Cimetidine for Molluscum

Molluscum contagiosum: chronic poxvirus infection

·         Common disease of childhood but also can occur in adults

·         Transmitted by skin-skin contact anywhere on body

o   sexually or in contact sports

o   scratching or touching a lesion

o   only host is humans but can be spread by fomites on towels or swimming pools

·         Associated with immunocompromised states (HIV or immunosuppressive drugs)

·         May be associated with atopic dermatitis

·         Incubation period typically 2-6 weeks

·         Flesh-colored, dome-shaped papules usually 2-5 mm in diameter

·         Shiny surface with central indentation or umbilication

·         May be associated with pruritus

·         May occur anywhere on body except palms and soles

·         Most common areas: trunk, axillae, antecubital and popliteal fossae, and crural folds

·         Diagnose based on appearance but can do histology to confirm

·         Lesions usually resolve within 2 months but may take up to 1 year

·         Self-limited to technically do not need to treat (in immunocompetent patients)

·         First-line therapy:

o   Cryotherapy – liquid nitrogen

o   Curettage – may cause scars

o   Cantharidin – topical blistering agent, without scarring

o   Podophyllotoxin – antimitotic gel or cream

·         Second-line

o   Imiquimod – topical immunomodulator

o   Potassium hydroxide

o   Salicyclic acid

o   Topical retinoids

·         Oral cimetidine ***

o   H2 antihistamine

o   Immunomodulatory properties

§  Stimulate delayed hypersensitivity

§  T suppressor lymphocytes possess histamine receptors

§  Cimetidine enhances cell-mediated immunity by preventing histamine-induced stimulation of T suppressor activity but underlying mechanism is not clearly understood

§  Has been shown to benefit in varicella zoster, herpes simplex, mucocutaneous candidiasis, etc.

o   Dose studied: 40 mg/kg/day x 2 months – associated with clearance of all lesions

§  Dosage less than 40 mg/kg/day was inffective for viral warts

§  NOT a randomized placebo controlled trial

·         Need to prevent transmission  

o   Cover lesions with clothing or watertight bandage

o   Avoid sharing towels, sponges, etc

angioneurotic edema

A prescription came in to pharmacy electronically from an urgent care for a depo-Medrol injection with an icd10 code for angioneurotic edema

Angioneurotic Edema: a hereditary/genetic form of angioedema, also known as Quinke's disease

• genetic deficiency of C1 esterase inhibitor protein
• autosomal dominant inhereitance
• normally this protein prevents activation of a cascade leading to angioedema
• diagnosis suspected with severe recurrent angioedema
• most common areas: limbs, face, intestinal tract, and airway
• when occurs in larynx --> airway can be compromised
• when occurs in intestinal tract --> severe abdominal pain, nausea, vomiting 
• other symptoms may include fever, joint pain, mucus membrane swelling, brain swelling
• 1/3 of people with condition develop a non-itchy rash called erythema marginatum
• confirm diagnosis by low levels of C1 esterase inhibitor in blood
• attacks can occur every 1-2 weeks and last 3-4 days long
• can be triggered by minor trauma, stress, physical activity, certain medications (anti-hypertensives and heart failure drugs) but can also occur without a known trigger
• treatment & prevention options:
• antihistamines will not work
• androgen steroids may prevent
• C1 esterase inhibitor concentrate prevent attacks
• Cinryze, Ruconest, Berinert -- injected into veins
• encallantide (Kalbitor), icatibant (firazyr) -- injected under skin

There really isn't much evidence in the literature about using steroids for this condition. In fact, the literature I found stated that corticosteroids would not work. Androgen steroids such as danazol, oxandrolone, or methyltestostorone

• these agents work by increasing the level of aminopeptidase P which inactivates kinins which are responsible for angioedema

tetracyclines for blepharitis

tetracyclines for Chronic blepharitis

• one of the most difficult ocular diseases to treat
• 6 types: staphylococcal, seborrheic, seborrheic with staph infection, seborrheic with meibomian seborrhea, seborrheic with spotty inflammation of the meibomian glands, primary meibomianitis
• 2/3 of primary meibomianitis have associated skin condition, acne rosacea
• tetracyclines shown to be effective at treating primary meibomianitis 
• inhibit lipase activity and decrease the release of noxious free fatty acids
• minocycline given 50 mg daily x 2 weeks followed by 100 mg daily until end of study for 6 months
• also doses of 50 mg BID has been studied successfully showed symptom improvement compared to placebo
• meibum is the lipids that come from meibomian glands of patients with primary meibomianitis
• meibum was collected and contains wax and sterol esters, free cholesterol, triglycerides, and diglycerides
• minocycline had greatest effect on decreasing diglycerides, free fatty acids, and cholesterol
• fatty acids and diglycerides promote inflammation
• free cholesterol stimulates bacterial growth
• minocycline decreases fatty acids production and ROS produced by neutrophils
• tetracyclines reduce cytokine levels (IL-6, IL 1b, IL17a, TNFalpha)
• novel anti-inflammatory approach
• tetracyclines also used in ocular rosacea, corneal inflammatory disease, corneal infections
• effects not related to anti-biotic effects -- reduce the free fatty acids that are formed by bacteria on the eyelids
• should also recommend warm compresses 1-4 x day to increase flow of oil from the meibomian glands and help open clogged pores