Showing papers in "Clinical and Experimental Dermatology in 1995"

Allergic airborne contact dermatitis from essential oils used in aromatherapy.

Abstract: Contact allergy to various essential oils used in aromatherapy was demonstrated on patch testing in a 53-year-old patient suffering from relapsing eczema resistant to therapy on various uncovered parts of the skin, in particular the scalp, neck and hands. Sensitization was due to previous exposure to lavender, jasmine and rosewood. Laurel, eucalyptus and pomerance also produced positive tests, although there was no hint of previous exposure. A diagnosis of allergic airborne contact dermatitis was thus established. On topical and systemic glucocorticoid treatment (peroral methylprednisolone at an initial dose of 60 mg/day) the skin lesions eventually resolved. Due to persistence of the volatile essential oils in the patient's home after a year-long use of aroma lamps, complete renewal of the interior of the patient's flat was considered essential. Due to changing self-medication habits, with increasing orientation to 'natural' modes of treatment, increasing numbers of such sensitizations might be on the horizon.

Neuropeptides in the skin of patients with atopic dermatitis

Abstract: There is increasing evidence that neuropeptides may be involved in the pathogenesis of atopic dermatitis (AD). This study examines whether neuropeptide distribution in the skin of patients with AD differs from normal controls. The distribution and density of several neuropeptides were examined in lesional and non-lesional skin of AD patients (n = 5) and in normal controls (n = 4) using indirect immunofluorescence and image analysis. Cholinergic innervation was studied using cholinesterase histochemistry. Staining with the general neuronal marker protein gene product 9 x 5 showed a subepidermal network of nerves with fibres penetrating the epidermis, and nerves around blood vessels, sweat glands and hair follicles. Image analysis of nerves around sweat glands showed a significantly higher nerve density in non-lesional compared with both normal controls and lesional skin (P < 0.05); lesional compared with control skin showed no significant difference. In the epidermis the density of nerves was not significantly greater in non-lesional compared with lesional skin and controls. Calcitonin gene-related peptide immunoreactivity was similar in all subjects except in three of the AD patients, where more nerves appeared to penetrate the epidermis. Substance P immunoreactivity in the papillary dermis was seen in all AD patients but no controls. Vasoactive intestinal polypeptide and neuropeptide Y staining were similar in all groups. Acetylcholinesterase-positive nerves were found around sweat glands in all subjects, the staining being greatest in non-lesional and least in lesional skin. Occasional nerves were seen in the papillary dermis in lesional skin of two out of the four patients. We have demonstrated quantitative differences in nerve growth in clinically normal skin of AD patients, and altered cutaneous neuropeptide expression in these patients which may contribute to the pathogenesis of AD. The cause of atopic dermatitis (AD) has not been fully established but it is believed that there is a complex interaction between genetic susceptibility, precipitating environmental factors and disordered immune responsiveness. There is increasing evidence that neuropeptides may be involved in the pathogenesis of AD. Exacerbations of the disease can be provoked by stress, scratching and sweating which may be the result of neurogenic inflammation. One of the first features of an exacerbation is flushing of the affected skin and pruritus. Several neuropeptides that have been identified in human skin are potent inducers of vasodilation and may induce pruritus. Substance P (SP), calcitonin gene-related peptide (CGRP) and vasoactive intestinal polypeptide (VIP) all cause vasodilation when injected intradermally, and SP and CGRP have been shown to be mediators of the weal and flare reaction. Spantide, a competitive antagonist of SP, has been shown to inhibit immediate and delayed-type hypersensitivity reactions. Part of these responses may be due to release of histamine and indeed elevated concentrations of histamine have been found in vivo in the skin and plasma of patients with AD. In this study the distribution and density of several neuropeptides were examined in lesional and nonlesional skin of AD patients and in normal controls using indirect immunofluorescence and image analysis. Cholinergic innervation was studied using cholinesterase histochemistry. Because many afferent fibres do not express CGRP or SP, the general neuronal marker protein gene product (PGP 9 x 5) was used to assess the overall nerve supply to the skin.

Sleep difficulties and their management in preschoolers with atopic eczema

Abstract: Summary Sleep disruption is known to be common in preschool children. Those with atopic eczema (AE) would seem to heat particular risk because of itching. In this preliminary survey parents confirmed clinical impressions that sleep loss is a common feature when a child's atopic eczema is flaring. Sleep disturbance was reported by parents for 86% of the relevant nights with an average of 2.7 wakings per night and an average parental sleep loss of 2.6 h per night. Parents used a common core of strategies to help their children sleep at these times. Some of the strategies employed are likely to perpetuate sleep disturbance beyond the time of the flare. Parents gained most benefit from their own idiosyncratic approaches. For the majority of children (59%) sleep disruption is limited to times when their AE is flaring.

Nail incorporation kinetics of terbinafine in onychomycosis patients

Abstract: Patients with toe-nail onychomycosis were treated with terbinafine (250 mg daily, n = 20) for either 6 or 12 weeks in a randomized double-blind study. Plasma and distal nail clippings were taken before initiation of therapy and 1, 6, 12, 18, 24, 36 and 48 weeks thereafter. Analytical data of terbinafine extracted from nail clippings or plasma were obtained by high-performance liquid chromatography (HPLC). Nail extracts and isolated HPLC terbinafine peaks were analysed using a combined gas chromatography-mass spectroscopy system (GC-MS) for unequivocal identification of the drug. Terbinafine could be detected in the distal nail in the majority of the patients within 1 week of starting therapy. Maximum terbinafine levels of 0.52 and 1.01 micrograms/g were measured after 18 weeks in the 6- and 12-week treatment groups, respectively. While plasma levels decreased rapidly after termination of therapy terbinafine was detected in the nails as long as 30 weeks (6 weeks treatment) and 36 weeks (12 weeks treatment) after termination of therapy at a range of 0.28-0.19 microgram/g. The drug concentrations measured at all time points are well above the minimum inhibitory concentration (MIC) for dermatophytes and other fungi. These data suggest that the drug reaches the nail plate rapidly and persists there for several months after cessation of active treatment.

Management of the immunobullous disorders. II. Pemphigus

Abstract: In the second of our reviews on the management of the immunobullous disorders, we review the therapy of pemphigus disorders, including pemphigus vulgaris, pemphigus vegetans, pemphigus foliaceus, pemphigus erythematosus, pemphigus herpetiformis, drug-induced pemphigus, IgA pemphigus and paraneoplastic pemphigus.

Androgen levels in pruritic folliculitis of pregnancy

Abstract: A case of pruritic folliculitis of pregnancy associated with elevated androgens is reported, supporting the view that the condition is a form of hormonally induced acne.

Azathioprine hypersensitivity-like reactions--a case report and a review of the literature.

Abstract: Azathioprine is used in a variety of dermatological conditions. However, because of its side-effect profile, azathioprine is limited for use in patients with severe disease. An unpredictable, rare and potentially fatal side-effect of azathioprine is the development of a hypersensitivity reaction, often consisting of fever, hypotension and oliguria. We describe a 17-year-old patient with leucocytoclastic vasculitis who was placed on azathioprine; within 15 days of start of therapy, she developed a fever. Azathioprine was discontinued and an evaluation for sepsis was undertaken; all cultures were negative and the fever abated. Azathioprine was restarted 5 days later. After a single dose, fever, nausea and vomiting, diarrhoea, hypotension, tachycardia and oliguria developed and the patient was admitted to an intensive care unit. Azathioprine was discontinued and investigations revealed no sign of an infection. All the above signs and symptoms abated within 24 h and the patient was discharged from hospital in 7 days. A review of 28 case reports in the literature of azathioprine-induced hypersensitivity reactions suggest that most commonly a fever and gastrointestinal symptoms occurred on initial presentation. In addition, a maculopapular rash, urticaria, vasculitis, erythema multiforme or erythema nodosum may occur. Hepatotoxicity and nephritis have also been reported. The aetiology of the reaction is unknown but sudden onset of fever and hypotension suggests that this reaction may be due to cytokine or mediator release induced by azathioprine. As azathioprine is metabolized to 6-MP, rechallenges to both should be avoided in patients who experienced an azathioprine hypersensitivity-like reaction.

Benefits and risks of intralesional corticosteroid injection in the treatment of dermatological diseases.

Abstract: Intralesional corticosteroid (CS) injections have been used to treat a variety of dermatological and non-dermatological diseases with variable results. The purpose of the injection is to attain a high concentration of the drug at the diseased site, with minimal systemic absorption. Several CS preparations are available for intralesional injection, although triamcinolone derivatives have gained the widest usage in dermatology. The dose and the interval between injections depend on the type, size and severity of the lesion as well as the response to the previous injections. The most critical issue in the efficacy and also in the development of complications of the injections, is the method of injection. Several local and systemic side-effects have been reported following intralesional injections, but most of them are rare or acceptable. Thus intralesional CS injection is an integral part of the clinical practice of dermatology. Since their introduction in 1951, intralesional CS injections have become an integral part of clinical practice in dermatology. They are used alone or in combination with other therapeutic modalities in the treatment of many skin diseases. The purpose of the injection is to attain a high local concentration of the CS at the diseased site, without significant systemic absorption, thus avoiding the numerous side-effects associated with systemic administration. Intralesional CS injection may be a valuable therapeutic modality in situations where topical CS are not suitable for use, either because of low potency and inefficient epidermal barrier penetration or in clinical conditions associated with epidermal atrophy.

Follow-up of adult patients with atopic eczema treated with Chinese herbal therapy for 1 year.

Abstract: Adult patients with severe atopic eczema who had completed a double-blind placebo-controlled crossover trial of a specific formulation of Chinese herbal therapy were offered continued therapy for 1 year. Of 31 patients who completed the original placebo-controlled study and after a washout period and 2 months of further treatment, 17 continued treatment (group 1), 11 chose not to continue treatment (group 2), one was lost to follow-up and two patients originally in group 1 decided to stoptreatment and became pregnant. At the end of the year, 12 of the patients in group 1 had greater than 90% reduction and the remaining five had greater than 60% reduction in clinical scores compared with baseline values. Clinical scores of patients in group 2 gradually deteriorated so that by the end of the year the difference between groups 1 and 2 was highly significant (P=0.005 and P=0.002 for erythema and surface damage, respectively). At the end of the year no patient in group 1 felt able to discontinue treatment permanently, but eight patients were on an alternate-day regimen by 6 months and remained on this regimen until the end of the year, and seven were able to control their eczema with a 1 in every 3 day treatment by the end of the year. The remaining two patients continued on daily treatments. Toxicology screening revealed no abnormalities in either full blood counts or biochemical parameters in any patient on continued treatment. Improvement in disease was not associated with any significant change in serum IgE level or peripheral blood lymphocyte subsets. This study has shown that Chinese herbal therapy produces a sustained remission of disease activity in patients whose atopic eczema had been unresponsive to a variety of conventional treatments. Furthermore it has suggested that withdrawal of treatment in patients whose eczema had responsed to treatment, produces a gradual relapse of the disease but to a severity less than pretreatment levels. No evidence of toxicity was observed in any patient receiving this specific formulation of Chinese herbal therapy, but we advise continued surveillance of patients receiving such therapy

Neuropeptides and general neuronal marker in psoriasis an immunohistochemical study

Abstract: Summary Nerve fibres immunoreactive to antibodies to vasoactive intestinal polypeptide (VIP) and substance P (SP) were increased in lesional psoriatic skin when assessed semi-quantitatively. Biopsies from psoriatic plaques on the arm were studied in 13 patients and compared with biopsies from non-lesional areas (in three of the same psoriatic subjects) and from normal skin in seven non-psomtic controls. Immunohistochemical methods were used on cryocut skin sections to demonstrate the neuropeptides SP, VIP, calcitonin gene-related peptide and neuropeptide Y, and the general neuronal marker protein gene product (PGP) 9.5. The immunofluorescence was examined by semiquantitative and, for PGP 9.5, by quantitative methods. VIP reactive nerve fibres were increased at areas of eccrine sweat glands throughout the dermis, at the dermo-epidermal junction, and in the epidermis, in psoriasis lesional skin. SP reactive nerve fibres were increased at the dermo-epidermal junction, where the nerves ran parallel with and perpendicularly through the junction. PGP 9.5 reactive nerve fibres showed an increase at the dermo-epidermal junction, in the papillary dermis, and at the eccrine sweat glands in lesional psoriatic skin but not in non-lesional, or in control skin. These findings support the hypothesis that neuropeptides may be involved in the pathogenesis of psoriasis.

ANCA‐associated vasculitis and lupus‐like syndrome caused by methimazole

Abstract: A 24-year-old woman with Graves' disease treated with methimazole for 4 years, developed recalcitrant ulcers on the lower legs. Histological studies demonstrated vasculitis in deep dermal vessels accompanied by C3 deposition. Laboratory investigation revealed lupus-like abnormalities (leucocytopenia, positive antinuclear and antidouble strand (ds) DNA antibodies, and positive ANCA). The leg ulcers dramatically improved after methimazole was withdrawn. In addition, leucocytopenia and the immunological abnormalities soon faded. Although lupus-like syndrome is well known to be induced by antithyroid drugs, vasculitis is a rare complication. To the best of our knowledge, this is the first report describing ANCA-associated vasculitis caused by methimazole.

Squamous carcinoma following lichen planus of the vulva.

Abstract: Summary A 58-year-old woman presented with typical cutaneous features of lichen planus (LP). She had suffered from vulval pruritus for 3 years, and examination showed lesions suggestive of LP on the vulva. Three months later a plaque developed on the clitoral hood, and biopsy showed an invasive squamous carcinoma. After vulvectomy, features of LP were found in the excised specimen. Vulval LP should be carefully monitored for possible malignant transformation.

Topical sphingolipids in antisepsis and antifungal therapy.

Abstract: Sphingosine and sphinganine, free sphingolipids of the stratum corneum, are, in vitro, strongly inhibitory for both bacteria and fungi. Whether or not they are suitable, indeed active, in vivo was examined: (i) on human volunteers, first as a preventative antiseptic against subsequently applied Staphylococcus aureus and Candida albicans, and second as a restorative antiseptic against the previously expanded normal skin flora; and (ii) on guinea-pigs as therapy for experimental C. albicans and Trichophyton mentagrophytes infections. In the antiseptic studies, which involved 200 micrograms/cm2 of sphinganine in ethanol (50 microliters of a 1.6% solution), up to three-log reductions in the population of target micro-organisms were obtained, compared with vehicle and untreated controls (P < 0.001). The daily application of sphingosine as 1.5% ethanol-petrolatum ointment was able to diminish inflammation slightly in dermatophyte-infected guinea-pigs (P = 0.02-0.05), although the animals remained culture positive over the 3-week sampling period. The candida infections, treated daily with 1.5% sphinganine in ethanol, showed no improvement in inflammation compared with controls, except for 2 days of the 2-week observation period (P = 0.01-0.03); however, by the fourth day of therapy the yeast was eliminated in 75% of animals. No gross toxicity was observed among animals or human volunteers. These experiments further support simple sphingolipids as important antimicrobial agents of the cutaneous barrier and point toward a new biochemical approach in treating infectious disease.

Diltiazem‐induced acute generalised exanthematous pustulosis

Abstract: Pustulation is a major feature in several different dermatoses, and it may also occur as a manifestation of drug hypersensitivity. Acute generalized exanthematous pustulosis (AGEP) is an uncommon eruption characterized by acute, extensive formation of sterile pustules, fever and peripheral blood leucocytosis. It shares several clinical and histological features in common with pustular psoriasis. Most reported cases have been triggered by ingestion of broad spectrum antibiotics, particularly betalactams and macrolides. There is usually rapid resolution of the eruption on drug withdrawal. We report the case of a 58 year-old woman who developed AGEP shortly after commencing treatment with the calcium channel blocker diltiazem hydrochloride. The eruption followed a biphasic course, and improved following treatment with systemic corticosteroids and methotrexate. AGEP appears to be a rare adverse cutaneous reaction to diltiazem, whereas a wide range of other skin eruptions have been reported more commonly with this drug.

Treatment of cicatricial pemphigoid with tetracycline and nicotinamide.

Abstract: Cicatricial pemphigoid is a rare autoimmune blistering disease involving predominantly mucosal areas in elderly patients. It runs a chronic relapsing course. Immunosuppressive treatments are frequently complicated by adverse effects and require careful monitoring. A 69-year-old woman is reported who responded well to a simple regimen of combined tetracycline and nicotinamide after 15 years of inadequate disease control and numerous adverse effects from immunosuppressive agents.

Benign familial chronic pemphigus (Hailey‐Hailey disease) responds to cyclosporin

Abstract: A patient with benign familial chronic pemphigus was treated with cyclosporin at a dose ranging from 2.8 to 3.4 mg/kg per day. There was a clear improvement in the area of skin affected and in exudation and soreness. The response was maintained for 24 weeks but there was a gradual deterioration after treatment was stopped.

Reticulate acropigmentation of Dohi.

Abstract: Two cases of reticulate acropigmentation of Dohi are reported, both patients demonstrating the typical features of this disorder. Reticulate acropigmentation of Dohi (dyschromatosis symmetrica hereditaria or symmetrical dyschromatosis of the extremities) is characterized by pigmented and depigmented macules mixed in a reticulate pattern on the extremities. It was first described in 12 patients from Japan, where it appears to be a well-established condition. Patients have been reported from Europe and a family from India has recently been described. We report two cases of reticulate acropigmentation of Dohi occurring in an Afro-Caribbean and an Indian patient, in order to alert clinicians to the possibility that this disorder may present in the UK.

Primary cutaneous cryptococcosis and Cryptococcus neoformans serotype D

Abstract: We report a healthy, 73-year-old Japanese woman who presented with primary cryptococcosis on the skin of both cheeks. She had initially developed an erythematous, partly ulcerated lesion on the right cheek 2 weeks earlier following an injury. There was no regional lymphadenopathy, and chest X-rays were normal. Histopathological findings showed granulomatous cell infiltration. Periodic acid Schiff staining revealed spores that were identified by the indirect immunoperoxidase staining method as Cryptococcus neoformans. The isolate was identified as C. neoformans var. neoformans serotype D. The skin lesions healed in 1 month without antifungal therapy. A literature review indicates that this serotype tends to produce cutaneous lesions without systemic involvement.

Bullous pemphigoid and multiple sclerosis : a report of three cases and review of the literature

Abstract: Three patients with longstanding multiple sclerosis (MS) who developed bullous pemphigoid (BP) are reported. All patients had immunological features of typical BP as determined by immunofluorescence and Western immunoblotting studies. The clinical features, however, differed from those observed in typical BP. In two the BP started near an indwelling catheter and two had striking involvement of the soles. None of our patients, or a further nine cases reported in the literature, had mucous membrane involvement. In MS patients BP appears to develop at a younger age. Multiple drugs were taken by the MS patients; these, however, appear not to play a role in triggering their BP. The course of BP in patients with MS is moderate, although the majority require systemic treatment.

Vascular proliferation and angiogenic factors in psoriasis.

Abstract: Psoriasis is a common, chronic skin disorder characterized by hyperproliferation of the epidermis, inflammatory cell accumulation and increased tortuosity and dilatation of dermal papillary blood vessels. Research into the pathogenesis of psoriasis has concentrated mainly on the interplay between inflammatory cells and epidermal proliferation. Central to the proposed pathogenetic pathway are cytokines produced by activated keratinocytes, which are thought to induce both keratinocyte proliferation and lymphocyte migration. Cytokines also mediate upregulation of adhesion molecules on vascular endothelium which in turn permits lymphocyte recruitment. The close spatial relationship between altered microvasculature and epidermis is clearly important in psoriasis. Consequently, understanding the mechanisms underlying vascular changes is fundamental to an elucidation of pathogenetic mechanisms in psoriasis.

Class II MHC typing in pemphigoid gestationis

Abstract: Pemphigoid gestationis (PG) is a rare, autoimmune skin disease associated with pregnancy or the immediate post-partum period, previously shown to be associated with the HLA class II antigens DR3 and DR4. Advances in molecular analytical techniques now allow the identification of HLA alleles previously difficult to define by serological assays. Unsuspected polymorphism within the HLA-DR3 and DR4 classes can, therefore, be identified. The aim of our study was to apply these newer techniques to the question of genetic predisposition in PG by re-evaluating the association with DR3 and by studying a possible link with DQ. We have investigated by restriction fragment length polymorphism, the DQA, and by sequence specified oligonucleotide probing the DQB and DRB1 (HLA DR) specificities of 41 women with immunofluorescence-confirmed PG. The principal finding of this study is that there is an association between PG and DRB1*0301 (DR3) and DRB1*0401/040X (DR4). Although there is also an increase (P = 0.06) in the concurrent presence of both antigens, this appears to be due to the association with either antigen alone. We also found an increase in the frequency of DQA1*2 (P = 0.016 vs. control) and a decrease in frequency of DQB1*0201 (P = 0.022 vs. controls) and DQB1*0602 (P = 0.026 vs. controls).

Oral cyclosporin A restores hair growth in the DEBR rat model for alopecia areata

Abstract: The Dundee experimental bald rat (DEBR) undergoes hair loss associated with the development of peri- and intrafollicular mononuclear cell infiltrates, as occurs in human alopecia areata. We studied the effect of orally administered cyclosporin A (10 mg/kg; 5 days/week for 7 weeks) on established lesional DEBR rats displaying extensive areas of hair loss. New hairs appeared after 10 days and there was simultaneous regrowth of hair over the whole body with restoration of a full pelt by 5 weeks. Semiquantitative histological examination of flank skin biopsies revealed early reduction of the cellular infiltrate associated with conversion of dystrophic anagen follicles to normal, hair-producing follicles. These results confirm the value of the DEBR model of alopecia areata in evaluating existing and new therapies for this disease in humans.

HLA antigens in Omani patients with vitiligo

Abstract: Fifty native Omanis with vitiligo were studied to compare the incidence of HLA ABC and DR antigens with a control population. HLA Bw6 was found in 82% of patients compared with 49% controls (P c =0.0009 RR=4.56) and HLA DR7 occurred in 40% of patients and 9% is controls (P c =0.00075 RR=6.17). HLA DR7 was significantly increased in those patients with acrofacial, compared to focal disease (57% vs. 24% P=0.038). Sixty-six per cent of the patients is this study had parents who were consanguineous and a positive family history was only found in this group with an incidence of 32%. HLA Bw4 segregated 100% with patients with a positive family history compared with 48% in consanguineous patients without a positive family history (P c =0.011 RR=23). Vitiligo appears to be associated with different HLA antigens in different ethnic groups

Erythrodermic mycosis fungoides treated with total body irradiation and autologous bone marrow transplantation

Abstract: We describe a middle-aged man with aggressive erythrodermic mycosis fungoides whose responses to several well-established therapies for the disease were either poor or short-lived. Infusion of antibodies engineered against cells expressing the CD4 molecule produced little response. Total body irradiation coupled with autologous bone marrow transplantation led to an encouraging but unfortunately unsustained improvement.

Pityrosporum (Malassezia) folliculitis in Saudi Arabia—diagnosis and therapeutic trials

Abstract: Pityrosporum folliculitis (PF) is frequently misdiagnosed as acne vulgaris, resulting in unnecessary and prolonged treatment. Sixty-two patients with PF seen in the Dermatology Clinic, King Gahad Hofuf Hospital, Saudi Arabia were evaluated clinically. The diagnosis was confirmed by routine histology with haemotoxylineosin staining and Periodic acid-Schiff staining. Scrapings of the lesions, especially the molluscum-like papules, were mounted in KOH/Parker blue ink and examined under the microscope. Patients, divided into three groups as follows, were given treatment for 4 weeks: (1) 20 were treated with ketoconazole, 200 mg orally in addition to ketoconazole shampoo 2% daily; (2) 20 were given only ketoconazole, 200 mg daily, orally; (3) 12 used econazole nitrate 1% solution applied twice daily; and (4) 10 used miconazole nitrate 2% cream twice daily. Cases in groups 3 and 4, who did not respond, were given the same treatment as for group 1. All who responded were kept on ketoconazole shampoo 2% twice weekly. PF was commoner in young adult females as the female to male ratio was 2:1 while the mean age was 21.5 years. The most common site involved was the trunk (95%) in the form of papules, pustules and molluscoid lesions. The latter type of lesion yielded the highest number of spores using KOH/Parker blue ink. Biopsy was positive in 87% of the patients but is usually not necessary. Combined topical and systemic ketoconazole produced clearance of the lesions in 20 patients (100%), while systemic therapy only resulted in 75% clearance (15 of 20). Topical econazole and miconazole failed in 20 of 22 (90%) and improved only two patients. There were no significant side-effects from the drugs.

Dermatomyositis treated with high-dose intravenous immunoglobulins and associated with panniculitis.

Abstract: Summary Polymyositis and dermatomyositis are idiopathic inflammatory myopathies characterized by subacute symmetrical weakness of proximal limb and trunk muscles. Dermatomyositis is distinguished from polymyositis by the presence of rash.1,2 We describe an adult patient with treatment-resistant childhood-type dermatomyositis who made a good response to high dose intravenous immunoglobulins. Additionally, there was evidence of panniculitis which is an unusual histopathological finding in dermatomyositis.

Arterial hypertension causing leg ulcers

Abstract: Summary We report clinical and histological features of 16 consecutive patients with hypertensive leg ulcers. The lumen/wall ratio in arterioles at the edges of these hypertensive leg ulcers was compared with that in other types of chronic leg ulcers and was found to be significantly reduced (P < 0.001). Additional conditions such as venous hypertension or main vessel arterial disease contributed. Nineteen of 22 ulcers were completely healed after a mean of 4.9 months. Recognition of this condition enables correct treatment choice, which usually involves excision and grafting, and early healing. The classical hypertensive leg ulcer was initially described by Martorell in 19451 and subsequently by others.2–8 As described, it is situated on the lateral aspect of the lower leg above the ankle, is painful, often severely so, and has necrotic edges. Patients have a history of arterial hypertension, although the blood pressure may be normal at presentation. There is usually no surrounding oedema or stasis pigmentation and peripheral vascular disease is absent. The ulcers are often resistant to conservative treatments and most reported cases eventually require excision and grafting or lumbar sympathectomy before healing occurs. Martorell1 emphasized that usually there is no evidence of main vessel arterial disease or a disturbance in the venous circulation. Milder or atypical cases may be misdiagnosed. We studied patients with leg ulcers in which hypertension was considered the main aetiological factor to document features.

Coexisting lichen planus and subacute cutaneous lupus erythematosus.

Abstract: We report a patient who presented with annular erythematous skin lesions and generalized lichenoid papules. The clinical picture as well as histopathology, immunofluorescence and laboratory findings indicated coexistence of subacute cutaneous lupus erythematosus (SCLE) and extensive generalized lichen planus (LP). Clinically and histologically, SCLE-like lesions appeared to progress into LP-like lesions, supporting the concept of a common autoimmune pathophysiology in these disorders. Treatment with cyclosporin A (2.5 mg/kg body weight) resulted in a significant remission of the inflammatory skin lesions.

Bullosis diabeticorum. A case report and literature review

Abstract: We report a case of bullosis diabeticorum with blisters confined to the lower legs and feet. Histology of a lesion demonstrated a bulla at the dermo-epidermal junction, and ultrastructural studies confirmed the split to be at the level of the lamina lucida which we propose is the site of the pathology in this condition. Immunofluorescence studies were negative, excluding an immunobullous disease. We postulate that in our patient a combination of increased venous pressure and poor vascular supply in diabetic skin, led to the blister formation. The literature on this condition is reviewed.

Oral terbinafine and erythema multiforme

Abstract: Two patients developed classical erythema multiforme while taking oral terbinafine. A case of Stevens-Johnson syndrome occurring after terbinafine therapy has recently been described, but there have been no published reports of an association with erythema multiforme until now.