Showing papers in "British Journal of Dermatology in 1978"

Psoriasis and occlusive vascular disease

Abstract: To test the hypothesis that psoriasis is associated with an increased incidence of occlusive vascular disease (thrombophlebitis, myocardial infarction, pulmonary embolization, and cerebrovascular accident), the clinical records of 323 psoriatic and 325 non-psoriatic patients admitted to the dermatology service of the Roger Williams General Hospital were examined. The data obtained in this study suggest that (1) the occurrence rate of occlusive vascular disease is significantly greater in the psoriatic than in the non-psoriatic dermatological patient. This is particularly true in the male population; (2) psoriasis predisposes to occlusive vascular disease; and (3) the psoriatic patient with certain predisposing factors is at greater risk of experiencing an occlusive vascular episode than both the non-predisposed psoriatic and the non-psoriatic dermatological patient.

Oral psoralen photochemotherapy of atopic eczema.

Abstract: SUMMARY Oral administration of 8-methoxypsoralen followed by exposure to a high-intensity longwave ultraviolet treatment system resulted in clearing of atopic eczema in 15 patients. Paired-comparison studies demonstrated that this treatment was superior both to conventional ultraviolet light therapy and to no treatment. Short-term observation suggests that regular therapy is necessary to maintain remission of the disease.

Low nickel diet in the treatment of patients with chronic nickel dermatitis.

Abstract: Of 28 patients with chronic nickel dermatitis 17 experienced aggravation following oral ingestion of 2.5 mg nickel, but not a placebo tablet. The dermatitis of 9 of the 17 patients improved during a period of 6 weeks on a low nickel diet. The dermatitis of 7 of the 9 patients flared again when a normal diet was resumed. Nickel excretion over a 24-h period was measured for 14 of the 17 patients by atomic absorption spectrophotometry before, during, and after the diet. Reduced excretion was seen during the diet with no statistically significant difference between patients whose dermatitis improved during the diet and those whose dermatitis showed no change.

The effect of skin disease on self image

Abstract: Fifty patients were investigated psychiatrically over several years, and 26 of these were also seen independently by a clinical psychologist. The psychological investigations suggest a personality structure characterized by inward looking self-centred attitudes. The patients' interests are generally limited and constricted. Warm-hearted outgoing personalities enjoying well-established satisfactory relationships with others are rare. Psychiatric investigations suggest a background of emotional disturbances which, during the formative years, are often due to adverse home circumstances, illness, bereavement or sibling rivalry. In later years matrimonial and work problems play a similar role. The results are often feelings of isolation and insecurity. The onset of dermatitis artefacta is very often related to definable precipitating events varying from school problems to sexual, matrimonial, or work difficulties and ill health according to age and circumstances. The skin lesions, visible in part at least, can be understood as an attempt at nonverbal communication by persons who find it difficult to say what they feel. Therapeutic approaches and prognosis will be discussed in some detail.

Chilblain lupus erythematosus (Hutchinson). A clinical and laboratory study of 17 patients.

Abstract: SUMMARY Chilblain lupus erythematosus (LE) is a chronic unremitting form of LE seen predominantly in women. It occurs commonly on the digits, calves and heels. Nasal lesions are rare. Chronic facial discoid LE usually appears before the chilblain form but, in most instances, resolves even though the chilblain lesions persist. Transformation to systemic LE occurs more often in those who develop both forms of cutaneous LE simultaneously and in the erythema multiforme syndrome. The chilblain lesions are the result of microvascular injury secondary to exposure to cold and possibly hyperviscosity from immunological abnormalities. Elevated serum gammaglobulins, positive latex factor and speckled pattern antinuclear factor are common. None of the usual treatments for cutaneous LE is effective for the chilblain lesions, probably because none is directed towards prevention and treatment of the microvascular stasis.

Pemphigoid and pemphigus antigens in cultured epidermal cells

Abstract: SUMMARY Fractions of IgG from sera of patients with pemphigoid and pemphigus added to monolayer cultures of mouse epidermal cells resulted in a sparse distribution of cells. Direct immunofluorescence studies of these monolayers revealed epidermal cell surface antigens reacting with pemphigoid and pemphigus antibodies. We suggest that these antibodies may bind to epidermal cell surface antigenic molecules which are important in maintaining epidermal cell adhesion in culture. Pemphigoid and pemphigus are diseases in which epidermal cell adhesion is abnormal (cell-to-cell in pemphigus and cell-to-basement membrane in pemphigoid). This defective adhesion process is associated with an auto-immune antigen/antibody reaction occurring on surfaces of epidermal cells, i.e. basal cells in pemphigoid, differentiating keratinocytes in pemphigus. We are studying the in vitro effects of pemphigoid, pemphigus and normal IgG fractions on mouse epidermal cells grown in culture to determine whether the epidermal cell adhesion defect and the autoimmune reaction are pathogenetically related. The present investigation was undertaken, flrst to determine the presence of pemphigus and pemphigoid antigens on mouse epidermal cells grown in culture, and second to detect changes in monolayer morphology that may occur as a result ofthe antigen/antibody reaction.

PUVA-treatment of urticaria pigmentosa.

Abstract: Treatment of urticaria pigmentosa (UP) has been unsatisfactory. The patients' complaints of itching, swelling and increased skin sensitivity are well known and distressing and are unrelieved by local or systemic remedies. We have treated io patients suffering from UP with oral 8-methoxypsoralen (8-MOP) followed by long wave ultraviolet irradiation (UVA). The treatment schedule currently used for the treatment of psoriasis was adopted (Wolff ef al., 1975). All patients showed typical generalized cutaneous involvement of late onset (except patient 10). None of them were of the telangiectasia macularis eruptiva perstans type. All diagnoses were confirmed by biopsy (except patient 10). The patients received 05-0-8 mg/kg 8-MOP 2 h prior to UVA irradiation (Waldmann PUVA 4000). PUVA was given 4 times a week until no wealing could be produced by mechanical irradiation of the skin (Darier's sign). The data relevant to treatment are summarized in Table i. Treatment with PUVA resulted in generalized tanning and loss of Darier's sign. While the hyperpigmented macules overlying the mast cell infiltrates showed some persistence, wealing and dermographism following physical trauma could no longer be provoked. The padents unanimously noted rehef from itching and physical distress.

Psychiatric aspects of dermatitis artefacta

Abstract: Fifty patients with dermatitis artefacta were investigated psychiatrically over several years and twenty-sic of these were seen independently by a clinical psychologist. The psychological investigations suggest a personality structure characterized by inward-looking self-centered attitudes leading to increasing isolation. The psychiatric investigations suggest a background of emotional disturbances during the formative years and in later life often resulting in feelings of isolation and insecutity. The onset of dermatitis artefacta is very frequently related to definable precipitating events which vary according to age and life situations. The visible skin lesions can be understood as an attempt at non-verbal communication subserving an appeal function. Therapeutic methods and prognosis are discussed in some detail.

A new syndrome with pigmentation, scleroderma, gynaecomastia, Raynaud's phenomenon and peripheral neuropathy.

Abstract: A middle-aged man developed impotence, gynaecomastia, peripheral neuropathy, pigmentation lymphadenopathy, scleroderma, malabsorption and Raynaud's phenomenon following prolonged exposure to trichlorethylene. Somes, but not all, of these features have previously been reported in vinyl chloride disease, and trichlorethylene is related chemically to vinyl chloride. Seven patients with a similar but not identical syndrome have been described in Japan and U.S.A., apparently unrelated to exposure to industrial toxins.

Induction of UV light tolerance by PUVA in patients with polymorphous light eruption.

Abstract: SUMMARY A tan induced by 8-methoxypsoralen-long wave ultraviolet light has proved an effective photo- protective sunscreen in 5 patients with long wave ultraviolet light-induced polymorphic light eruption.

Circulating Sézary cells in hospitalized dermatology patients

Abstract: Sezary cells in the circulation were counted daily in 14 hospitalized dermatology patients: six with contact dermatitis, five with atopic dermatitis, and three with exfoliative psoriasis. All had circulating Sezary cells, but absolute counts of Sezary cells of more than 1000/mm3 appeared to correlate with a severe refractory course in two patients. It is probable that low, intermittent levels of circulating Sezary cells accompany many inflammatory dermatoses, and it is reasonable that monitoring this cell population may aid in anticipating more consequential skin disease.

Tests to establish the diagnosis in cholinergic urticaria.

Abstract: Methods for establishing the diagnosis in cholinergic urticaria are reviewed and compared. Provocation by exercise or hot bath is more effective than local provocation by intradermal tests. Of the intradermal tests, responses to nicotine acid tartrate and acetyl beta methylcholine chloride are positive only in patients with the more severe, readily induced eruptions. Furthermore, intradermal testing is not always reproducible in the same patient. In our patients, exercise proved the simplest, most effective diagnostic test.

Controlled study of PUVA and adjunctive topical therapy in the management of psoriasis.

Abstract: SUMMARY In a random study of 116 patients with psoriasis vulgaris, oral psoralen photochemotherapy (PUVA) used alone was compared to PUVA plus adjunctive topical therapy with tar, dithranol, or topical corticosteroids. PUVA plus topical corticosteroids produced more rapid clearing of psoriasis but despite maintenance therapy, the frequency of recurrences of the disease during the early phase of follow-up was significantly higher with that treatment, as compared to all other treatments. Dithranol plus PUVA also cleared psoriasis quicker than PUVA alone but patient acceptability for that regimen was low. The addition of tar to PUVA therapy appeared to have little influence on results.

Trioxsalen bath plus UVA effective and safe in the treatment of psoriasis

Abstract: SUMMARY Seventy-four patients with psoriasis were treated using a trioxsalen bath (50 mg/150 1 of water) and long wave ultraviolet light (UVA) given in an ordinary PUVA-cabin. Good or excellent results were observed in 92% of the patients in the initial phase and in 63% during the maintenance treatment. Because of local side-effects the therapy was discontinued in two patients. One of them developed contact hypersensitivity to trioxsalen and the other developed blisters with such low doses of UVA that it was difficult to maintain the proper dose. The therapy was started with 0-28 J/cm2 of UVA and after an average of 18 treatments, when the average dose was 1.70 J/cm2, the patients were moved to maintenance treatment which took place at 1-4 week intervals. The therapy was well tolerated and cosmetically very acceptable. The final tan was even on all but the face, which remained untanned.

Verrucous lesion in patients with discoid lupus erythematosus. Clinical, histopathological and immunofluorescence studies.

Abstract: Seven cases of classical discoid lupus erythematosus of the face associated with hyperkeratotic, papulo-nodular lesions on the arms and hands were studied. Clinically the hyperkeratotic lesions resembled keratoacanthomas or hypertrophic lichen planus. The clinical course was marked by chronicity, an absence regression of the lesions, and resistance to treatment. Histopathologically, a lichenoid cellular reaction seemed to play a key role in the development of the hypertrophic lesions which resembled either keratoacanthomoas or hypertrophic lichen planus. Elastic fibres were prominent in the upper dermis, the lower levels of the epidermis and in the hyperkeratotic horny layer. Immunofluorescence of the papulo-nodular lesions demonstrated the deposition of IgG and IgM in a globular pattern at the dermal-epidermal junction. Discontinuous deposition of these antibodies was also seen at the basement membrane zone. On the basis of the immunofluorescence, histopathological and clinical studies, we suggest that the verrucous, hyperkeratotic lesions on the upper extremities represent an unusual, but distinct, form of discoid lupus erythematosus.

Oral photochemotherapy in the treatment of lichen planus (LP). Clinical results, histological and ultrastructural observations.

Abstract: SUMMARY Seven patients with diffuse lichen planus were treated with oral photochemotherapy. Remission was effected in 6 cases. The only failure may be attributable to a low UVA dose. Histological examination after treatment showed disappearance of the superficial dermal lymphocytic infiltrate. Ultrastructural study revealed nuclear alterations of keratinocytes and nuclear and cytoplasmic changes in superficial dermal cells. Various theories concerning the mode of action of photochemotherapy in lichen planus are discussed in the light of these observations.

Enhancement of comedogenic substances by ultraviolet radiation

Abstract: Ultraviolet radiation enhanced the capacity of human sebum, sulphur, cocoa butter, squalene, and coal tar to produce comedones in the external ear canals of rabbits. An enhancement of the comedogenicity of coal tar and squalene was similarly demonstrated in man. We conjecture that in occasional patients sunbathing may aggravate acne by augmenting the comedogenicity of sebum.

Cimetidine in chronic idiopathic urticaria: a randomized double-blind study

Abstract: Ash & Schild (1966) demonstrated the existence of two subclasses of histamine receptors subsequently termed Hi and H2 (Black et al, 1972). Recently studies of the responses of human skin blood vessels to the synthetic Hi agonist 2-methyl histamine and the H2 agonist 4-methyl histamine led Robertson & Greaves (1978) to conclude that these vessels possessed both classes of receptor. Further support for this view arose from studies of the inhibitory action of the selective H2 receptor antagonist cimetidine (Brimblecombe et al., 1975). Cimetidine caused suppression of erythema and wealing due to three doses of histamine. In combination with the Hi antagonist chlorpheniramine, cimetidine caused a significantly greater inhibition of histamine erythema than either drug alone (Marks & Greaves, 1977). These findings raise the possibility that combination therapy using cimetidine and chlorpheniramine might have advantages over conventional (Hi) antihistamine treatment in skin disorders involving histamine release. Patients with chronic idiopathic urticaria are usually treated with conventional Hi antihistamines, but the response is good in no more than about 1/3 of patients (Champion et al, 1969). Furthermore, the use of higher doses of antihistamines is limited by troublesome atropine and hyoscine-like sideeffects. We have therefore explored the possibility that combination therapy with a conventional Hi antihistamine (chlorpheniramine) and the specific H2 antihistamine cimetidine might be more effective than chlorpheniramine alone in the treatment of chronic urticaria.

Plasma exchange in the treatment of pemphigus vulgaris.

Abstract: The technique of plasma exchange has been applied to a number of immune disorders in which circulating antibodies are present (Lockwood et al., 1976; Pinching et al., 1976). The serum of patients with pemphigus vulgaris contains an antibody (usually IgG) directed against an antigen in the epidermal intercellular spaces. There is some evidence that the titre of this antibody correlates with disease activity (Sams & Jordon, 1971), It seemed that plasma exchange, with removal of the circulating antibody, might be a useful adjunct to conventional treatment. The patient, a 49-year-old man, presented in December 1975. The clinical diagnosis of pemphigus vulgaris was confirmed by histological and immunohistological examination of a skin biopsy. The disease was controlled with systemic prednisolone, but in the subsequent 18-month period it proved impossible to reduce the daily dose below 15 mg without precipitating a relapse. The development of serious steroid side eflFects appeared inevitable. There were no contra-indications to plasmapheresis and informed consent to the procedure was obtained. Three plasma exchanges were carried out during a 2-week period using a Haemonetics Model 30 cell separator (Haemonetics Corporation, Natick, Boston, U,S,A,), Volumes ranging from 3-3 to 3-6 litres were exchanged for fresh frozen plasma. Forearm veins were used for vascular access. On the whole the procedure was well tolerated. Pemphigus antibodies were present in a titre of 1/45 prior to plasma exchange. Thereafter they remained undetectable during the 3-week study period. The presence of inter-epidermal cell antibodies was confirmed by skin biopsy before exchange in lesions and uninvolved skin. Biopsy of uninvolved skin after the exchanges did not demonstrate antibodies but this fact must be cautiously interpreted since the distribution of these antibodies in unaflFected skin may well be patchy. Unfortunately, there was no demonstrable clinical benefit from the procedure. New blisters formed throughout the period of treatment. Plasma exchange was terminated because of difficulties with vascular access. Despite our lack of success we propose to re-evaluate this form of treatment in other suitable patients. If applied to new cases with high titres of circulating antibodies, control of the disease might be obtainable with less than the present formidable doses of corticosteroids, '1 Recently, plasma exchange has proved of use in the management of herpes gestationis (Carruthers & Ewins, 1978), a disease in which clinical activity does not correlate with the plasma levels of any recognized factor.

Pathogenicity of the intercellular antibodies of pemphigus and their periodic removal from the circulation by plasmapheresis.

Abstract: SUMMARY The authors are convinced that the intercellular antibodies of pemphigus are pathogenic. Consequently periodic plasmapheresis in two patients with pemphigus has been performed to remove the antibodies from the circulation. After larger plasma-exchanges there was a decrease of the antibody titre and a parallel improvement of the clinical condition.

New concepts in the pathogenesis of psoriasis

Abstract: The pathogenesis of psoriasis has stimulated many studies. We suggested in 1972 that immunological factors could explain the biochemical abnormalities ofthe psoriatic lesion (Rimbaud et al., 1972b) and subsequently at the 1975 French National Dermatological Society Meeting we proposed an immunobiochemical theory (Guilhou & Meynadicr, 1976). In the light of numerous recent immunological, biochemical and ultrastnictural investigations we can try to integrate all these findings, going step by step from the main epidermal feature (cellular proliferation) to the initial events ofthe pathogenesis of psoriasis (Fig. i).

The pathogenesis of miliaria rubra. Role of the resident microflora.

Abstract: Anhidrosis was induced in volunteers by covering the skin with an impermeable plastic film. The degree of sweat suppression and miliaria after a thermal stimulus was directly proportional to the increase in the density of resident aerobic bacteria, notably cocci. No anhidrosis resulted when antibacterial substances were used to prevent the expansion of the microflora. Histological study showed a PAS-positive diastase resistant amorphous mass deep within the acrosyringium after 2 days of occlusion, accompanied by a periductal dermal infiltration of leukocytes. After another 2 days the duct became clogged by an amalgam of degenerating leukocytes. This impaction sloughed after about 3 weeks as a result of epidermal renewal. Colonies of bacteria were never found within the ducts. It is postulated that cocci secrete a toxin which injures luminal cells and precipitates a cast within the lumen. Infiltration by leukocytes creates an impaction which completely obstructs the passage of sweat for several weeks.

HLA antigens in persistent palmoplantar pustulosis and its relationship to psoriasis

Abstract: SUMMARY HLA typing was performed on 93 patients with persistent palmoplantar pustulosis. The incidence of either HLA B13 or BW17 was not significantly increased as compared to controls. In addition the frequency of BW35 was no different from controls. However, the present results document a significantly increased frequency (38.7%) of B8. Taken together these data are good evidence that palmoplantar pustulosis is a genetically distinct disease entity from psoriasis vulgaris, despite the increased incidence of psoriasis in the condition.

Bullous pemphigoid induced by PUVA therapy IS THIS THE AETIOLOGY OF THE ACRAL BULLAE PRODUCED DURING PUVA TREATMENT

Abstract: SUMMARY Among 24 psoriatic patients treated with PUVA therapy, five developed bullae. Direct and indirect immunofluorescence studies supported the diagnosis of bullous pemphigoid in one patient. In the others, the blisters were a phototoxic acral eruption.

Mycosis fungoides, nitrogen mustard and skin cancer

Abstract: SUMMARY The prevalence of epithelial cancer was determined in 202 patients with mycosis fungoides and the Sezary syndrome and was found to be 10.5%. In an attempt to establish a possible association with topically applied nitrogen mustard, it was noted that 4.0% of these patients had lesions prior to nitrogen mustard therapy (although over half subsequently developed further lesions) and 6.5% of the patients developed them de novo after therapy. In two patients in this latter group, malignancies developed in areas not usually associated with solar-induced cancer. These findings indicate that epidermal neoplasia is not uncommon in these patients and that nitrogen mustard may function as a carcinogen or a co-carcinogen.

Epidermolytic hereditary palmoplantar keratoderma. Report of a family and treatment with an oral aromatic retinoid.

Abstract: This study describes a family of 30 people in which 14 members have hereditary epidermolytic palmoplantar keratoderma. Four patients were treated with an oral aromatic retinoid for up to 5 months. They responded in a uniform and dramatic way: 10-14 days after the onset of therapy, the hyperkeratotic horny layer was sequestered in large sheets resulting in normal appearing skin and restoration of normal surface sensitivity. Biopsies revealed that the underlying disorder of keratinization had remained unchanged. Treatment with the retinoid had to be discontinued as the sensitivity and vulnerability restricted normal function of hands and feet.

Gluten-free diet in dermatitis herpetiformis. II. Morphological and immunological findings in the skin and small intestine of 12 patients and matched controls.

Abstract: Twelve patients with dermatitis herpetiformis whose skin condition responded to a gluten-free diet (GFD) were re-examined after diet treatment. The findings were compared with those in matched patients on a normal diet. Jejunal histology revealed morphological improvement in every patient on a GFD whereas all patients on a normal diet continued to have villous atrophy. Intra-epithelial lymphocyte counts were normal in 8 patients on a GFD in contrast to one on a normal diet. Immunofluorescence examination of the jejunal mucosa revealed that the numbers of cells containing IgA and IgM were increased significantly in the normal diet group. The figures were lower in the GFD group but these also exceeded the values in the controls. IgA deposits were found in the uninvolved skin of every patient irrespective of the diet treatment, but the fluorescence seemed to be less intense in patients on a GFD. A clear difference was found in the occurrence of C3 deposits in the uninvolved skin. Three patients on a GFD had C3 deposits; two of these did not follow a strict diet. However C3 was found in 8 patients on a normal diet. Circulating dietary and auto-antibodies were found in two patients on a GFD and in 9 on a normal diet. Serum immunoglobulin (IgG, IgA, IgM) and complement (C3, C4) levels were within normal limits in both patient groups.

Evaluation of PUVA, topical corticosteroids and the combination of both in the treatment of psoriasis

Abstract: SUMMARY A total of 90 patients with psoriasis were treated either by photochemotherapy (PUVA) or by topical steroids under occlusion (TOC). In a third group of patients a combination of both regimens was applied. All patients received approximately 15 treatments of either type. During therapy, biopsies were taken in all treatment groups and the epidermal thickness was monitored planimetrically. After clearing of the skin the patients were left without treatment and the time of onset of new lesions was recorded. While TOC produced rapid clearing of the skin this was followed by early relapses (in 50% of the patients after 3 weeks). PUVA reduced psoriatic hyperplasia more slowly; however, 50% of the patients remained free of psoriasis for approximately 10 weeks after clearance. Psoriasis treated with steroids under occlusion together with PUVA showed a significantly faster return of the skin to normal as compared to PUVA. As in PUVA-treated patients relapses occurred after approximately 12 weeks in this group. Therefore the combination of both treatments appears to be advantageous for rapid skin clearance and comparatively long remissions.

Skin problems associated with multifunctional acrylic monomers in ultraviolet curing inks

Abstract: SUMMARY Fifteen cases of contact dermatitis and three of irritant contact conjunctivitis due to multifunctional acrylic monomers in printing inks are described. Seven with dermatitis were sensitized to pentaerythritol triacrylate but evidenced no cross-reactivity to methyl methacrylate. The other eight cases of dermatitis were irritant. Pentaerythritol triacrylate has been shown experimentally to be a cutaneous sensitizer for guinea-pigs and man. Multi-functional acrylates should be handled with minimal skin contact, to avoid cutaneous problems.

Primary mucinous carcinoma of the skin

Abstract: SUMMARY Only twenty-seven cases of primary mucinous carcinoma of the skin have been reported. Three additional cases are included in this paper. The clinical presentation is distinctive: they are found most commonly in middle-aged, black males in the head and neck region as painless nodules, usually less than 3 cm in diameter. Previous reports have indicated the probable sweat gland origin of these tumours; one of our cases demonstrates a transition from a solid hidradenoma-like pattern to nests of tumour cells floating in mucin lakes, adding support for the sweat gland hypothesis. The clinical behaviour is relatively benign; late recurrences are common but metastases are rare. Only one case had widespread metastases. Although the histological appearance is distinctive, other primary sites first must be excluded. Local excision is the treatment of choice.