Clinical Briefs

By Louis Kuritzky, MD, Clinical Assistant Professor, University of Florida, Gainesville. Dr. Kuritzky is a consultant for GlaxoSmithKline and is on the speaker's bureau of GlaxoSmithKline, 3M, Wyeth-Ayerst, Pfizer, Novartis, Bristol-Myers Squibb, AstraZeneca, Jones Pharma, and Boehringer Ingelheim.

Penile Rehabilitation Post-Prostatectomy

After prostatectomy, many men lose erectile function. It has been recently noted that penile stimulation that actively produces cavernosal dilation may reduce the likelihood of loss of function. Simplistically, it appears that with protracted periods of not infusing the cavernosal sinusoids with freshly oxygenated blood, the lack of endothelial stimulation ultimately results in some degree of fibrosis and/or subsequent refractoriness to stimulation. Tools such as vacuum constriction devices or PDE5 inhibitors (eg, sildenafil) when employed post-prostatectomy have shown promise in reducing development of post-surgical erectile dysfunction.

A combination of treatments might further enhance likelihood of return of sexual function. Nandipati et al prospectively studied patients who underwent bilateral nerve-sparing prostatectomy. Postoperatively, patients received sildenafil 25-50 mg QD beginning at hospital discharge. At 3 weeks postoperatively, patients were instructed in the technique of penile intracorporeal injection (ICI), and advised to perform this 2-3 times weekly, stopping if spontaneous erections returned.

During mean followup of 6 months, 95% of patients were able to resume sexual activity. The active induction of penile erection with combination pharmacotherapy provides the opportunity for most men to resume sexual activity post-prostatectomy.

Nandipati K, et al. Int J Impot Res. 2006;18:446-451.

Sunburn in the United States

In 2004, there were almost 8,000 deaths from malignant melanoma. When combined with squamous cell carcinoma and basal cell carcinoma, skin cancers are the most common malignancy in the United States. UV light is a primary risk factor for induction of actinic keratosis and non-melanoma skin cancers; malignant melanoma is almost twice as common in individuals with sunburn history.

The Behavioral Risk Factor Surveillance Survey (BRFSS) is a representative sample of the adult US population who agreed to be interviewed about health issues. In 2003, subjects who provided information about sunburn (n = 248,042) formed the population from which these data are derived.

Overall, when queried about the previous 12 months history, 39% of adults reported having had at least one sunburn, with 26% indicating two or more sunburn experiences, and 24% having 3 or more sunburns in less than one year's time. There was a definite relationship between age and sunburn experience: young adults (18-24 years) reported the highest sunburn frequency. Men experienced sunburn about 30% more frequently than women. Utilization of alcohol and smoking also correlated with sunburn prevalence.

Young adults apparently do not appreciate the risks associated with sunburn. Increased educational efforts, combined with enhanced skin protection techniques, are in order to curb the burgeoning burden of skin cancer.

Brown TT, et al. J Am Acad Dermatol. 2006;55:577-583.

What is the Best Diagnostic Test for Onychomycosis?

Of all nail disorders seen in pri-mary care, onychomycosis (ONYC) is the most common. Since ONYC increases in prevalence with age, clinicians are destined to see the disorder with greater frequency. There are numerous potential ways in which the ONYC diagnosis may be confirmed, but the gold standard is generally considered to be culture. Lilly et al compared 7 different diagnostic tests using toenail tissue from 204 patients with a clinical diagnosis of ONYC. Patients were excluded if they suffered other nail dystrophies or had recently used antifungal medications (topical or systemic).

Cost-effectiveness was the primary end point. Methods compared were KOH wet mount (lab-technician interpreted), KOH wet mount (dermatologist interpreted), KOH+DMSO wet mount, KOH + Chlorazol black E wet mount, periodic acid-Schiff staining (PAS), and two different culture methods (dermatophyte test medium and Mycobiotic and Inhibitory Mold Agar).

PAS was the most sensitive test (98.8%), but the least cost effective, with a typical price for PAS histology more than $100. The KOH wet mount with Chlorazol black E was the most cost effective. The authors suggest that for persons not experienced with the KOH/Chlorazol black E microscopy, even though PAS is more expensive, it may be a reasonable choice because of its high sensitivity and the fact that it is generally considered 'operator independent.'

Lilly KK, et al. J Am Acad Dermatol. 2006;55:620-626.