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' 11: N 0 m 1 Roberta M. McKay, MD Vesiculo-Bullous Disorders of the Neonate
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11:
N
0
m
1
Roberta M. McKay, MD
Vesiculo-Bullous Disorders of the Neonate
SUMMMARY
RESUME
This is the first of three artides which outline
the diagnoses to be considered when
II s'agit du premier d'une serie de trois articles ayant
pour but de decrire le diagnostic a considerer en
presence de lesions vesiculo-bulleuses identifiees
vesiculo-bullous lesions are identfified in the
neonate, children, and adults. This paper
presents a brief sketch of blistering disorders
chez les nouveau-nes, les enfants et les adultes. Cet
article presente un bref apercu des affections
which may occur
during
the firstfew weeks
vesiculaires qui peuvent se manifester au cours des
premieres annees de vie. Chez le nouveau-ne, les
of life. Vesiculo-bullous lesions in the neonate
may represent benign, infectious, genetic, or
lesions vesiculo-bulleuses peuvent s'averer des
affections benignes, infectieuses, genetiques ou
menaqantes
sur le plan du pronostic vital.
life-threatening disorders. Earlyrecognition,
L'identification precoce, les procedures
appropriate diagnosticprocedures, and
diagnostiques appropriees et des interventions
specific
therapeutic
interventions can be vital
therapeutiques specifiques peuvent jouer un role
in
reducing potential morbidity
and
mortality.
critique dans la reduction de la morbidit6 et de la
mortalit6 potentielles. L'auteur discute les lignes de
General
guidelines
fordiagnosticprocedures
and therapeuticinterventions
are
discussed,
conduite generales permettant de choisir des
procedures diagnostiques et des interventions
along
with
some of the newer etiologic and
therapeutiques, de meme que certains nouveaux
epidemiologic concepts. (Can Fam Physician
concepts etiologiques et epidemiologiques.
1987; 33:2297-2301.)
Keywords: vesiculo-bullous disorders., neonatalblisters, neonatal dermnatology
~~~~~~~~~~~~~~~~~~~~~m -
--- --
Dr. McKay, a dermatologist, is
that the neonatal immunologic system
an assistant clinical professor
in the
is anatomically intact but antigeni-
gency. First reported in the mid-
1930s, it is estimated to occur in one in
Department of Medicine,
University
3,000 to one in 15,000 live births per
of Saskatchewan, and Coordinator
of the Undergraduate Student
cally inexperienced and functionally
deficient, may result in a variety of
Intern and Resident Training
programs in Internal Medicine,
vesiculo-bullous disorders in the new-
born. This paper will review a spec-
trum of infectious and non-infectious
year. Without therapy, widely dissem-
inated disease occurs in more than
80% of cases. Of these severely af-
fected infants, 50%-80% die, and
Plains Health Centre, Regina.
diseases in the neonate which range
Reprint requests to: Dr. Roberta
M. McKay, Regina Internal
from the banal to life-threatening.
those who survive rarely escape sig-
nificant neurologic impairment. Even
localized involvement of skin, eyes
Medicine Specialists, 1821 Rose
Street, Regina, Sask. S4P 1Z7
Infectious Neonatal Blisters
and/or mucosae can lead to neuro-
logic impairment in as many as 30%
of the affected babies.'
G ENETIC ABERRATIONS, in-
Herpes simplex
Neonatal herpes simplex viral (HSV)
Cutaneous signs of HSV infection
J trauterine events, and the fact
infection constitutes a medical emer-
may be evident at birth or may de-
CAN. FAM. PHYSICIAN Vol. 33: OCTOBER 1987
2297
velop as late as 28 days post partum; dromes are notable for their bullous the
velop as late as 28 days post partum;
dromes are notable for their bullous
the average interval before the signs
develop is seven to 11 days. The vesi-
cles, as small as 1mm in diameter,
appear in clusters and evolve through
pustular and crusted stages. Conjunc-
tivitis and keratoconjunctivitis may
also be present. Only 70%-80% of
neonates develop cutaneous lesions;
the remaining 20%- 30% shed the
virus from the oropharynx or show
evidence of neural involvement.
Early diagnosis of HSV infection is
essential. Isolation of the HSV from
vesicular fluid is the hallmark of in-
fection. A Tzanck smear from the
base of the vesicle, electron micro-
scopy of vesicular fluid, and a skin
biopsy suggest the possibility of a
viral etiology. Babies without skin le-
sions who display neurologic signs re-
quire cultures of cerebrospinal fluid
and possibly a brain biopsy to estab-
lish a definitive diagnosis. A history
of genital herpes in the mother or her
lesions. Epidermolysin or exfoliatin,
an exotoxin elaborated most com-
monly by S. aureus, group II, phage
type 70/71, causes cleavage of the
epidermis in the granular layer. The
localized form (bullous impetigo) and
the generalized exfoliative state (sta-
phylococcal scalded skin syndrome)
occur more frequently in neonates be-
cause their relatively immature kid-
neys are unable to excrete the exo-
toxin efficiently.
rare. When it does occur, ccc is
usually present at birth, though it oc-
casionally appears a few days later,
with intense diffuse erythema and
vesiculopustular lesions on the trunk
and limbs. Palmar and plantar lesions
are the hallmark of the disease, while
the face and oral mucosa are rela-
tively free of lesions. Nail involve-
ment with nail dystrophy sometimes
occur. The infant is clinically well.
The duration of the eruption varies
with the intensity of the reaction.
A Gram stain of the pus or a potas-
sium hydroxide preparation of des-
quamating skin will demonstrate bud-
ding yeasts and pseudomycelia.
Routine cultures will confirm these
observations. Neonates of low birth
weight or with respiratory distress
should be observed for signs of disse-
minated disease, and if such signs are
sexual partners, a characteristically
abnormal EEG or CT scan in the infant,
Localized bullous impetigo is char-
acterized by discrete flaccid bullae
containing clear or cloudy yellow
fluid and surrounded by normal-ap-
pearing skin. Ruptured bullae show a
glistening red base which re-epi-
thelializes in five to seven days. The
lesions are often localized to the um-
bilical, axillary, or diaper areas. The
infant has no other signs of disease.
Staphylococcal scalded skin syn-
drome (ssss) begins with diffuse
blanchable erythema which, within 24
hours, acquires a scalded appearance.
observed cultures of urine, stool, and
gastric aspirates are required.
Topical therapy using standard anti-
candidal preparations (clotrimazole,
econazole, miconazole, nystatin),
usually effect resolution of the cuta-
or an increasing cerebrospinal fluid
(CSF) protein parallelling clinical de-
terioration provide other diagnostic
Large, ill-defined, flaccid, wrinkled
bullae may cover the entire skin sur-
face. Exquisite tenderness of the in-
volved areas results in irritability,
lethargy, and poor feeding, while
temperature regulation is abnormal
because of the extensive areas of
damaged and denuded skin. Light
stroking of the skin will cause separa-
tion of the upper epidermal layers
(positive Nikolsky's sign). Healing
neous infection within days. Oral
clues. The infant's eyes should also
be evaluated for corneal involvement.
nystatin may be given to eradicate
possible gastrointestinal seeding. Dis-
seminated disease requires much more
Treatment of all HSV-infected neo-
nates, even those with the most lim-
ited forms of the disease, is essential.
Both adenosine arabinoside (ARA-A,
aggressive therapy with parenteral an-
tifungal agents.
Congenital varicella
If maternal infection with varicella
VIRA-A) and acyclovir (Zovirax) have
demonstrated efficacy when adminis-
tered intravenously.
occurs within 17 days of delivery,
occurs in five to seven days.
Staphylococcal infections
about 24% of infants will develop the
disease. In infants with this disease,
teardrop or "dewdrop on a rose
petal" vesicles appear during the first
Bacterial colonization studies of
neonatal skin and mucous membranes
10 days of life and gradually evolve
into crusted lesions. These infants can
show the absence of staphylococci at
birth. Only 30% of infants had evi-
A diagnosis of bullous impetigo
may be established by preparing
Gram stain smears and culturing vesi-
cular fluid. However, Gram stain
smears and cultures of material from
skin lesions in ssss will be negative,
as the primary site of infection is
develop severe illness in which the
risk of mortality is 20%.
dence of colonization at six days of
A Tzanck smear may demonstrate
usually an extracutaneous site such as
age. Resident staphylococci are more
the nasopharynx, conjunctiva, or mid-
often acquired from nursery staff than
from the mother. Infants with nasal
the presence of multinucleated giant
cells and balloon cells, electron mi-
dle ear.
croscopy may show the viral parti-
colonization at the time of hospital
Systemic therapy with penicillin-
cles, and a culture may provide evi-
discharge are more likely to have con-
tinued nasal carriage and to develop
ase-resistant penicillins appropriate to
culture and sensitivity profiles is re-
dence for a positive identification of
the virus.
clinical infection during the first six
months of life. However, the inci-
quired. Mortality is low (2%- 3%)
and morbidity uncommon if treatment
In the absence of clinically appar-
ent disease, immediate administration
dence of colonization does not always
correlate with the incidence of clinical
infection because certain strains of the
is given.
of zoster-immune globulin to the in-
Congenital cutaneous candidiasis
fant is recommended if maternal in-
fection was present for five days be-
bacteria are
more
virulent than
As a result of improved nutrition
and medical care, oral candidiasis in
fore, to two days after, delivery.
others.2
As in herpes simplex viral infec-
The clinical manifestations of Sta-
neonates is less commonly encoun-
tered today,3 and congenital cuta-
neous candidiasis (ccc) is distinctly
tions, efficacy of acyclovir and vi-
phylococcus aureus infection are mul-
tiple. The staphylococcal toxin syn-
darabine have been demonstrated, but
the lower toxicity and ease of admin-
CAN. FAM. PHYSICIAN Vol. 33: OCTOBER 1987
2298
istration of acyclovir make it the drug atum, or a suspension of benzyl ben- weeks
istration of acyclovir make it the drug
atum, or a suspension of benzyl ben-
weeks of life, and individual lesions
of choice. The recommended dose is
zoate in a 12.5%-25% concentration.
500mg./m2 each eight hours for seven
Since Eurax has no reported systemic
days.4 To be effective, therapy must
be instituted early.
effects, it is safe for infants. How-
ever, it has the disadvantage of being
Congenital syphillis
Fortunately, congenital syphillis is
irritating on raw or denuded skin.
Thus it should be used with caution
on acutely inflamed skin. It is prefera-
ble to delay treatment of the scabies
now rare in North America. A com-
plete discussion of this is not possible
until the eczematous
reaction is
may last a few hours to 16 days. Palms
and soles are spared.
Diagnostic procedures include a
Wright's or Giemsa's stain of lesional
contents and histologic examination of
a biopsy specimen. In both cases, if
the disease is present, eosinophils are
seen in abundant numbers. Micro-
scopic examination of the biopsy will
here, other than to indicate that bul-
lous lesions may occur especially on
the palms and soles. Their occurrence
is infrequent, but if present, they are
considered diagnostic. Other features
brought under control with topical
steroids and, if necessary, antibiotics.
show clustering of eosinophils around
the pilosebaceous unit. Peripheral
Two applications of Eurax in 48 hours
is recommended, and bathing should
be delayed for three days post ther-
apy.
Gamma benzene hexachloride
(Kwellada) is recommended therapy
for all household occupants and close
contacts of a patient with scabies. It
blood shows eosinophilia in 7%-15%
of the disease, such as "'snuffles",
mucous patches, maculopapular erup-
tions, as well as visceral and osseous
signs, are more likely to occur and to
alert one to the diagnosis than are the
bullous lesions.
should be applied to all these persons
on the same night. A second applica-
Scabies
tion may be done one week later, but
Sarcoptes scabiei infestations in in-
fants have an altered distribution com-
pared with that in older children and
adults. This distribution includes the
neck, face, head, palms, and soles.
Bullous lesions are uncommon, but
repeated treatments must be dis-
couraged, as this will lead to irritant
and hypersensitivity reactions. The
of cases.5 Eosinophilia in adults is as-
sociated with hypersensitivity reac-
tions, but in neonates it appears to ac-
company a variety of inflammatory
responses. Perhaps this disorder repre-
sents a transient and normal response
to mechanical and thermal stimuli.
Treatment is not required, but the
physician should always rule out the
other disorders listed in this article,
especially if they represent a threat of
contagion, systemic dissemination, or
mortality.
primary reason for overuse is that pa-
vesicles are frequently present, owing
tients are not informed thatthe pruritus
may continue until all remnants of the
mite are eliminated from the stratum
to the predisposition for blister forma-
tion found in this age group. Secon-
corneum. The hypersensitivity con-
tinues, but the infectivity is eliminated
within 24 hours after proper treatment.
dary complications are common as a
Transient neonatalpustular melanosis
Although the name of this disorder
appears restrictive because it includes
the word 'pustular', it must be recog-
nized that skin lesions can change very
rapidly. Vesicles become pustules to
Reported instances of toxicity and con-
result of scratching and rubbing, over-
the naked eye when enough acute in-
vulsions in infants are most probably a
zealous attempts at hygiene, and ap-
flammatory cells accumulate at a su-
result of such over-treatment. If the
plication of numerous topical thera-
perficial epidermal level. If the degree
peutic agents. In infants, especially
those predisposed to atopic disease,
treatment modalities mentioned above
do not result in a cure, the infant may
the complications may be
widespread
require one 12-hour application of
Kwellada.
and severe.
Secondary pustulation, bullous im-
petigo, and severe crusting may be
Non-Infectious
present. Cultures should be obtained,
of edema is great in contrast to the vol-
ume of cells, a lesion is more likely to
be perceived as a vesicle. Thus pap-
ules may become vesicles which, in
turn, may become pustules. The nearer
the damage is to the surface, the more
likely the lesion is to appear vesicular
Neonatal Blisters
as scabetic lesions seem to be particu-
larly favourable to the growth of viru-
lent M-strains of nephretogenic strep-
tococci.
or pustular.
Erythema toxicum neonatorum
This disorder, which is more com-
Erythema toxicum neonatorum is a mon in Blacks (4.4%) than Caucasians
characteristic, asymptomatic, benign,
self-limiting, cutaneous eruption that
occurs in approximately 50% of neo-
(0.2%), is characterized by vesiculo-
Corticosteroid administration, topi-
pustules which rupture easily and then
cal or systemic, can mask the diag-
nosis of scabies by
causing a diminu-
resolve leaving hyperpigmented ma-
cules, often with a collarette of fine
tion of the signs
and symptoms. This
often results in unusual clinical pre-
sentations and atypical
distributions
nates. The eruption, which is of un-
known etiology, seems to have a lower
rate of incidence in premature infants
than in full-term infants. It appears
most frequently in the first three to
white scales. Most commonly, lesions
are found under the chin, on the fore-
head, nape of neck, lower back and
which in some cases
closely simulate
shins, but other areas may be in-
a variety of other conditions. Referred
to as "'scabies incognito", this situa-
tion is notable because the transmissi-
bility of the infestation persists. In
four days of life, but does occur from
birth to the tenth day of life.
Blotchy erythema, extending from a
any pruritic patient, the diagnosis of
few millimeters to several centimeters,
heralds the onset of this disease; then
volved.
The lesions are sterile; with
Wright's stain, they demonstrate vari-
able neutrophils and cellular debris but
few or no eosinophils, in contrast to
scabies should
always
be considered.
1mm- 3mm papulo-vesicular or pa-
erythema toxicum neonatorum. A
Recommended
treatment in neo-
pulo-pustular lesions develop within
biopsy is useful to obtain additional
nates consists of 10% crotamiton
these areas. Exacerbation and remis-
supportive data.
(Eurax), 6%- 10% sulfur in petrol-
sions may occur during the first two
This benign disorder has no syste-
2299
CAN. FAM. PHYSICIAN Vol. 33: OCTOBER 1987
mic manifestations and requires no treatment, but it is always important the first inherited skin
mic manifestations and requires no
treatment, but it is always important
the first inherited skin disorder to be
to rule out the infectious and life-
threatening disorders before deciding
that therapy need not be instituted.
diagnosed by fetoscopy.7 It is an auto-
somal dominant disorder, but it has a
high rate of spontaneous mutation. If
neither parent of an affected infant has
the disorder, the subsequent offspring
are not at increased risk for the dis-
Miliaria
There are two commonly recog-
nized forms of this sweat-retention dis-
order: miliaria crystallina and miliaria
rubra. The pathogenetic pathway in-
volves the maceration and occlusion of
eccrine sweat ducts, arising from heat,
occlusion, perspiration, and possibly
bacterial toxins. In neonates, imma-
turity of sweat ducts may also be a fac-
tor.6 The blocked ducts rupture, and
sweat escapes into the tissues below
the level of obstruction. If the obstruc-
order. As this form of ichthyosis is one
of the most disfiguring of the hyper-
keratotic disorders, it is important for
not occur in the newborn period. Onset
of the vesiculo-bullous stage is at birth
or within six weeks, and the disorder
may be intermittent or persistent for
months. Erythema with vesicles in lin-
ear or swirling arrangements occurs
mainly on extremities but occasionally
on the trunk and head. Leucocytosis to
50,000 per mm2 and blood eosinophil-
the physician to recognize the signs
and to give the infant's parents appro-
priate counselling.
At birth, the appearance of the dis-
ia of 50% may be present, but in spite
of this, the infant appears well.7 A
smear of vesicular fluid will also show
many eosinophils.
order may be striking, with large
erythematous denuded areas not unlike
those seen with epidermolysis bullosa.
With time, the hyperkeratosis devel-
ops on planes transverse to the longitu-
The verrucous phase occurs in two-
thirds of affected infants, and may re-
semble a linear epidermal nevus. The
final pigmentary stage occurs in over
98% of affected infants; it begins as
the first two stages are resolving. It
may even be present at birth if the pre-
tion is within the superficial layers of
skin, the sweat accumulates and forms
dinal axes of the extremities. The thick
ridges of grayish-brown scales are
more pronounced in the anticubital and
a blister, the response typical of mi-
liaria crystallina. A deeper level of ob-
struction results in the inflammatory
response seen in miliaria rubra.
Infants suffering from miliaria crys-
tallina present with crops of 1mm
- 2mm vesicles on otherwise normal-
popliteal fossa. Bulla which are easily
denuded are common in childhood and
continue to appear in 20% of adults.
vious stages occur in utero.
Extracutaneous involvement may
result in hair, nail, tooth and ocular ab-
normalities in 50% of affected per-
One of the socially handicapping
sons. One-third have central nervous
system signs and symptoms such as
aspects of this disorder is the distinc-
tive and unpleasant odour related to
bacterial decomposition within the
thick, compact, keratinaceous scales.
convulsive disorders, mental retarda-
tion, and motor deficits.8
appearing skin. These asymptomatic
lesions occur most frequently in inter-
triginous areas.
Miliaria rubra or "prickly heat"
occurs in areas where friction from
Characteristically, these scales are
tightly adherent, and removal creates
large eroded areas. In addition, hyper-
clothing is an additional etiologic fac-
keratosis of the palms and soles may
be present, but the central face is
Curious cutaneous pigmentation or
vesicular lesions in a "marble cake"
pattern provide visible clues to this
disorder. It is believed that the number
of cases is under-reported as a result of
poor recognition or misdiagnosis.
Unfortunately, there is no cure for
tor. The papules, vesicles, or papulo-
usually spared.
vesicles are surrounded by erythema
and are pruritic. Magnified examina-
tion will show that none of the lesions
are associated with hairfollicles, a fea-
Since the introduction of the syste-
mic retinoids, particularly etretinate
(Tegison), treatment has been benefi-
cial in some cases. The drug, how-
ture which differentiates this condition
from folliculitis.
ever, is not without side-effects, and
long-term therapeutic complications
Management requires avoidance of
may develop. Antibiotics may be re-
this disorder, but systemic retinoids
(Tegison, Accutane) may be useful in
reducing the verrucous lesions. Paren-
talcounselling about potential extracu-
taneous manifestations in the affected
infant is essential. Most important,
however, is the fact that early recogni-
tion will allow for genetic counselling
excessive heat and humidity.
quired to control or diminish the
odour.
so that future pregnancies may be
avoided if the parents so desire. At the
Sucking blisters
Sucking blisters are said to occur in
one of every 240 deliveries. A bulla or
erosion varying from 0.5cm to 2cm in
diameter may be present on the dor-
sum of digits, hands, wrists or
forearms. No management is required
present time prenatal diagnosis by fe-
Incontinentiapigmenti
toscopy or amniocentesis is not pos-
sible.
As 97% of the 600 reported cases of
incontinentia pigmenti occur in fe-
beyond observing that there are no
progression of the lesion and no new
areas of involvement, which
might
suggest the more serious diagnosis
of
Epidermolysis Bullosa.
Bullous congenital ichthyosiform
erythroderma
males, incontinentia pigmenti is as-
sumed to be an X-linked disorder. Af-
fected mothers also have an increased
spontaneous abortion rate, which is as-
sumed to mean lethality in hemizygous
males. The pattern of the skin lesions
is also thought to lend support to the
X-linked theory, as random lyoniza-
tion of X chromosomes in neural crest
cells would produce the characteristic
swirled lesions.
This neurocutaneous disease has
Epidermolysis bullosa
Although this disorder may appear
and be diagnosed in the neonatal
period, it will be discussed in the sec-
ond article of this series, Vesiculo-
bullous Disorders of Childhood.
Conclusions
When vesiculo-bullous lesions are
present in the neonate, the essential
diagnostic protocol should include: a
This disorder, which is also termed
three phases: vesicular, verrucous, and
detailed maternal and
family history,
a
'epidermolytic hyperkeratosis', was
pigmentary. The latter two phases do
Tzanck smear, a Wright's
or Giemsa
2300
CAN. FAM. PHYSICIAN Vol. 33: OCTOBER 1987
SAlUpentsIlLBRONCHODILAMR stain, viral and bacterial cultures, and a biopsy. The discussions and descrip- tions in
SAlUpentsIlLBRONCHODILAMR
stain, viral and bacterial cultures, and
a biopsy. The discussions and descrip-
tions in this article are far from ex-
Syrup
THERAPY
THArSEASY
haustive, but I hope that some of the
details covered will help the readers to
determine quickly the nature of blisters
in neonates.
orciprenaline sulphate
PRESCRIBING INFORMATION
TO SWALLOW
Indications
References
Increased
airways resistance on the basis of
Alupent has been found useful in the
bronchospasm
alone is reversed
promptly by
following
conditions Bronchial asthma,
bronchodilators,
and if this does not occur, a
1. Whitby RJ, Barnes DW. Herpes simplex
virus infection. In: Kass EH, Platt R, eds.
Chronic bronchitis, pulmonary emphysema
more serious
Alupent is also useful in
sarcoidosis, silicosis,
Admission to
condition should be suspected
hospital for intensive support of
Current therapy
in infectious diseases.
carcinoma of the
lung
and tuberculosis when
the cardiovascular and respiratory systems
Toronto:
B.C. Decker Company, 1986;
may be necessary.
pp. 376-81.
bronchospasm contributes to the disability.
When used regularly, Alupent offers effective
management of chronic bronchospasm with
Contraindicatlons
reduction
in
frequency and severity of acute
Known
sensitivity to
the drug
or other
2. Herbert AA, Esterley NB. Bacterial and
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attacks.
sympathomimetic amines.
The use of
Alupent
and
other beta stimulators is generally
considered to be contra-indicated
in
patients
As ith all
drugs,
the ideal dosage of Alupent
with cardiac
arrhythmias
associated with
phia:
W.B. Saunders Company. Vol. 4,
varies from patient to patient The following
tachycardia Beta blocking
agents,
e.g.
recommended dosages represent
No.
1, January, 1986; pp. 3-21.
general
propranolol,
effectively
antagonize the
action
guidelines which will be found suitable for the
majority of patients.
Tablets 20
of
Alupent
Their
concomitant
use,
except
in
3. Allen HB, Rippon JW. Superficial and
deep mycoses. In: Moschella SL, Hurley
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Ages 4-12, 10 mg (1/2 tablet)
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HJ, eds. Dermatology. 2nd ed. Philadel-
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above 12, 20 mg (1 tablet) ti.d. - qi.d
Availability
Syrup 10
mg/5
ml
Alupent 20
mg
tablets are available as
round,
p.
230.
Ages 4-12, 10 mg (one teaspoonful) ti.d
above 12, 20 mg (two teaspoonsfu) ti.d. -
white,
single
scored compressed
tablets,
printed
on
one side with the
Boehringer
Ingelheim symbol. Supplied in
bottles of
100
4.
Savoia M, Oxman MN. Guidelines for
qi.d.
antiviral
therapy.
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Metered Aerosol
One to two inhalations will
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Alupent
Syrup
is clear,
sugar-free
and
eds. Current therapy in infectious diseases.
Toronto: B.C. Decker Co., 1986;
control of an acute attack of
bronchospasm
woodruff
flavoured. 5
ml
contains 10
mg of
for
periods
of 5 hours or
longer.
As a
general
active ml. ingredient Supplied in bottles of 250
p.
2330.
rule, patients should not exceed a total of 12
inhalations per day.
Alupent
Metered Aerosol is
supplied as a 15
ml metal vial (with
free disposable
5.
Hurwitz S. Clinical pediatric dermatol-
Solution
5%
Hand nebulizer. 5 to 15 inhalations of 5%
mouthpiece) containing 300 individual doses.
ogy. Philadelphia: W.B. Saunders Com-
solution
by
hand nebulizer DeVilbiss No. 40
Each
depression
of the
valve releases 0.75
pany, 1987; pp. 11-2.
or 42 administered
up
to three times
daily.
mg
of active
ingredient as a micronized
Intermittent positive pressure breathing: 1/2-
powder.
6. Fitzpatrick TB, et al. eds. Dermatology
1
ml of 5% solution
diluted
if
desired
and
Alupent
Solution
5% is supplied in bottles
containing
10 mL
in
general
medicine. 3rd ed. New York:
administered over a period of about 20
Forfurther information consult the
minutes.
Alupent
McGraw-Hill Book Co., 1987; p. 2625.
Product
Monograph
or
your Boehrnger
Ingelheim
7. Golbus MS. Prenatal
of bul-
Side Effects
In the recommended
representative.
diagnosis
dosage,
adverse
lous congenital
ichthyosiform
erythro-
Engl
reactions to Alupent are infrequent Mild
tachycardia, nausea, vomiting, palpitafions,
derma
by
fetal skin
biopsy.
New
J
minimal
hypertension, nervousness,
bad
Med 1980; 302:93- 5.
taste and tremor have been reported
8. Kegel
MF. Dominant disorders with
Precautions
multiple organ
involvement. In: Hurwitz S,
In acute
tests,
Alupent has shown minimal
effect on blood
pressure
and pulse. The drug
ed.
Dermatology clinics. Philadelphia:
should be used
with
care, however,
in
W.B. Saunders Co., Vol 5, No. 1,
pp. 205-219.
1987;
asthmatic or
emphysematous patients
who
also have
systemic hypertension, coronary
arterydisease,
acute and
recurring
congestive heart
failure,
diabetes
mellitus,
glaucoma or
must also be
hyperthyroidism.
Extreme care
exercised
in
the concomitant
use of
Alupent with epinephrine or MAO
inhibitors
Wamings
Alupent
should not be administered to
pregnant women or to women of childbearing
potential unless,
in the
opinion
of the
physician, the expected benefits outweigh
the
possible
risk to the foetus. Occasional
patients
have been
reported
to have
developed
severe
paradoxical airways
resistance with
repeated
excessive use of
sympathomimetic
inhalation
preparations
The cause
of this
refractory
state
is unknown.
It is advisable that
in
such instances the use
of the
preparation
be discontinued
immediately
and
altemative
therapy
instituted,
since in the
reported
cases the
patients
did not
respond
to other forms of
therapy
until the
drug
was withdrawn.
Fatalities have been
reported following
,n Boehringer
excessive use of
isoproterenol
inhalation
Ingelheim
preparations
and the exact cause is
unknown.
Cardiac arrest was noted in several
instances.
Patients should be advised to seek medical
aid in the event that
they
do not
respond
to
Boehringer
Ingelheim
(Canada)
Ltd./LtUe
their usual dose of a
aerosol. The failure to
sympathomimetic
amine
977 Century
Drive,
Burlington,
Ontario L7L 5J8
respond may
be due to
retention of viscid bronchial
secretions,
associated with an
allergic
or infective
Respiratory/G.I.
exacerbation of the patient's condition.
B-103/87
2301
CAN. FAM. PHYSICIAN Vol. 33: OCTOBER 1987