Sulfasalazine is an anti-inflammatory medication first used to treat rheumatoid arthritis. It also has been used to treat inflammatory bowel disease, seronegative arthropathies, and psoriasis.[1] Sulfasalazine, a compound of sulfapyridine and 5-aminosalicylic acid, works as both an immunomodulator and an immunosuppressant medication. It inhibits inflammatory cell chemotaxis and cytokine and antibody production.
The most common side effects are nausea, vomiting, anorexia, dyspepsia, malaise, and headaches. These side effects become especially problematic at doses higher than 3 g per day. Taking the medication with food or using enteric-coated tablets can help minimize gastrointestinal side effects. Rare side effects include fever, rash, hepatitis, pancreatitis, pneumonitis, and agranulocytosis. Liver function tests and complete blood counts should be monitored closely for the first 3 months, then every 3-6 months thereafter. Because sulfasalazine inhibits folate absorption, folate supplementation is recommended. Finally, patients with allergies to sulfa should not be started on sulfasalazine.
Sulfasalazine is not a first-line therapy, but it has been used to treat alopecia areata. The literature is primarily anecdotal, and it is important to remember that this drug has not been approved by the US Food and Drug Administration for use in alopecia areata. Patients must be made aware of this prior to starting sulfasalazine. A retrospective chart review performed by Ellis and colleagues[2] showed that 7 (23%) of 30 patients with alopecia areata treated with sulfasalazine for 3 months achieved cosmetically acceptable regrowth. Doses ranged from 1 to 4 g per day. Eleven patients discontinued the medication due to side effects, mainly gastrointestinal distress.
Although sulfasalazine is not commonly used to treat alopecia areata, the low incidence of severe side effects makes it a reasonable choice for patients who have failed multiple agents and are able to tolerate the side effects. It is typically started at 500 mg per day and increased up to 3 to 4 g per day as tolerated. An adequate trial of at least 4 months on 3 g per day should be tried before discontinuing the drug. In terms of dosing schedules for teenagers, there are no regimens that are different from those in adults, although you may consider starting at a lower initial dose.
Posted 01/01/2003
Gulsen Akoglu, Gonca Boztepe, Aysen Karaduman
Department of Dermatology, Hacettepe University Faculty of Medicine, Ankara, Turkey
Background/Aims: Prurigo pigmentosa (PP) is an uncommon inflammatory disease with pruritic reddish papules, papulovesicules or vesicules that are symmetrically localized on the trunk and nape, accompanied by reticular hyperpigmentation. Currently available therapeutic options seem somewhat unsatisfying. Herein, we report an 18-year-old female with PP successfully treated with low-dose isotretinoin. Methods: The patient presented with a symmetrical pruritic eruption on the lateral sides of her trunk with erythematous papules on a hyperpigmented background. Based on the typical clinical and associated histological findings, the patient was diagnosed as PP and a treatment with low-dose isotretinoin 0.3 mg/kg/day (20 mg/day) was started. Results: After a total of 3 months of 20 mg/day isotretinoin therapy, all erythematous macules and papules resolved and the residual pigmentation had almost disappeared. Conclusion: Low-dose isotretinoin is not only adequate for the improvement of erythematous lesions, it also helps resolve the reticular hyperpigmentation of PP. Further studies are needed to observe the efficacy of isotretinoin in the treatment of PP.
— Mary Wu Chang, MD
Published in Journal Watch Dermatology August 18, 2006Careful examination and history taking are more valuable than serotyping for identifying sexual abuse in children with HPV.
The rate of anogenital warts in children is on the rise, due to increased prevalence and recognition of human papillomavirus (HPV). How common are anogenital warts in young children, and can we identify which of these children have been sexually abused? Investigators in Montreal delineated clinical characteristics, identified HPV types, and assessed the value of HPV typing for identifying abuse in 72 prepubertal children seen at one clinic for anogenital warts (age, <12> in their patient population, 1.7/1000).
Age-of-onset data were available for 68 patients (mean age at onset, 3 years, 9 months). In two children, the warts had been transmitted prenatally or during birth. Onset of infection occurred before age 2 years in 28%, and between 2 and 6 years of age in 62%. Only 10% were older than 6 years at onset. Sexual abuse was confirmed in 6 children and suspected in another 12; onset in these children occurred at a mean age of 4 years, 8 months. Twenty-six percent of patients ages 2 to 6 years at onset had suspected or confirmed sexual abuse, compared with 85% of patients older than 6.
HPV serotypes 2A, 3, 6, 7, 11, 16, and 57 were noted (7 and 57 are unusual types). The mode of transmission could not be identified by HPV typing, age of onset, or clinical appearance of the lesions. The authors conclude that the best way to identify possible sexual abuse remains history taking, careful assessment of the socioclinical context, and physical examination.
Comment: Children may become infected with HPV at any time and via various modes of transmission. Given these realities and possible viral latency, evaluation of the mode of transmission is extremely challenging. In this study, all infants under age 1 year had innocent transmission. In this small sample, children older than 6 had a high rate of suspected or proven sexual abuse, and most abused children were girls. However, there are no reliable rules. There is no substitute for careful examination and interview. Clinicians must use their judgment, not necessarily to establish sexual abuse, but to determine whether referral to child protective services is indicated.
The 25% rate of suspected or proven sexual abuse is sobering. In any case of suspected abuse, clinicians should document all findings and refer to child protective services (ideally, a multidisciplinary child abuse team) as soon as possible. In addition, it may be best to defer the questioning of the young child to the abuse team. Repeated questioning of young children can contaminate the evidence, as children may change their answers to please adults. Lastly, long-term follow-up of girls with anogenital warts is indicated, as malignancy can follow pediatric infection.
Citation(s):Marcoux D et al. Pediatric anogenital warts: A 7-year review of children referred to a tertiary-care hospital in Montreal, Canada. Pediatr Dermatol 2006 May/Jun; 23:199-207.
[Medline abstract]
