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Chapter 58: Therapeutic Approaches for Acquired Perforating Disorders

William J. Nahm; Wilce F. Gonzalez; John G. Zampella

ACQUIRED PERFORATING DISORDERS

Therapeutic Approach

Acquired perforating disorders are characterized by the transepidermal elimination of connective tissue occurring in adult patients. These patients may have associated diabetes mellitus or chronic renal failure, which is often secondary to diabetic nephropathy. There are four major categories of acquired perforating disorders grouped according to the eliminated tissue and type of epidermal disruption. There include Kyrle disease (KD), acquired perforating collagenosis (APC), acquired elastosis perforans serpiginosa (AEPS), and perforating folliculitis (PF). Since there are no placebo-controlled randomized studies evaluating the various treatment options, the currently available evidence for treatment efficacy is confined to case reports or case series. In the authors’ experience, topical or injectable corticosteroids are often sufficient first-line therapy in mild to moderate disease states with phototherapy +/− an oral retinoid reserved for refractory cases. See Table 58-1.

Table 58-1Acquired Perforating Disorder Treatment Table
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Table 58-1 Acquired Perforating Disorder Treatment Table
MEDICATION NAMEb INDICATIONa MECHANISM OF ACTION DOSING ADVERSE EFFECTS SUGGESTED MONITORING LEVEL OF EVIDENCE (REFERENCE)
Topical Therapy

Topical Corticosteroids

  • -Betamethasone

  • -Clobetasol

 ARPC Corticosteroid-antiinflammation Topically BID Skin atrophy No systemic monitoring required. Assess improvement after 2-4 wk IV1

Retinoids

  • -Tazarotene

  • -Retinoic acid

  • -Tretinoin

 APD, AEPS, ARPC, KD, PF Retinoids-Down regulation of keratins; antiproliferative Tazarotene: 0.1% gel QHS; retinoic acid: 0.025%-0.1% BID-TID Mild skin irritation No systemic monitoring required IV1
Other Topicals
Cantharidin with occlusion APD Vesicant 0.7% occluded for 8 h Blistering No systemic monitoring required. Await re-epithelialization before retreatment IV1
Imiquimod AEPS TLR7 agonist 5% cream QHS for six wk, then 3x/wk for 4 wk Redness and irritation No systemic monitoring IV2
Maxacalcitol ARPC Vitamin D analogue 0.0025% ointment BID for 2 mo None reported No systemic monitoring IV1
Tacrolimus KD Calcineurin inhibitor 0.1% ointment QD None reported No systemic monitoring required. Assess improvement after 2-4 wk IV3
Salicylic acid soap (Actine™) KD Keratolytic soap Daily washing None reported None IV4
Systemic Therapies
Oral Antibiotics
Clindamycin KD Antibiotic 300 mg TID for 1 mo Diarrhea, nausea, vomiting, C. difficile-associated diarrhea

  1. Bowel frequency

  2. In severe liver disease: LFTs every 3-6 mo

  3. Prolonged therapy: CBC, CMP yearly

 IV5
Dapsone ARPC Neutrophil inhibition 50 mg QD Hemolysis, hemoglobin decrease, methemoglobinemia, hypersensitivity syndrome, Steven Johnson’s syndrome

  1. Initiation: G6PD

  2. CBC (weekly for the 1st mo, monthly for 6 mo, and semiannually thereafter)

  3. LFTs (baseline and periodic)

 IV1
Doxycycline ARPC Antibiotic 100 mg QD Skin photosensitivity, GI discomfort CBC, renal, and LFTs yearly with prolonged therapy IV1
Metronidazole KD Antibiotic 500 mg BID CNS effects, disulfiram-like reaction, nausea, vaginitis, headache CBC with differential at baseline, during, and after prolonged or repeated courses of therapy IV6
Rifampicin APD Antibiotic 300 mg BID C. difficile-associated diarrhea, hematologic effects, hepatotoxicity, hypersensitivity reactions Baseline LFTs, serum creatinine, CBC; periodic (every 2-4 wk during therapy) monitoring of LFTs with ...

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