CLINICAL OUTCOME AND COST ANALYSIS OF ISOTRETINOIN VERSUS CONVENTIONAL REGIMENS IN THE TREATMENT OF MODERATE ACNE VULGARIS IN MALE PATIENTS

Abstract

Correspondence 329(3), we still think that our case is compatible with clear cell papulosis.The main difference between our case and the previous cases is the location of the lesions, as we have already described in our article (3). The previous cases of clear cell papulosis occurred most commonly on the lower abdomen and usually along the milk line (1,2), but our case occurred on the lumbar area and buttocks (3). However, not all of the previously described lesions occurred exactly along the milk line, and we think the location of the lesion is not a diagnostic criteria. You mentioned that in previous cases the lesions tended to increase in number gradually the first 2 to 3 years after birth, but our case increased within 1 year after birth. However, this is not a significantly different point.Histopathologically, you pointed out that in our case the nuclei of the clear cells appear to be eccentric and about same size and the same degree of basophilia as the neighboring keratinocytes, suggesting basal melanocytes. Although some clear cells had these features, the clear cells in our case usually had centrally located nuclei, as shown in Fig. 3 (electron microscopy finding) in our article (3). Furthermore, the main histologic finding of clear cell papulosis is that the clear cells in the epidermis are larger than the adjacent epidermal cells and are round or oval, with abundant clear cytoplasm, as described in previous cases (2). Our case also had these histopathologic findings. The clear cells in our case were negatively stained by PAS. We did not perform any more stains to confirn this result because the clear cells in original cases were stained variably by several mucin stains and not all clear cells were positive (2). After we received your letter we performed a PAS stain again and did several other mucin stains. Some of the clear cells were positively stained by PAS, alcian blue, and colloidal iron but were negatively stained by mucicannine. If you want to see the photos of these stains, we will be happy to send them to you.You suggested that the clear cells in our case are melanocytes or a hybrid of melanocytes and epithelial cells. We think our positive immunohistochemical stainings for AEl , CEA, and EMA, and negative stainings for S-100 and Fontana-Masson stain can exclude the possibility of melanocytes, and we doubt the existence of a hybrid of melanocytes and epithelial cells.In conclusion, we think the diagnostic findings of our case are multiple white papules clinically, and histopathologically, multiple clear cells in the epidermis which are larger than the adjacent epidermal cells and have abundant clear cytoplasm. These cells stained with the epithelial immunohistochemical markers, AE1, CEA, and EMA. REFERENCES1. Kuo T, Chan HL, Hseuh S. Clear cell papulosis of the skin: a new entity with histogenetic implications €or cutaneous Paget's disease. Am J Surg Pathol 1987;11:827-834.2. Kuo T, Huang C, Chan L, Yang L, Chen M. Clear cell papulosis: report of three cases of a newly recognized disease.

The pharmacoeconomics of acne treatment: Where are we heading?

“…Some of these studies cited that early use of oral isotretinoin versus other treatment regimens had a higher cost in the short term but had lower longterm costs, a shorter time to the goal of treatment, more effectiveness by clinical measures, decreased rates of relapse and scarring, and benefits for earlier use and use in mild to moderate acne (18)(19)(20)(21). This is in contrast to a managed care study from the United States which showed a 35% reduction in per member per month cost after restricting oral isotretinoin to patients until they were determined to be unresponsive to topical retinoids, at least two other topical medications, and two oral antibiotics (27).…”

“…However, other studies in the literature have taken a stricter dollar-cost per effect approach in attempting to evaluate cost-effectiveness. A good example of this is the US study from 1998 which compared direct cost and clinical outcome (20). This study assessed the direct costs of oral isotretinoin treatment versus the direct costs of conventional therapy and compared them with an outcome measured by complete clearing of acne (Table VI).…”

“…The latest study compared two oral antibiotics (22). Three compared oral isotretinoin with conventional therapy (topical retinoids and/or oral antibiotics), and each concluded that oral isotretinoin was more costeffective (18,20,21). One study compared the costeffectiveness of oral isotretinoin for patients with various grades of acne using quality-adjusted lifeyears as an outcome.…”

“…All of the studies varied in their methods for assessing costs and their outcome measures. Only two were from the United States (17,20). The earliest of these studies compared initial therapy with topical retinoids to initial therapy with topical retinoids plus oral antibiotics (17).…”

“…to March 2003) (17)(18)(19)(20)(21)(22). Four of the studies were a CEA, one a CUA, and one a CMA ( Table V).…”