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Indian Journal of Dermatology, Venereology and Leprology
Medknow Publications on behalf of The Indian Association of Dermatologists, Venereologists and Leprologists (IADVL)
ISSN: 0378-6323 EISSN: 0973-3922
Vol. 69, Num. 4, 2003, pp. 313
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Indian Journal of Dermatology, Venereology & Leprology, Vol. 69, No.
4, July-August, 2003, pp. 313
Letter to the Editor
Response from the author
Vijay Gandhi
A-242, Surya Nagar, Ghaziabad - 201011
Correspondence Address: A-242, Surya Nagar,
Ghaziabad - 201011
Code Number: dv03045
Sir,
I thank Dr. S. Panda for taking interest in our article and sharing the results
of his own study (yet unpublished). It is true that the report of Kano
et al,[1] who treated 3 patients with a low
dose of pentoxifylline (300 mg daily), stimulated us to carry out a trial in
a
larger patient group to assess whether an economically viable and safe
drug like pentoxifylline (Pf) would provide a therapeutic option for Schamberg's
disease (SD) which, till date, remains a condition that is easy to diagnose
but difficult to treat. Our preliminary results were gratifying. Now responding
to Dr Panda's comments and queries:
- Dr. Panda's statement that the topical steroids are the traditional therapeutic
modality in this disorder' is far from true. Topical steroids may be of some
help, particularly in itching purpura, but prolonged use may only exacerbate
the problem.[2]
-
Dr. Panda agrees that capillary stasis and gravity are contributory factors
in the pathogenesis of SD.[3],[4] So
there has been no paradigm shift as proposed by Dr. Panda after the study
of Kano et al. For astute clinicians, SD always was and remains a capillaritis
treated not by taking refuge in the panacea of topical steroids (as proposed
by
Dr. Panda). In fact, modalities like PUVA, azathioprine, griseofulvin and
cyclosporin
A have been successfully used in the recent past.
- Regarding the methodology, it is clear from the title itself that we have
conducted a preliminary therapeutic trial and not a case-control randomized
study or a dose comparison study. So the question of using a placebo group
does not arise. The purpose of conducting a pilot study is to test the
efficacy of a drug in a limited number of patients and to stimulate the interest
of
other workers in the field. Indeed this is exactly what Panda et al have
done. In fact, their own results (whatever vignettes are available from Dr.
Panda's
correspondence as his study is yet to be published and so unavailable for
detailed review) seem to echo our methodology and results and serve as an
endorsement
for the efficacy of Pf. Their treatment period is also 8 weeks but surprisingly
they have concluded that a 2 month period was deemed inadequate. Indeed
this aspect of Dr. Panda's study disappoints me. He had the luxury of a large
study
group (n = 112), which was not the case with us. So what prevented him
from conducting a proper dose ranging study with a placebo group instead
of a comparative
trial with a single dosage regimen of 1200 mg and comparing it with an
outdated modality like topical steroids. Why did he limit his treatment period
to 8
weeks instead of carrying on from where other preliminary trials (including
ours) have ended and extended the period to 6 months. Then perhaps many
of the queries he has raised would have been answered. I may further remind
Dr
Panda that till date our trial remains the largest published trial (n =
20) of Pf in SD. We will reserve our comments on his study for later when
it is
published.
- The optimum dose of Pf in SD remains open to debate. SD is a capillaritis
and not a true vasculitis. So blindly aping the conventional dose used
in vasculitides (400 mg thrice daily) may not be wise. The classic example
of D-penicillamine
is fresh in our mind where conventionally a dose of 250 mg thrice daily
was accepted in systemic sclerosis till a dose ranging study found a lower
dose
of 125 mg on alternate days to be equally effective.[5] Who
knows we may be in for another pleasant surprise in the case of Pf in SD.
Our recommendation is to conduct a dose ranging placebo controlled trial.
If Dr.
Panda et al, with the luxury of a study population of 112 patients, had
done so, they would have provided answers to all the queries that they
are raising.
REFERENCES
1. |
Kano Y, Hirayama K, Orihara M, Shiohara T. Successful treatment of Schamberg's
disease with pentoxifylline. J Am Acad Dermatol 1997;36:827-30. Back to cited text no. 1 [PUBMED] [FULLTEXT] |
2. |
Dowd PM, Champion RH. Purpura. In: Champion RH, Burton JL, Burns DA,
Breathnach SM, editors. Textbook of dermatology. 6th ed. Oxford: Blackwell;
1998. p. 2151. Back to cited text no. 2 |
3. |
Lahiri K, Malakar S, Panda S. Are Schamberg's disease and stasis dermatitis
spectral manifestations of the same disease? Ind J Dermatol 1999;44:220-1. Back to cited text no. 3 |
4. |
Shelley WB, Swaminathan R, Shelley ED. Lichen aureus: A hemosiderin
tattoo associated with perforator vein incompetence. J Am Acad Dermatol
1984;11:260. Back to cited text no. 4 [PUBMED] |
5. |
Clements PJ, Furst DE, Wong WK, et al. High-dose versus low-dose D-penicillamine
in early diffuse systemic sclerosis. Arth Rheum 1999;42:1194-203. Back to cited text no. 5 |
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