outcome over a 10-year period was 16.5%. Subsequently, after the onset of autoimmune bullous dermatosis, 65.7% of patients required the prescription of glucocorticosteroid therapy. Decompensation of concomitant pathology was diagnosed in 39.1% of patients, therefore they needed consultation of related specialists. The median polymorbidity index increased to 3.5 (2–5), the risk of a death increased to 34.5% ( p < 0.05). Conclusion . Polymorbid pathology worsens the course of autoimmune bullous dermatoses, increases the risk of disability and mortality, especially in patients receiving systemic glucocorticosteroid therapy, and therefore these patients should be under regular medical check-up not only of a dermatovenereologist, but also of related specialists.

Alternative methods of delivering steroids to the middle ear in treatment of sudden sensorineural hearing loss

Introduction. Sudden sensorineural hearing loss is the most common pathology of polyethological sound perception. Systemic glucocorticosteroid therapy has long been considered the main treatment method. In recent years, topical therapy has been of great interest. However, intratympanic injections cause considerable discomfort to the patient and require about 1 hour per day to perform the procedure.Materials. In order to modernize and reduce the time spent on delivering steroids into tympanic cavity, this article considers the experience of managing 41 patients with sudden unilateral sensorineural hearing loss. Patients of the first group received dexamethasone 4 mg / ml in a volume of 1 ml by catheterization of the auditory tube, followed by introduction into the tympanic cavity. Patients of the second group were divided into 2 subgroups: in the first subgroup, dexamethasone 4 mg / ml in a volume of 0.5 ml was administered into tympanic cavity through a pre-imposed hole in the eardrum using a radio-wave device, and patients of the second subgroup received a classic intratympanic injection of dexamethasone 4mg / ml 0.5 ml after application anesthesia of the eardrum. The audiometry was performed before treatment, after 1, 2 weeks, 1 and 6 months.Results. The average time spent in the clinic of patients of the first group was 30 minutes, while patients of the first subgroup of the second group had 20 minutes a day. The longest time in the clinic was 2 subgroup of patients from 2 groups-about 1 hour.Conclusions. Radio-wave myringotomy is the safest and most convenient method. The smallest amount of time spent on the patient was observed in the subgroup of intratympanic injections that performed radio-wave miringotomy. It has been proved that the methods of topical treatment are not inferior in efficiency to each other.

Alopecia areata. How not to miss Satoyoshi syndrome?

Satoyoshi syndrome is a multisystem disorder of suspected autoimmune etiology, characterized predominantly by alopecia, muscle spasms and diarrhea. Antinuclear antibodies are present in 60% of patients. The syndrome primarily affects girls and young women. Trichoscopy shows regularly distributed yellow dots, indistinguishable from typical alopecia areata. The condition may be easily misdiagnosed and treated as alopecia areata. On the basis of an in-depth analysis of all published cases we developed diagnostic criteria for Satoyoshi syndrome. We also suggest that two subtypes of the disorder should be distinguished, the ANA-positive Satoyoshi syndrome with generally good response to systemic glucocorticosteroid therapy and the ANA-negative Satoyoshi with less favorable prognosis. In our opinion all patients will alopecia areata (in particular alopecia totalis) should be inquired about muscle spasms and diarrhea and tested for antinuclear antibodies to decrease the risk of missing Satoyoshi syndrome.

Eosinophilic cholecystitis: A rare manifestation of hypereosinophilic syndrome

Eosinophilic cholecystitis (EC) is a rare form of acute cholecystitis, of which diagnosis is based on classical symptoms of cholecystitis with a presence of > 90% eosinophilic infiltration within the gall bladder. EC rarely manifests in idiopathic hypereosinophilic syndrome (IHES). Here, we report two cases of EC with IHES. One is a 57-year-old male who presented with acute right upper quadrant (RUQ) pain, jaundice and fever. The initial peripheral blood eosinophil count was 2,070/mm, and further elevated to 12,590/mm. Acute acalculous cholecystitis with cholangitis was confirmed by computed tomography (CT). He improved with endocopic nasobiliary drainage and antibiotic therapy. The other is a 64-year-old female who presented with acute RUQ pain. She also complained of dyspnea and tingling sensation of both hands and feet. The initial peripheral blood eosinophil count was 10,400/mm. Abdominal CT revealed findings suggestive of acute acalculous cholecystitis. She improved with systemic glucocorticosteroid therapy. No other causes of hypereosinophilia were found in either patients. Thus, cholecystectomy may not be mandatory for the treatment of EC with IHES. (Allergy Asthma Respir Dis 2014;2:222-226)

Chronic hepatitis B reactivation and systemic glucocorticosteroid therapy: reply from authors

Conflicts of interest: none declared. Sir, We thank Dr Wang and colleagues for their comments on our paper on reactivation of chronic hepatitis B virus (HBV) following systemic glucocorticosteroid therapy that was published in the September 2007 issue of this Journal.1 The authors raise two issues. Firstly, they question whether the hepatitis in four patients described in this article does not represent ‘reactivation’ because they do not have a baseline HBV DNA viral titre for reference, and thus cannot fit the definition of HBV reactivation. Secondly, Wang et al. question the feasibility of antiviral drug prophylaxis therapy as recommended by us. Regarding the first issue, the published article was limited by its scope as a retrospective study. As most dermatologists have traditionally neglected the risk of HBV infection and reactivation during corticosteroid therapy, only 21 of 98 patients (21%) were screened or recorded for serum hepatitis B markers status in this retrospective study. Thus, it was not possible to acquire a baseline HBV DNA viral titre. Even without a baseline HBV DNA viral titre for comparison, however, it is reasonable to conclude that there was a reactivation of HBV in these four patients based on the clinical history and course, as prednisolone is a known risk factor for HBV reactivation, as reported previously.2

Chronic hepatitis B reactivation and systemic glucocorticosteroid therapy

Chronic hepatitis B reactivation and systemic glucocorticosteroid therapy

Chronic hepatitis B reactivation: a word of caution regarding the use of systemic glucocorticosteroid therapy

Chronic hepatitis B reactivation: a word of caution regarding the use of systemic glucocorticosteroid therapy

Chronic hepatitis B reactivation: a word of caution regarding the use of systemic glucocorticosteroid therapy

Background The potentially fatal complications associated with viral hepatitis B (HBV) reactivation have not been characterized in bullous/connective tissue disease patients receiving prolonged systemic glucocorticosteroids (GCs). Objectives This study reports HBV reactivation following GC therapy for a case series of pemphigus vulgaris and dermatomyositis. Methods The retrospective study cohort comprised 98 patients who received at least 6 months of systemic GC therapy. Results Four cases of HBV carriers with viral hepatitis flare were identified. Two patients suffered fulminant hepatitis and died, while the remaining two patients experienced recurrent hepatitis flare following antiviral medication. The mean time from the start of GCs to the time of HBV reactivation was 10.5 months. Conclusions HBV infection is an important global public health problem. Fatal HBV reactivation may occur following long-term systemic GC therapy. Given the risk of mortality, all bullous/connective tissue disease patients should be screened for serum hepatitis B markers before commencing systemic GC therapy.

Adverse effects of systemic glucocorticosteroid therapy in infants with hemangiomas.

To evaluate the short- and long-term adverse effects of systemic glucocorticosteroid (GS) therapy in infants with hemangiomas. Retrospective chart review of infants treated with GSs for hemangiomas during a 3-year period. Tertiary care children's hospital. Of 141 patients identified with hemangiomas, 22 were treated with GSs. Minimum of 1-month GS therapy at a minimum starting dose of 0.5 mg/kg per day. Demographic and anthropometric measurements, starting dose and duration of GS therapy, subjective parental concerns, complications related to hemangioma, adjunctive treatment, and morning cortisol levels and/or results of corticotropin stimulation tests. The average starting dose was 2.23 mg/kg per day; average length of therapy was 28.1 weeks. Complaints of irritability, fussiness, or insomnia were identified in 16 patients (73%). Hypertension, defined as 3 or more episodes of systolic blood pressure higher than 105 mm Hg, was observed in 10 patients (45%). Morning cortisol levels were abnormal in 13 (87%) of the 15 patients evaluated. Low-dose corticotropin stimulation test results were abnormal in 2 of the 3 infants tested. While GS therapy for infantile hemangiomas was tolerated well overall, changes in behavior, insomnia, and gastrointestinal symptoms were common parental concerns. Hypertension and hypothalamic-pituitary-adrenal axis suppression were observed frequently. Infants undergoing long-term GS treatment of hemangiomas should be monitored carefully for these potential adverse effects.

Pharmacokinetics of budesonide controlled ileal release capsules in children and adults with active Crohn's disease

Systemic glucocorticosteroid therapy is effective in Crohn's disease, but is associated with side-effects. Budesonide has high topical anti-inflammatory activity, but considerably lower systemic activity than other oral glucocorticosteroids. To evaluate the systemic exposure to budesonide (controlled ileal release capsules) in children and adults with active Crohn's disease, and to assess the suppression of plasma cortisol. In an open label study, patients (eight children and six adults) with active Crohn's disease received 9 mg budesonide (Entocort capsules) orally once daily for 7 days. Plasma concentrations were determined on the seventh day of administration, and pharmacokinetic parameters were calculated. For reference, 0.5 mg budesonide was given intravenously separately. Plasma cortisol levels were compared with the pre-treatment baseline values. Systemic exposure to budesonide (AUC0-24 h) after 1 week of oral administration was 41 +/- 21 nmol/L x h (mean +/- s.d.) in children and 35 +/- 20 nmol/L x h in adults. The estimated systemic availability in children was 9 +/- 5% and in adults 11 +/- 7%. The mean plasma cortisol (AUC0-24 h) decreased by 64 +/- 18% in children and by 50 +/- 27% in adults. The systemic exposure, systemic availability and cortisol suppression after oral administration of 9 mg budesonide were similar in children and adults with active Crohn's disease. Budesonide was well tolerated and no clinically important safety-related findings were identified.

Epidermal Langerhans cell density in patients with pulmonary malignancies and chronic obstructive pulmonary disease.

To evaluate the relationship between ELC density and pulmonary malignancies, as reported in previous investigations, we examined the nonsun-exposed epidermis of 18 patients with pulmonary cancer (CA) not receiving immunosuppressive therapy, 20 patients with chronic obstructive pulmonary disease (COPD-S), and 10 patients with COPD receiving glucocorticosteroid (GCS) therapy (COPD + S). The ELC density was not significantly different between lung tumor patients (1024 +/- 167) and COPD-S (1072 +/- 200, p less than 0.4) control patients, and we found no significant correlation between ELC density and tumor cell type, presence or absence of metastases, tumor stage, or present smoking status. Although we did detect that systemic GCS therapy significantly reduced the ELC density in COPD + S patients (910 +/- 211, p less than 0.05); use of inhaled or chronic low dose (less than or equal to 20 mg daily) GCS did not appear to significantly alter ELC density. In addition, anergy to epicutaneous dinitrochlorobenzene in CA and COPD + S patients positively correlated with a reduction in ELC density, suggesting a possible functional deficit arising from the numerical change. Further investigation is needed to elucidate whether factor(s) other than a reduction in ELC density are involved in the anergic state.

Systemic glucocorticosteroid therapy of skin disease in children.

The role of systemic glucocorticosteroid therapy in the management of dermatologic disorders in children is limited. Most skin diseases requiring the antiinflammatory or antiproliferative effects of steroids are best managed with topical preparations, because they exert local effects almost exclusively and cause few if any systemic side effects when used properly. There are, however, certain skin diseases, which because of their severity or their intrinsic nature, do not respond adequately to these agents. We propose the indications for pharmacologic doses of systemic glucocorticosteroids in dermatologic disease, the preferred route of administration, the most common as well as the more rare side effects of this therapy. Withdrawal of patients from chronic use of these drugs is also discussed.