Journal of the
American Academy of
692 Correspondence
uated to determine if the lesion may be caused by an
infection or any of several causes of urticaria, cellulitis,
or pyoderma. When the skin becomes necrotic by 24
to 72 hours, this clinical sign excludes numerous pos-
sibilities so that the coexistence of systemic symptoms
becomes important. In an otherwise healthy nondiabetic
and immunocompetent adult, this diagnostic decision
is usually settled within the first 72 hours. The physician
and the patient can be more comfortable about the prog-
nosis when this potentially unstable period is over and
no serious illness is present. Similarly, the suspected
brown recluse bite victim should be tested to see if a
hemolytic anemia or thrombocytopenia has developed.
If proved or suspected brown recluse bites do not be-
come clinically necrotic within 72 hours, then only
rarely is there a serious wound healing problem.
Ourfindings 6 in thirty-one patients with severe brown
recluse bites treated with either immediate surgical
excision l or dapsone 305 and delayed surgical excision,
if required, were striking. Immediate surgical excision
of brown recluse bite sites induced more complications
than using dapsone with or without delayed excision
and/or repair. 6 We saw no beneficial effect of intrale-
sional steroids in either clinical or experimental studies,
and they may be contraindicated if the diagnosis of
brown recluse bite is not well established. 6 . 9 Applying
heat to brown recluse bite sites makes lesions much
worse.? Blisters, necrosis, or ulceration were induced
when heat was applied to otherwise unremarkable
brown recluse bites. 7 Clinically, applying ice or cold
packs to bite sites markedly reduced inflammation,
slowed the evolution of lesions, and improved all other
combinations of brown recluse bite therapy used in our
studies. l06 Since secondary infections also increase lo-
calized skin temperature, we use erythromycin or ceph-
alosporins. We also empirically use aspirin. We suggest
that brown recluse spider bites have a more favorable
clinical course if (1) bites sites are treated with ice bags
and elevation, (2) strenuous exercise is avoided, (3)
localized heat and immediate surgery are avoided, and
(4) antibiotics and aspirin are given. We use cultures,
biopsies, and response to therapy to guide our further
management of these difficult clinical problems until
definitive diagnostic methods are available.
Lloyd E. King, Jr., M.D., Ph.D.,
and Riley S. Rees, M.D.
Division of Dermatology and Division of Plastic
Sur/Jery, Vanderbilt University and
Veterans Administration Medical Centers
1310 24th Ave. South, Nashville, TN 37203
Dermatology
REFERENCES
1. Rees R, Shack RB, Withers EH, et al: Management of
the brown recluse spider bite. Plast Reconstr Surg
68:768-773, 1981.
2. Rees RS, O'Leary JP, King LE Ir: The pathogenesis of
systemic loxoscelism following brown recluse spider
bites. J Surg Rcs 35:1-10,1983.
3. King LE Jr, Rees R: Dapsone treatment of a brown re-
cluse spicier bite. JAMA 250:648, 1983.
4. King LE Jr, Rees R: Management of brown rccluse spider
bite. JAMA 251:889-890, 1984.
5. Rees RS, Fields JP, King LE Ir: Do brown recluse spicier
bites induce pyoderma gangrenosum? South Med J
78:283-287, 1985.
6. Rees RS, Altenbern DP, Lynch lB, et al: Brown recluse
spicier bites: A comparison of early surgical excision
versus clapsone ancl delayed surgical excision. Ann Surg
202:659-663, 1985.
7. King LE Jr, Rces R: Brown recluse spider bites: Keep
cool. JAM A 254:2895-2896, 1985.
8. Berger RS, Millikan LE, Conway F: An in vitro test for
Loxosceles reclusa spieler bites. Toxicon 11:465-470,
1973.
9. Berger RS: The unremarkable brown recluse spider bite.
JAMA 225:1109-1111, 1973.
10. Fardon'DW, Wingo CW, Robinson DW, et al: The treat-
ment of brown spicier bite. Plast Reconstr Surg 40:482-
488, 1967.
Abnormal night vision and altered dark
adaptometry in patients treated with
isotretinoin for acne
To the Editor:
We report briefly a potentially important side effect
associated with isotretinoin therapy for acne. Among
fifty patients in an open prospective study of muscu-
loskeletal changes associated with isotretinoin (1 mg/
kg/day), three patients spontaneously complained of
decreased night vision and/or excessive glare problems,
especially while driving. In two patients this occurred
shortly after beginning a second four-month course of
the drug, while the third patient developed symptoms
10 weeks into his first course of treatment.
We evaluated these patients with electroretinograms
(ERG), electrooculograms (EOG) , dark adaptometry,
visual fields, color vision, and funduscopic examina-
tions. I ERG is a test of retinal function that sums the
flash-evoked action potential of photoreceptors and
middle and inner retinal neurons into one action poten-
tial measured at the cornea. A significant portion of
retinal function must be disturbed before there is a sig-
nificant decrease in ERGs. EOG measures the resting
Volume 14
Number 4
April, 1986
potential of the eye and is a sensitive measure of the
functional integrity of the retinal pigment epithelium
(RPE).
ERG showed subnormal dark-adapted cone-me-
diated and, to a lesser degree, dark-adapted rod-me-
diated responses in two of three patients tested. EOG
was subnormal in one of three patients tested. Dark
adaptometry revealed elevation of the cone, and in some
instances rod, thresholds in all patients tested. Visual
fields, visual acuity, and funduscopic examinations
were normal in all patients tested. Subjective improve-
ment had occurred with drug cessation in all patients
and follow-up ERG had normalized in one patient re-
tested.
Since being apprised of these findings, one of us
CR. P.) has elicited symptoms of decreased night vision
in two patients treated for acne in his private office.
One had mild elevation of both the rod and cone thresh-
olds as determined by dark adaptometry, but a normal
ERG. We have not as yet tested retinal function of the
second patient.
ABSTRACTS
Delusions of infestation treated with pimozide: A
follow-up study
Lindskov R, Baadsgaard 0: Acta Derm Venereol
(Stockh) 65:267-270, 1985
Monosymptomatic delusions of infestation in fourteen pa-
tients were followed up 19 to 48 months after treatment with
pimozide was terminated. Dosages were up to 4 mg daily,
with improvement noted in 2 to 4 weeks in all but one of the
patients. Seven patients remained completely free of symp-
toms during follow-upof 19 to 48 months after termination
of treatment. Three patients had recurrences after termination
of treatment; four patients had symptoms during follow-up
or only moderate relief with therapy.
J. Graham Smith, Jr., M.D.
Ketoconazole for hirsutism
Carvalho 0, Pignatelli D, Resende C: Lancet 2:560,
1985
A 27-year-old woman with hirsutism and polycystic ova-
ries had striking improvement of hirsutism after 200 mg of
ketoconazole twice daily for 2 months. Because of liver func-
tion abnormalities, the drug was stopped; however, improve-
ment was noted at 4 months after cessation of therapy.
J. Graham Smith, Jr.. M.D.
Correspondence 693
Isotretinoin may adversely influence cone- and pos-
sibly rod-mediated dark adaptation in a small proportion
of patients. It is not known if isotretinoin could interfere
with vitamin A function within the retina. We have
begun a study to evaluate prospectively this possible
effect on retinal function in acne patients taking iso-
tretinoin.
Susan Denman, M.D.,* Richard We leber, M.D.,**
Jon M. Hanifin, M.D., *
William Cunningham, M.D.,*** Clnd
Richard Phipps, MD. *
Departments of Dermatology* and Ophthalmology, **
The Oregon Health Sciences University,
Portland, OR, and Hoffmann-La Roche Inc., ***
Nutley, NJ
REFERENCE
1. Weleber RG, Denman ST, Cunningham WC, Hanifin JM:
Abnormal night vision, dark adaptation and electrophys-
iologic responses associated with isotretinoin therapy for
acne. Clin Res 33:158A, 1985.
Isolation of human t-lymphotropic virus type III
from the tears of a patient with the acquired
immunodeficiency syndrome
Fujikawa LS, Salahuddin 5Z, Palestine AG, et al:
Lancet 2:529-530, 1985
Human T lymphotropic virus type III has previously been
isolated from lymphocytes in the peripheral blood, bone mar-
row cells, lymph nodes, brain, saliva, semen, and cell-free
plasma. I~ this study the virus was isolated from tears of one
patient with the acquired immunodeficiency syndrome.
J. Graham Smith, Jr., M.D.
Prophylactic antibiotics in cutaneous surgery
Sebben JE: J Dermatol Surg OncoI1l:901-906, 1985
Antibiotics have no effect on the incidence of infection in
clean, uncomplicated surgical wounds. Infection rate is re-
duced when prophylaxis is used in clean-contaminated and
contaminated surgical wounds. Maximum effects are achieved
by presence of the drug in the tissue at the time of wounding.
Antibiotics should be given for 24 to 48 hours longer; how-
ever, more prolonged treatment provides no greater protection
from infection. The most satisfactory drugs are cephalosporin
and erythromycin by the oral route.
J. Graham Smith, Jr., M.D.