Showing papers in "Clinical and Experimental Dermatology in 1996"

Botulinum toxin--a possible new treatment for axillary hyperhidrosis.

Abstract: The inhibitory action of botulinum toxin is not limited to the neuromuscular junction. The toxin also blocks the autonomic cholinergic fibres, including the sympathetic fibres to sweat glands. We have previously demonstrated that the toxin produces localized anhidrosis. To determine the dosage, pattern and duration of the anhidrotic effect of botulinum toxin and to test the efficacy of axillary injections, we further studied seven healthy volunteers. Two individuals had subcutaneous injections of botulinum toxin (20 mouse units, Dysport-Porton Products) in the dorsum of the hand. Five healthy volunteers had 15-50U of botulinum toxin A (Botox) injected in one axilla. A circular area of complete anhidrosis on the dorsum of the hand was evident on day 2 and persisted for 11 months. By day 3, two of the axillae (injected with 50 U each) were totally dry and in one (injected with 30 U) the sweating was substantially reduced. The effect persisted for 6-8 months before wearing off. No effect was appreciated in two axillae (injected with 15 and 20 U). No significant side-effects were encountered. Subcutaneous injections of botulinum toxin causes chemodenervation of the sweat glands. In normal individuals axillary sweating can be abolished by 50 U of botulinum toxin A (Botox). The results offer a possible novel treatment for severe cases of axillary hyperhidrosis.

Factors affecting responses on Dermatology Life Quality Index items among vitiligo sufferers

Abstract: Finlay and Khan have recently suggested that the Dermatology Life Quality Index (DLQI) can be used to measure the effects of dermatological conditions on the quality of patients' lives. The aims of this study were to assess its applicability in a nonclinic sample of vitiligo sufferers and to measure its relationship with questionnaires designed to measure a variety of psychological and demographic factors. The DLQI was completed by 614 members of the Vitiligo Society in a postal survey. The results supported the validity of the DLQI for this sample. DLQI scores were related to perceived stigma (a version of Ginsburg and Link's psoriasis stigma questionnaire), recent experiences, self-esteem (Rosenberg's scale), personal distress (both a symptom checklist and the 12-item General Health Questionnaire) and race, suggesting that levels of disability might be reduced by interventions that target these variables.

Hidradenitis suppurativa ‐ characteristics and consequences

Abstract: Summary The general characteristics of patients with hidradenitis suppurativa have not been previously described in detail. Although rare complications of the disease have been described, little is known of the average impact of hidra-denitis suppurativa. We have now aimed to describe the general characteristics of the disease and its impact on patients with an established diagnosis of hidradenitis (a= 68) and compare these with those of an unselected general population sample (n= 523). Pierced earlobes were more common in patients than in the controls (P < 0·02). Female patients were younger (P= 0·0002) and better educated (p < 0·0001), and fewer had been pregnant (P= 0·0006). The median number of treatments prior to referral was two, and an average of 2–7 work days/patient per year were lost due to hidradenitis. The self-reported health of patients was significantly inferior to that of the general population (P < 0·001), mainly because of soreness and restriction of movement. Low grade hidradenitis suppurativa therefore has a considerable impact on the health of patients. Previously implied associations with the disease such as the use of cosmetics or oral contraceptives, menstrual cycle and body mass index (BMI) were not confirmed in our study, although they may influence the course of pre-existing disease.

Methotrexate for psoriasis.

Abstract: Summary Methotrexate is an effective antipsoriatic agent and has been widely used to treat severe psoriasis since the 1960s.1 It is especially useful in acute generalized pustular psoriasis,2–4 psoriatic erythroderma,4 psoriatic arthritis5–7 and for extensive chronic plaque psoriasis in patients who are inadequately controlled by topical therapy alone.4 It has not, however, been formally compared with other systemic treatments for severe psoriasis such as cyclosporin, retinoids or photochemotherapy with psoralen and UVA (PUVA), but in comparison with these other therapies it is inexpensive, with correct use, its safety profile is favourable. In summary, therefore, it can be used as a short-term option to gain control of unstable psoriasis such as pustular psoriasis or erythroderma before returning to other modes of treatment, or more often, as long-term maintenance treatment. The most important potential side-effect is acute myelosuppression,9 which is the cause of most of the rare deaths attributable to this therapy for psoriasis. Myelosuppression is more likely in the elderly, in patients with renal impairment and/or folate depletion, and with overdose or drug interactions. Long-term therapy carries with it a risk of liver tihrosis which is related to the dosage regimen employed,10 and is increased by exposure to other hepatic toxins, particularly alcohol.11 The correlation between the risk of development of liver fibrosis, cumulative lifetime dose and duration of treatment with methotrexate is not clear-cut,8,12–14 but may have been overstated in some studies.15,16

Consensus meeting on the definition of physical urticarias and urticarial vasculitis.

Abstract: Sustained physical pressure applied to the skin causes the development of itchy, sometimes painful weals at the site of pressure application after a delay of at least 30 min but usually within 6 h. Lesions may last up to 72 h. Two methods for quantifiable reproduction of the lesions have been described. In the first, weighted metal rods are lowered vertically on to the skin through perforations in a supporting perspex sheet, which holds the rods perpendicularly on the patient's back or anterior thigh. The times of application vary according to the severity of the patient's disease. Using a rod of 1-5 cm diameter the weight necessary varies from 2-5 to 4-5 kg, the lesser weight being applied for 20 min and the greater weight for 15 min. Development of an indurated lesion at the test site within 6 h is considered to be a positive response.^ The other quantifiable test is performed by firmly pressing a dermographometer (as described above) calibrated at 100 g/mm for 70 s perpendicularly against the back. A test is positive if an indurated papule appears at the test site 30 min to 6 h later.'

Patient-physician consensus on quality of life in dermatology

Abstract: Summary This study was undertaken in order to establish the correlation between physician-assessed and patient self-reported quality of life (QOL) when using a proposed Dermatology Life Quality Index (DLQI) in a random Sample of 51 dermatological out-patients and in-patients. A substantial correlation was found between physician scores and DLQI (r2= 0·306, P < 0·001), suggesting that the DLQI can be used to assess QOL and general morbidity. Comparison of the observed and ideal patient–physician consensus suggests that patients with relatively benign or quiescent disease may overestimate disease impact, while dermatological patients with more malign or aggressive disease may underestimate it compared with the physician estimate.

Erosive and generalized lichen planus responsive to azathioprine.

Abstract: Systemic corticosteroids are of value in severe lichen planus which interferes with the patient's life or is ulcerative or where there is nail destruction. Azathioprine has been shown to be effective steroid sparing treatment for generalized lichen planus. We report two patients with severe lichen planus who responded to azathioprine alone and suggest it may be an alternative therapy, especially when there are risk factors against corticosteroid use. Lichen planus accounts for approximately 1% of new presentations to a dermatology unit. It can affect all body areas and markedly interfere with a patient's life. Mucous membrane lesions are common (30-70%) but ulcerative lesions in the mouth are uncommon. Lichen planus seems to be immunologically mediated with evidence favouring a lymphocytotoxic process described in the literature. Treatment is mainly symptomatic and can be difficult. Systemic corticosteroids are of value in treating severe cases where the disease is interfering with a patient's life or when ulcerative mucous membrane lesions have occurred or if there is severe nail destruction. Relapse can occur on cessation of steroids. Azathioprine has been shown to be effective steroid sparing therapy for generalized lichen planus. However, the use of azathioprine alone has not been described. We report two cases of generalized, erosive lichen planus that responded well to azathioprine alone.

The under-reporting of skin disease in association with squamous cell carcinoma of the vulva.

Abstract: Histology sections from 61 cases of squamous cell carcinoma (SCC) of the vulva presenting after 1988 were reviewed for evidence of associated epithelial abnormality. Of the 50 patients with epithelium adjacent to the tumour, 24 had histological evidence of lichen sclerosus (LS), 20 of severe vulvar intraepithelial neoplasia (VIN 3), 22 of human papilloma virus (HPV) infection and three of lichen planus (LP). The clinical records and the original histology report were also subsequently reviewed and with the exception of VIN 3, these disorders were poorly reported by both clinicians and pathologists. Lichen sclerosus was diagnosed clinically in only two of the 36 hospital records available for inspection. Old terminology was used to describe some patients with epithelial disease (erythroleucoplakia in one patient with LS, leucoplakia in two patients with LS and one with LP). This study demonstrates the need to adopt standard nomenclature and increase the awareness of epithelial disease associated with SCC of the vulva among clinicians and pathologists.

Port wine stains on the lower limb: response to pulsed dye laser therapy.

Abstract: The pulsed tunable dye laser is the established treatment for facial port wine stains (PWSs), particularly in children There have been very few studies specifically addressing the efficacy of this laser in the treatment of lower limb PWSs Twenty-seven patients with lower limb PWSs have been treated with the Candela pulsed tunable dye laser Seventeen patients have been discharged; one patient had greater than 95% clearance of the naevus and three others had a good response to treatment Ten patients who are continuing treatment have had an average of 94 treatments Only one patient has achieved a good result, and none an excellent result These results are disappointing compared with published figures for outcome following pulsed tunable dye laser treatment to facial PWSs, and confirm the clinical impression that PWSs on the lower limb do not respond well to pulsed dye laser therapy

Clinical manifestations in 100 Japanese bullous pemphigoid cases in relation to autoantigen profiles

Abstract: The relationship between clinical findings and antigen profiles in 100 bullous pemphigoid (BP) patients has been investigated. The patients were divided into four groups based upon the results of immunoblot analysis, namely patients whose sera detected the 230-kDa BP antigen (BP230) and the 180-kDa BP antigen (BP180), those recognizing either BP230 or BP180 alone, and those recognizing neither antigen. Analysis by the chi-squared test showed predominant occurrence of oral (P < 0.05) and facial lesions (P < 0.005) in patients whose sera detected BP180, and these patients also tended to have more extensive lesions (P < 0.005). Patients that were positive for BP180 alone needed treatment with higher doses of steroids than the patients positive for BP230 alone (P < 0.05). Furthermore, all five recalcitrant cases, which did not respond well to steroid treatment, were shown to possess autoantibodies against BP180 in their sera. Patients with antibodies to BP230 had a tendency to have a high titre of anti-BMZ antibodies (P < 0.005). These results suggest that anti-BP180 antibodies may be more related to the disease severity than anti-BP230 antibodies. Bullous pemphigoid (BP) is an autoimmune blistering disorder characterized clinically by tense blister formation and immunologically by the presence of tissue-bound and circulating antibasement membrane zone (BMZ) autoantibodies. A number of immunoblot analyses have indicated that two major antigenic proteins of epidermal extracts, the 230-kDa BP antigen (BP230 or BPAG1) and the 180-kDa BP antigen (BP180, BPAG2 or type XVII collagen), are detected by sera from patients with BP in various patterns. Some BP sera recognize both antigen proteins, while others detect only BP230 or BP180 or none. Recently, cDNAs for these antigens have been isolated, and the characteristics for these molecules have been investigated in more detail. The exact relationship between these two proteins is still unclear; however, more recent studies showed that BP180 has an extracellular domain and polyclonal rabbit antibodies raised against an extracellular non-collagenous domain of the murine BP180 antigen were pathogenic in a passive transfer model. Several investigators have suggested a relationship between clinical findings and laboratory data in BP. Arbesman et al. compared the extent and duration of the disease with age, serum levels of IgE, IgA and IgG and titre of anti-BMZ antibodies. The results indicated that serum level of IgE and IgA correlated significantly to the extent of the disease and that titre of anti-BMZ antibodies correlated significantly (only in males) to the duration. There has been only one report which has analysed the relationship between pemphigoid antigens and clinical findings or laboratory data; no correlation was found. In a previous study, the reactivities of BP sera by immunoblotting using human epidermal extracts and two recombinant polypeptides produced from a mouse cDNA clone BPM1 were examined. The results of immunoblotting using epidermal extracts revealed that the two major BP antigens, BP230 and BP180, were detected by 74% and 51% of BP sera, respectively. Comparison of the clinical data with BP antigens gave the impression that the cases whose sera reacted only with BP180 were clinically more severe and less respondent to steroid treatment than the cases which detected BP230 alone on immunoblots. In the study reported here we have examined further the relationship between clinical and immunoblot data by applying a statistical analysis to the results previously obtained.

Cutaneous Alternaria alternata infection successfully treated with itraconazole.

Abstract: A case of cutaneous alternariosis due to Alternaria alternata in a 47-year-old man who had the CREST (calcinosis, Raynaud's phenomenon, oesophageal dysfunction, sclerodactyly and telangiectasia) syndrome with pulmonary hypertension is presented. The patient, who lived in a rural area and was receiving prostacycline by continuous infusion, prednisone and azathioprine for his underlying disease, showed cutaneous lesions of the lower extremities spreading from the knees to the ankles. The patient was successfully treated with high doses of oral itraconazole.

Bullous pemphigoid—a report of 86 cases from Taiwan

Abstract: We reviewed 86 cases of bullous pemphigoid and the results were compared with those reported in the literature. Seventy-eight per cent of the patients developed generalized blisters and 22% had localized blisters, including three cases of dyshidrosiform pemphigoid and one case of pretibial pemphigoid. Oral mucosal involvement was noticed in 12.8% of the patients. Fifteen per cent of the patients had internal malignancies but the incidence was not significantly different from the control group. Direct immunofluorescence in our series showed a high positive rate of 98.8%. Indirect immunofluorescence was positive in 48.1% of the 54 patients in whom this was carried out. Peripheral blood eosinophilia was observed in 22.1% of the patients. Prednisolone alone or in combination with immunosuppressive agents was the mainstay of treatment. Treatment side-effects was observed in 33% of the patients. Thirty per cent of the patients had a complete remission after a mean follow-up period of 26.9 months. Bullous pemphigoid (BP) is a chronic debilitating autoimmune blistering disease. It is characterized clinically by generalized tense bullae and histologically by subepidermal blisters. Immunofluorescence is crucial in the diagnosis and shows linear deposits of C3 and/or IgG at the basement membrane zone (BMZ). Information regarding this disease in Chinese patients is quite limited. In this study, 86 patients with BP were reviewed. The clinical and histological features, immunofluorescence, modes of therapy and outcome were studied.

Multiple keratoses and squamous carcinoma after PUVA treatment of vitiligo

Abstract: PUVA is known to be carcinogenic when used in the treatment of psoriasis. To date skin cancer has not been demonstrated after PUVA treatment of vitiligo. We report a patient in whom multiple squamous cell carcinomata and keratoses developed in vitiligo areas after a prolonged course of PUVA.

Failure of pulsed dye laser therapy for resistant verrucae.

Abstract: Summary Treatment with the 585-nm pulsed dye laser was performed in seven patients with viral warts (six with plantar warts and one with a periungual wart) who had tailed to respond to conventional therapeutic modalities, including keratolytics, formalin soaks, cryotherapy, curettage, CO2 laser and systemic retinoids. Each patient was assessed and treated on six occasions, separated by intervals of 3 weeks, with fluences of 8.5–9.5 J/cm2. Final follow-up was performed 3 weeks after the final treatment. All patients showed some decrease in the thickness of their warts, this being of a small degree in five of the patients. In the remaining two, there was a moderate reduction in both thickness and wart size. None of the patients experienced complete resolution of their lesions. Symptomatic improvement was obtained in all three patients who had previously complained of pain. These data indicate that treatment of resistant viral verrucae of the periungual and plantar skin with the pulsed dye laser is not curative although partial resolution and symptomatic improvement may occur.

Kaposi's varicelliform eruption in a patient with healing second degree burns.

Abstract: A 15-year-old boy with Kaposi's varicelliform eruption complicating healing second degree burns is reported. Clinically, umbilicated vesicles and pustules evolving to extensive erosions appeared over previously burned areas, sparing normal skin. Rapid diagnosis was made on the basis of the presence of multinucleate giant cells in a Tzanck smear. Therapy with intravenous acyclovir was followed by complete epithelialization without scarring. Previous cases of Kaposi's varicelliform eruption in burned patients are reviewed. Kaposi's varicelliform eruption (KVE) is defined as the viral superinfection of a pre-existing dermatosis. The term eczema herpeticum has long been used because atopic dermatitis is the dermatosis usually pre-existent, and herpes simplex virus (HSV) is the most frequent viral agent. Despite this fact, other viruses may cause KVE and the pre-existing dermatosis may be other than atopic dermatitis. Exceptionally, KVE has been described in patients with healing second degree burns (Table 1) and a further case of considerable interest is now described. 1-6 Some aspects of KVE are reviewed, with emphasis on burned patients, rapid diagnostic techniques and treatment to avoid life-threatening complications.

Erythema elevatum diutinum in human immunodeficiency virus-infected patients — report of a case and review of the literature

Abstract: Summary Erythema elevatum diutinum (EED) is a rare chronic disease of unknown origin, part of the spectrum of cutaneous leucocytoclastic vasculitis, A case of EED in a 32-year-old HIV-infected male patient, with no previous opportunistic infections and a CD4+ cell count of less than 200/mm3 is reported. Therapy with oral dapsone (100 mg/day for 15 days) resulted in clinical cure with no relapse after 6 months of follow-up. To our knowledge, only six cases of EED in HIV-positive patients have been reported to dale. A brief review of these seven cases is described.

Dowling-Degos disease associated with hidradenitis suppurativa.

Abstract: A case of Dowling-Degos disease coexisting with hidradenitis suppurativa is described. We propose that the follicular occlusion inherent in Dowling-Degos disease may predispose to the development of hidradenitis suppurativa.

Strict anatomical coexistence of vitiligo and psoriasis vulgaris – a Koebner phenomenon?

Abstract: We describe a patient who developed typical psoriatic plaques covering completely or partly the vitiliginous areas of her skin. Her psoriasis was strictly limited to the vitiliginous patches with no involvement of the normal skin. Strict anatomical coexistence of both diseases is extremely rare and suggests a causal mechanism, possibly due to a Koebner phenomenon, but genetic and environmental factors may also be involved. Psoriasis and vitiligo are two common skin diseases that may coexist in the same patient. Whether a pathogenic link exists between the two conditions remains to be clarified. 1-5 Studies have shown that the incidence of psoriasis in patients with vitiligo is no greater than that in the general population. 1,2 Strict coexistence of both diseases is rare and may be due to a Koebner phenomenon. Both diseases are believed to be T-cell mediated 6-9 and a number of inflammatory and proinflammatory cytokines released in the vitiliginous areas may be responsible for the development of a psoriatic process at the same site in genetically susceptible individuals.

A model to assess the efficacy of moisturizers – the quantification of soap‐induced xerosis by image analysis of adhesive‐coated discs (D‐Squames ®)

Abstract: Clinical grading of dry skin syndromes (xerosis) is beset by many variables which limit its reliability. Removing scales onto adhesive coated discs (D-Squames) has provided a means for objective measurement of xerotic states. Using image analysis we have modified the basic procedure to assure greater accuracy and reproducibility. The distribution of grey values on the discs was determined, from which a single value of the degree of scaling was calculated. We term this the scaling index. To induce xerosis, the lower legs of 22 women, aged 26-64, were washed daily for 10 days with soap. After washing, one side received a moisturizing lotion, the other served as an untreated control. At specified intervals, scaling was graded clinically, electrical conductance was measured and D-Squames were obtained. On the moisturizer-treated legs there was a significant decrease in dryness grades and scaling indices at all time points. Conductance was significantly increased on days 8 and 11. The untreated washed legs showed no changes in clinical grades, although conductance significantly decreased and the scaling indices increased in the last stage of the study. D-Squame analysis unequivocally revealed the beneficial effect of a moisturizer on soap-induced xerosis and the expected increase in scaliness without treatment.

Endothelial cell activation in cutaneous vasculitis

Abstract: Markers of endothelial cell activation were measured in 28 patients presenting with various forms of limited or focal type cutaneous vasculitis. Plasma levels of tissue plasminogen activator antigen (t-PA:Ag), plasminogen activator inhibitor type 1 antigen (PAI-1:Ag) and PAI-1 activity, fibrin plate, von Willebrand factor antigen (vWF:Ag), tissue factor (TF) and soluble thrombomodulin (sTM) were measured. In comparison with the control group (n = 20) there was a significant increase in t-PA:Ag, vWF:Ag and TF (P < 0.05, Mann-Whitney U-test) in the cutaneous vasculitis group. This study confirms that measurable degrees of endothelial activation occur in cutaneous vasculitis. Cutaneous vasculitis includes a diverse group of clinical conditions, which are associated with inflammatory changes in cutaneous blood vessels with local fibrin deposition. The aetiology and pathogenesis of the majority of these entities remain unknown. Causative mediators are thought to include immune complexes, anti-endothelial cell antibodies, cytotoxic lymphocytes and viruses. Histologically, immune complexes and complement are frequently detected on the vessel wall, and serologically anti-endothelial antibodies are often detected in patients with vasculitis and in systemic lupus erythematosus (SLE) which correlate with the severity of cutaneous vasculitis, arthritis and nephritis. Lymphocyte-mediated toxicity to endothelial cells has been reported in a small number of patients with giant cell arteritis and Takayasu's arteritis. The vascular endothelium plays a central part in the control of haemostasis. Under physiological conditions endothelial cells present an anticoagulant surface to blood constituents, partially due to surface expression of heparan sulphate and thrombomodulin (TM). Heparan sulphate binds antithrombin III (ATIII), thereby accelerating inactivation of intrinsic coagulation enzymes. Thrombomodulin is an endothelial cell surface glycoprotein which promotes anticoagulation by forming a complex with thrombin which then activates protein C. Activated protein C together with a cofactor, protein S, inactivates FVa and FVIIIa. von Willebrand factor (vWF) is synthesized by endothelial cells, stored in Weibel-Palade bodies and released into the circulation upon endothelial stimulation. vWF mediates the binding of platelets to the subendothelium and is the carrier molecule for FVIIIC. The endothelium controls fibrinolysis by producing t-PA and its inhibitor PAI-1. Inflammatory cytokines such as interleukin-1 (IL-1) and tumour necrosis factor (TNF) activate endothelial cells, causing a shift from an antithrombotic to prothrombotic state, including expression of tissue factor, increased synthesis of PAI-1 and decreased expression of TM. Fibrin deposition and intravascular thrombosis are seen in cutaneous vasculitis syndromes, suggesting local endothelial cell activation. The aim of this pilot study was to assess whether perturbation of the endothelium in cutaneous vasculitis could be detected in the patients' plasma samples. If so, further studies to assess any correlation in levels of these markers with disease activity might prove useful in the future.

Vulvar lymphangiectasia due to recurrent cellulitis

Abstract: We describe a 42-year-old woman in whom extensive lymphangiectasia of the vulva developed after recurrent severe episodes of cellulitis, producing changes rather similar to those seen in lymphangioma circumscriptum. We suspect that an underlying lymphatic abnormality predisposed her to cellulitis, resulting in local lymphatic fibrosis and vulvar lymphangiectasia.

The trigeminal trophic syndrome: an under-recognized complication.

Abstract: We report two cases of the trigeminal trophic syndrome, complicating peripheral and central interruption of the trigeminal sensory pathways. These cases illustrate the diagnostic and management problems that this syndrome presents.

Photodermatoses in a Singapore skin referral centre

Abstract: The inducing or exacerbating effect of sunlight on skin diseases is often not appreciated in tropical countries, perhaps because of the perennial presence of sunlight, and a retrospective review of photodermatoses seen in a referral skin clinic was therefore carried out. The photodermatoses seen were secondary photoaggravation of primary skin diseases (32.2%), systemic drug photosensitivity (11.3%), polymorphic light eruption (13%), chronic actinic dermatitis (5.3%), solar urticaria (5.3%), actinic prurigo (4%), photoallergic contact dermatitis (2.6%), porphyria (1.3%) and xeroderma pigmentosum (1.3%). Compared with the results of Western studies, there were more photoaggravated underlying skin diseases and systemic drug photosensitivity, and fewer idiopathic photodermatoses and photoallergic contact dermatitis; the common photoallergens were chlorpromazine, promethazine and musk ambrette, very similar to those seen in the West.

Demodex folliculitis on the trunk of a patient with mycosis fungoides.

Abstract: A 43-year-old man with tumour stage mycosis fungoides developed multiple follicular pustules on the trunk during total-skin electron beam therapy. A potassium hydroxide preparation of the contents of the pustules revealed the presence of Demodex mites. The patient was treated with 6% sulphur lotion with rapid improvement of the cutaneous lesions. We believe that this case represents a pustular folliculitis caused by Demodex mites. Immunosuppression associated with mycosis fungoides and its treatment may have resulted in the proliferation of this obligate parasite of the pilosebaceous follicle, and the development of the folliculitis. Demodex mites are common inhabitants of the pilosebaceous follicle. 1.2 Although the pathogenicity of the mites in humans is still controversial, several clinical observations indicate that they may cause various skin disorders of the face and scalp : 3-7 Demodex mites are normally most numerous at such sites. Recently, there have been cases in which demodicidosis developed on sites other than the face and scalp. These cases were associated with the acquired immunodeficiency syndrome, 8 diabetes mellitus or chronic liver disease. 9 We describe here the case of a man with mycosis fungoides in whom Demodex folliculitis developed on the trunk while he was receiving total-skin electron beam therapy.

Milia en plaque--a new site and novel treatment.

Abstract: Milia en plaque is an unusual eruption typically occurring in the retroauricular area. Two cases of this disorder occurring in a novel position and treated with oral minocycline are now reported.

Scalp necrosis in temporal (giant cell) arteritis:implications for the dermatologic surgeon.

Abstract: Temporal arteritis, a variant of giant cell arteritis, is a systemic granulomatous vasculitis of large and medium-sized arteries. Usually the clinical features are dominated by ophthalmological and neurological complications. In rare instances, ischaemic necrosis, especially of the scalp, may lead patients to the dermatologist. We report a 76-j , ear-old woman presenting with a unilateral scalp necrosis, accompanied by a dramatic ipsilateral impairment of vision. Immediately after duplex-sonography of the extracranial vessels and after initiation of corticosteroid therapy, the diagnosis of temporal arteritis was confirmed by temporal arteria biopsy. One month later, because of insufficient secondary healing of the ulcer, the defect was covered by a mesh graft. The taking of the graft was delayed due to immunosuppressive therapy, but was complete. The patient unfortunately died as a result of complications related to surgical removal of an aspergilloma in the sphenoid cavity secondary to immunosuppressive therapy We discuss the technique of artery biopsy and the possibility of surgical management of scalp necrosis in temporal arteritis. Giant cell arteritis is a systemic segmental granulomatous vasculitis of large and medium-sized arteries. Common histopathological features are found in temporal arteritis (TA), polymyalgia rheumatica and Takayasu's arteritis. Clinically, TA and polymyalgia rheumatica may overlap, whereas Takayasu's arteritis is considered to be a separate entitle. 1 While polymyalgia rheumatica and Takayasu's arteritis do not involve the skin, TA may become a dermatologic problem. TA is a disease of the elderly, occurring most commonly in the seventh and eighth decades of life with a higher prevalence in females and in populations of northern latitudes.2 TA may take a course of three stages.3 In a prodromal stage, lasting from weeks to several years, nonspecific signs and symptoms such as malaise, weight loss, low-grade fever and depression may occur. The acute stage is characterized by severe, mostly bilateral, diffuse or localized headaches. The superficial temporal arteries are frequently focally thickened, with their pulses weak or even absent. Jaw claudication is considered to be a pathognomonic sign of TA. 4 The retinal artery or other arteries supplying the eye are involved in approximately 50% of cases with sudden or gradual, mostly permanent impairment of vision, ischaemic optic neuritis, amblyopia and diplopia. 4 Involvement of other cerebral arteries may lead to nausea, disturbances of speech, psychoses or even lethal ischaemic stroke. 5,6 The disease activity may then tend to decrease over weeks or months, leading to a chronic stage with gradual reduction and disappearance of many symptoms. However, uni- or bilateral amaurosis is irreversible in most cases. In the case of scalp necrosis, the dermatologist may be confronted with TA. We describe such a patient with progressive ulceration of the scalp.

Annular elastolytic giant cell granuloma—actinic granuloma?

Abstract: A 56-year-old woman with annular elastolytic giant cell granuloma is reported. She had annular, slowly growing lesions on sun-exposed areas and the dorsum of one foot. Biopsies from both areas revealed a mid-dermal inflammatory infiltrate with many giant cells engulfing elastic fibres. The current nosological situation of this process is discussed.

Reactive perforating collagenosis–transepidermal elimination of type IV collagen

Abstract: Reactive perforating collagenosis (RPC) is a rare skin disorder characterized by reddish papules with a central keratotic plug which appear mainly on the extensor aspects of the limbs. An idiopathic or classical variant has been delineated from an acquired one which occurs in diabetes mellitus and renal failure. Histopathological examination of the lesions shows transepidermal elimination of abnormally staining bundles of collagen. To clarify the origin of this collagenous material we performed an immunohistochemical study including biopsies of two patients with RPC, one classical and one acquired. Staining reactivity to antibodies against type IV collagen was observed, thus providing evidence that the collagen eliminated in RPC may be derived from the basement membrane zone.

Successful treatment with topical PUVA of nodular cutaneous plasmacytosis associated with alopecia of the scalp

Abstract: We obtained a successful response to PUVA therapy in a 51-year-old Japanese man who had multiple nodules of the trunk, extremities and scalp along with polyclonal hypergammaglobulinaemia; the scalp lesions were associated with extensive alopecia. Examination of skin biopsies showed a dense infiltrate of mature plasma cells in the dermis and hair follicles; no systemic disease or functional involvement of other organs was detected. The clinical and histological findings were compatible with cutaneous plasmacytosis and treatment with topical PUVA gradually reduced the size and number of the lesions.

Vulval Crohn's disease: difficulties in diagnosis

Abstract: Four patients with chronic vulval inflammation are described. The histological features of non-caseating granulomata and multinucleated giant cells are compatible with Crohn's disease, but only two patients had proven gastrointestinal involvement. The clinical and histological characteristics of Crohn's disease and other granulomatous inflammations of the vulva are discussed and the literature is reviewed.