Showing papers in "International Journal of Dermatology in 1999"

The microbiology of infected and noninfected leg ulcers.

Abstract: Background A clinical study was undertaken to investigate and compare specifically the aerobic and anaerobic microbiology of infected and noninfected leg ulcers. Methods Leg ulcers, defined as being infected on the basis of clinical signs, were swab sampled and investigated for aerobic and anaerobic microorganisms using stringent isolation and identification techniques. Results Two hundred and twenty isolates were cultured from 44 infected leg ulcers, in comparison with 110 isolates from 30 noninfected leg ulcers. Statistical analysis indicated a significantly greater mean number of anaerobic bacteria per infected ulcer (particularly Peptostreptococcus spp. and Prevotella spp.) in comparison with the noninfected ulcer group (2.5 vs. 1.3, respectively) (P 0.05). The study failed to demonstrate a clear correlation between commonly implicated facultative pathogens and wound infection. The isolation rate of Pseudomonas aeruginosa was generally low and, although Staphylococcus aureus was a frequent isolate in both wound types, it was more prevalent in noninfected leg ulcers. Conclusions This study has demonstrated the complex aerobic–anaerobic microflora which exists in leg ulcers, the prevalence of anaerobes in infected wounds, and a poor correlation between the presence of specific aerobic pathogens and wound infection. In view of these findings, the role of microbial synergistic interactions in the pathogenesis of chronic wound infection may be of greater clinical importance than the isolated involvement of any specific potential pathogen.

Cytokines in psoriasis

Abstract: Many different stimuli can trigger the onset of psoriasis in genetically predisposed individuals.1 Although the disease was classified by Hebra as a distinct nosologic entity in 1841, the cell type(s) responsible for beginning the cascade of events leading to disease expression and the precise nature of the cell alteration are still unclear. Even with the new experimental approaches,2,3 no demonstration has yet been made of the possibility that the immunocyte or keratinocyte may be the principal actor in this disease and that the subsequent modifications may be mediated by different cytokines (see list of abbreviations in Table 1 and Fig. 1). Stimulated keratinocytes may act as initiators of an inflammatory process4 by means of the secretion of different modulators able to induce the expression of adhesion molecules on endothelial cells and the recruitment of circulating immunocytes (Fig. 1).4,5 These phenomena lead to the interaction between keratinocytes and activated T lymphocytes resulting in an increased proliferation of genetically predisposed keratinocytes.1,5 After stimulation, keratinocytes secrete a great variety of pro-inflammatory mediators, such as C5a, prostaglandins, leukotrienes, etc., also including many of the different cytokine types whose levels have been reported to be altered mainly at the level of psoriatic lesional skin (Table 2). These seem to play a key role in initiating and maintaining the two typical features of psoriatic lesions, i.e. keratinocyte hyperproliferation and inflammation (Table 3 and Fig. 1). Of the pro-inflammatory cytokines that are also produced by keratinocytes, the behavior of interleukin-1α (IL-1α), IL-1β, and tumor necrosis factor-alpha (TNF-α) in psoriasis will first be described. These three modulators, the socalled ‘‘primary cytokines,’’ activate a sufficient number of effector mechanisms to trigger independently cutaneous inflammation,6 and can be involved at an early stage in orchestrating the pathologic changes that occur in psoriasis.5

Maggot therapy for the treatment of intractable wounds.

Abstract: Background Fly maggots have been known for centuries to help debride and heal wounds. Maggot therapy was first introduced in the USA in 1931 and was routinely used there until the mid-1940s in over 300 hospitals. With the advent of antimicrobiols, maggot therapy became rare until the early 1990s, when it was re-introduced in the USA, UK, and Israel. The objective of this study was to assess the efficacy of maggot therapy for the treatment of intractable, chronic wounds and ulcers in long-term hospitalized patients in Israel. Methods Twenty-five patients, suffering mostly from chronic leg ulcers and pressure sores in the lower sacral area, were treated in an open study using maggots of the green bottle fly, Phaenicia sericata. The wounds had been present for 1–90 months before maggot therapy was applied. Thirty-five wounds were located on the foot or calf of the patients, one on the thumb, while the pressure sores were on the lower back. Sterile maggots (50–1000) were administered to the wound two to five times weekly and replaced every 1–2 days. Hospitalized patients were treated in five departments of the Hadassah Hospital, two geriatric hospitals, and one outpatient clinic in Jerusalem. The underlying diseases or the causes of the development of wounds were venous stasis (12), paraplegia (5), hemiplegia (2), Birger’s disease (1), lymphostasis (1), thalassemia (1), polycythemia (1), dementia (1), and basal cell carcinoma (1). Subjects were examined daily or every second day until complete debridement of the wound was noted. Results Complete debridement was achieved in 38 wounds (88.4%); in three wounds (7%), the debridement was significant, in one (2.3%) partial, and one wound (2.3%) remained unchanged. In five patients who were referred for amputation of the leg, the extremities was salvaged after maggot therapy. Conclusions Maggot therapy is a relatively rapid and effective treatment, particularly in large necrotic wounds requiring debridement and resistant to conventional treatment and conservative surgical intervention.

Wood’s light in dermatology

Abstract: Wood’s lampwas invented in 1903 by a Baltimore physicist, Robert W. Wood (1868–1955).1 The familiar long-wave ultraviolet (UV) light, known as Wood’s lamp, has become an invaluable tool in the practice of medicine. The first reported use of this lamp in dermatology occurred in 1925, being recommended for the detection of fungal infection of the hair.2 Unlike many other medical devices, which have tended to lose their popularity over time, Wood’s lamp has maintained its usefulness not only in dermatology, but also in ceramics where it can be used to determine repairs.

Head lice in pupils of a primary school in Australia and implications for control.

Abstract: Results Of the 456 children examined, 33.7% (95% confidence interval5 95%-CI 5 [26.9%, 40.4%]) had evidence of infestation with head lice, 21.0% (95%-CI 5 [15.2%, 26.8%]) with active infestation. The prevalence of infestation (active plus inactive) varied greatly between classes, ranging from zero to 72.2% (p , 0.001). Head lice were more prevalent in girls than boys (p , 0.001). Analysis of questionnaires showed that 47.7% (95%-CI 5 [43.0%, 52.4%]) of the children had been infested with head lice in the previous 6 months. For children with active pediculosis capitis on examination, 14.0% (95%-CI 5 [7.9%, 22.4%]) of parents or guardians had not noticed the infestation. Conclusions In an urban primary school in Australia, head lice infestation was present at a hyperendemic level. Clustering by class indicated the classroom as a main source of infestation. Control strategies implemented in schools and including the education of teachers and parents need to be evaluated.

The scope of onychomycosis: epidemiology and clinical features.

Abstract: The preliminary results of the Achilles Project data from Europe and East Asia were used to permit a more accurate estimate of the epidemiology of onychomycosis, the leading clinical features, and the most important predisposing factors of fungal foot infections. The Achilles foot-screening project is a scientific project to investigate the prevalence and seriousness of foot problems across Europe and East Asia. This project can be divided into two groups: a survey consisting of a clinical examination of the feet, and a study with a mycologic examination if an infection of the feet was suspected. Compared to other epidemiologic studies, a considerably larger population was screened; 80 396 subjects were examined: 13 695 in the European Study, 22 760 in the European Survey and 43 914 in the East Asian Survey. The clinical diagnosis of the physician was confirmed by a mycologic examination in the European study. Microscopic examination and culture were performed in order to identify the pathogen causing the fungal infection because this information is essential for the physician to choose the optimal treatment. The prevalence of foot diseases and, more specifically, of fungal infection is higher than imagined in this kind of population, i.e. patients who visit their physician for other problems than those with their feet. Dermatophytes were the most prevalent pathogens, especially Tricophyton rubrum, but yeasts like Candida albicanswere also possible infectious agents. Non-dermatophyte molds likeAspergillus

Squamous cell carcinoma and keratoacanthoma of the lower lip associated with "Goza" and "Shisha" smoking.

Abstract: Maxillofacial Surgery, Al-Azhar Background A positive correlation between lip and buccal cancers and pipe smoking University, Egypt, and Dermatology has been suggested. Various types of crude and manufactured tobacco products are Department, King Faisal University, consumed by smoking, chewing, and snuff dipping habits. ‘‘Shisha’’ and ‘‘Goza’’ smoking Al Khobar, Saudi Arabia are widely practiced in the Middle East. The ‘‘hubble-bubble’’ method and apparatus are Correspondence used. These smoking habits are hazardous to health, causing obstructive lung disease, Ibrahim E. El-Hakim, BDS , MDS , MS c, P h D and may be important predisposing factors for the development of oral cancers. Department of Oral and Maxillofacial Case reports Two cases of squamous cell carcinoma and a case of keratoacanthoma Surgery localized to the lower lip are presented in well-known ‘‘Shisha’’ and ‘‘Goza’’ smokers. 6 El-Gendy StreetHadayek Helwan 11433 Conclusions ‘‘Shisha’’ and ‘‘Goza’’ smoking have adverse effects on general health andCairo may predispose to oral cancer. An extensive epidemiological study should be performed

Comparative study of staphylococci from the skin of atopic dermatitis patients and from healthy subjects.

Abstract: Background Bacterial infections occur frequently on the skin of atopic dermatitis (AD) patients. The objectives of this study were to evaluate the microbiology of the skin of AD patients for staphylococci, the frequency and density of each species, and their susceptibility to antimicrobial drugs. Methods To study the staphylococci present on the skin of 21 AD outpatients and of 12 healthy subjects (HS), cutaneous organisms were obtained using the contact-plate method. ResultsStaphylococcus aureus was isolated in 85.7% of AD patients (mild type, 77.8%; moderate type, 87.8%; and severe type, 100%) and in 25% of HS, while Staphylococcus epidermidis was isolated in 83.3% of HS and in 38.1% of AD patients. Among the coagulase-negative staphylococci (CNS) identified, S. epidermidis was the common type and several other CNS were detected in both AD patients and HS. As the eruption grade of dermatitic skin became more severe, the average density of S. aureus increased (severe, 2.68 ± 0.86; moderate, 2.49 ± 0.48; mild, 2.28 ± 0.44). A reversed tendency was seen in S. epidermidis (severe, 1.80; moderate, 1.90; mild, 2.10). Among nine antimicrobial drugs tested against S. aureus, S. epidermidis, and some other types of CNS isolates, vancomycin (VCM) and minocycline (MINO) were the most active, gentamycin (GM) was the less active, and ampicillin (ABPC) was the least active. Conclusions The skin of AD patients was more frequently colonized with S. aureus than that of normal controls. As the severity of the AD lesions increased, the numbers of S. aureus isolated increased. The skin of HS was more colonized with S. epidermidis. Other species of CNS were isolated from several cases of AD patients and HS. In addition, S. aureus, S. epidermidis, and the other CNS showed poor susceptibility to some of the tested antimicrobial drugs.

The frequency of common nonmalignant skin conditions in adults in central Victoria, Australia

Abstract: Background Nonmalignant skin conditions are believed to be common in adults, although there are very few community-based studies to determine their exact frequency. Objective To record the prevalence of common, nonmalignant skin conditions in adults in central Victoria, Australia. Methods A total of 1457 respondents from a random selection of adults aged 20 years and over from Maryborough, central Victoria, were given a total body examination by a dermatologist or dermatology trainee. People with any nail or skin signs suggestive of tinea had scrapings taken for fungal culture. Results The age- and sex-adjusted prevalence of warts was 7.1% (95% confidence interval (CI), 5.8–8.4%), acne 12.8% (95% CI, 11.0–14.5%), atopic dermatitis 6.9% (95% CI, 5.6–8.3%), seborrheic dermatitis 9.7% (95% CI, 8.2–11.2%), asteatotic dermatitis 8.6% (95% CI, 7.1–10.0%), psoriasis 6.6% (95% CI, 5.7–7.9%), culture-positive tinea 12% (95% CI, 10.3–13.6%), seborrheic keratoses 58.2% (95% CI, 55.6–60.7%), and Campbell de Morgan spots (cherry angiomas) 54.4% (95% CI, 51.9–57.0%). There was variation in the prevalence of many of these conditions with age. Conclusions This study demonstrates that nonmalignant skin conditions are common in adults in Australia. Their diagnosis and management represent a considerable burden not only to those suffering from the conditions, but also to the health system which provides for their care.

The role of salicylic acid in the treatment of psoriasis.

Abstract: Psoriasis is a chronic, relapsing disorder in which the skin becomes scaly and inflamed; it affects 1–3% of the population of the U.S.A.1 In addition to classic plaque psoriasis, the condition can present in a variety of forms, including guttate, erythrodermic, inverse, and pustular psoriasis.1 Plaque psoriasis is characterized by hyperproliferation and poor differentiation of epidermal keratinocytes, by inflammation of the epidermis and dermis, and by profound alterations in the cutaneous vascular system.2 At one time, these changes were thought to be triggered by a dysfunction of keratinocytes, which then secondarily activated the delayed hypersensitivity response.3 Recent findings, however, suggest that the mechanism is primarily immunological. The observation that drugs such as cyclosporine and methotrexate can reduce the symptoms of psoriasis,4 combined with the discovery of activated, proliferating T-cell infiltration in epidermal plaques,5 strongly suggests that the disorder is due to alterations in the cell-mediated immune response. Psoriasis, however, is still not curable, and existing therapies focus on the control of its symptoms. Patients seek therapy to relieve pain and itching, which can be disabling, and to ameliorate cosmetic disfigurement. The goal of current psoriasis therapies, in short, is to minimize the severity and extent of the disease and its concomitant interference with quality of life.6 Today there are many therapies for psoriasis, all with varying degrees of effectiveness and safety. Salicylic acid is one commonly used topical agent;6 however, although salicylic acid has been known for more than a century,7 there is a remarkable lack of published data on its use in psoriasis. To assess the role of salicylic acid in the treatment of psoriasis, a consensus panel was convened at a roundtable discussion held in New York City on July 29, 1997. The results of this roundtable, including guidelines for the use of salicylic acid in psoriasis, will be presented in this review.

Diffuse hair loss

Abstract: The normal hair cycle (Fig. 1) results in the replacement of every hair on the scalp every 3–5 years.1 Hair growth on the adult human scalp is asynchronous. Thus, rather than all the hairs being replaced at once in a single moult, the shedding occurs continuously so that between 50 and 150 telogen hairs are shed each day. While there is some seasonal variation in the amount of hair lost each day, this amount remains fairly uniform throughout life. Most of this hair loss passes unnoticed, particularly when the hairs are short.2 Disease states that cause large numbers of hairs to fall out may be classified according to whether the follicle remains intact or is destroyed and replaced by scar, and to whether the hair loss is patchy, patterned, or diffuse (Table 1). Diffuse hair loss may be further classified by the type of hairs that are shed, in particular whether they are anagen or telogen hairs. As telogen hairs have a depigmented bulb, examination of the shed hairs with the naked eye will usually clarify this. The focus of this review is diffuse nonscarring telogen hair loss. The cause can usually be established on history together with a few simple screening blood tests, which include thyroid function tests and iron studies. In addition, serum zinc estimation, antinuclear factor antibody titer, and syphilis serology may be required in some cases. Diagnostic difficulty may occur when the pattern of the loss is unclear, as occurs in early androgenetic alopecia in women, rendering it hard to distinguish this condition from other causes of chronic diffuse telogen hair loss such as chronic telogen effluvium. In this situation a scalp biopsy will be required to establish the diagnosis.

Onychomycosis in Lahore, Pakistan.

Abstract: Background Onychomycosis, a common nail disorder, is caused by yeasts, dermatophytes, and nondermatophyte molds. These fungi give rise to diverse clinical presentations. The present study aimed to isolate the causative pathogens and to determine the various clinical patterns of onychomycosis in the population in Lahore, Pakistan. Patients In 100 clinically suspected cases, the diagnosis was confirmed by mycologic culture. Different clinical patterns were noted and correlated with causative pathogens. Results Seventy-two women (mean age, 32.6 ± 14.8 years) and 28 men (mean age, 40.6 ± 15.8 years) were studied. Fingernails were involved in 50%, toenails in 23%, and both fingernails and toenails in 27% of patients. The various clinical types noted were distolateral subungual onychomycosis (47%), candidal onychomycosis (36%), total dystrophic onychomycosis (12%), superficial white onychomycosis (3%), and proximal subungual onychomycosis (2%). Candida was the most common pathogen (46%), followed by dermatophytes (43%) (Trichophyton rubrum (31%), T. violaceum (5%), T. mentagrophytes (4%), T. tonsurans (2%), and Epidermophyton floccosum (1%) and nondermatophyte molds (11%) (Fusarium (4%), Scopulariopsis brevicaulis (2%), Aspergillus (2%), Acremonium (1%), Scytalidium dimidiatum (1%), and Alternaria (1%). Conclusions Onychomycosis is more common in women of 20–40 years of age. Distolateral subungual onychomycosis and candidal onychomycosis are the most common clinical presentations, and Candida and T. rubrum are the major pathogens in Pakistan.

Betamethasone valerate foam 0.12%: a novel vehicle with enhanced delivery and efficacy.

Abstract: Background: A new topical formulation of betamethasone valerate (BMV) with enhanced dermal penetration has been developed. Objective: These studies were designed to evaluate: (1) the relative bioavailability of BMV foam, and (2) the safety and efficacy of BMV foam in the treatment of scalp psoriasis as compared to a lotion formulation of BMV and placebo. Methods: Safety and efficacy were evaluated in a randomized, multicenter, double-blind, active-and placebo-controlled trial in adult patients with moderate to severe scalp psoriasis. A separate study in 18 patients was conducted to evaluate the potential for suppression of the hypothalamic–pituitary–adrenal (HPA) axis. Relative bioavailability was measured using the human cadaver skin model. Results: 72% of patients using BMV foam were clear or almost clear of disease at the end of 28-days of treatment as judged by the investigator’s global assessment of response. Only 47% of BMV lotion patients and 21% of placebo showed a similar level of response. There was no evidence of increased toxicity or HPA-axis suppression for BMV foam, but assessment of relative bioavailability showed BMV penetration into the skin to be more than two-fold greater than from BMV lotion. Conclusions: A novel foam formulation with enhanced BMV bioavailability has been shown to be of increased efficacy in the treatment of scalp psoriasis without an associated increase in toxicity.

The efficacy of low-dose oral corticosteroids in the treatment of vitiligo patients

Abstract: Background One of the most probable pathogeneses of vitiligo is autoimmunity. Systemic corticosteroids suppress immunity and may arrest the progression of vitiligo and lead to repigmentation. The clinical efficacy of low-dose oral corticosteroids was assessed to minimize the side-effects in actively spreading vitiligo patients. Methods Eighty-one patients with vitiligo were evaluated. The patients took daily doses of oral prednisolone (0.3 mg/kg body weight) initially for 2 months; the dosage was then reduced to half of the initial dose for the third month and was halved again for the fourth and final month. The effects of treatment were evaluated using photographs of before and after the study. Side-effects were assessed at the first, second, third and fourth month of treatment. Results Arrested progression of vitiligo and repigmentation were noted in 87.7% and 70.4% of patients respectively. Male sex, a patient age of 15 years or under, and a duration of disease of 2 years or less showed increased repigmentation with statistical significance. The side-effects of treatment were minimal and did not affect the course of treatment. Conclusions Low-dose oral corticosteroids are effective without serious side-effects in preventing the progression and inducing repigmentation of actively spreading vitiligo, which is difficult to treat with topical corticosteroids or photochemotherapy.

A controlled trial of traditional Chinese herbal medicine in Chinese patients with recalcitrant atopic dermatitis

Abstract: Background There have been published reports from the United Kingdom of good responses to the use of traditional Chinese herbal medicine (Zemaphyte®, Phytopharm Plc, Cambridge, UK) in treating recalcitrant atopic dermatitis. We conducted a double-blind, placebo-controlled, cross-over study among Chinese patients with recalcitrant atopic dermatitis using this same herbal preparation. Methods Forty patients were recruited. They were given Zemaphyte® and placebo in random order, each for 8 consecutive weeks with a 4-week wash-out period in between. Scores based on the severity and extent of four clinical parameters (erythema, surface damage, lichenification and scaling) were recorded at baseline and at 4-weekly intervals throughout the 20-week trial period. Results Thirty-seven patients completed the trial. There was a general trend of clinical improvement with time throughout the trial period in both patient groups, irrespective of whether they received Zemaphyte® or placebo first. Zemaphyte®, however, offered no statistically significant treatment effect over placebo for all four clinical parameters, except for lichenification at week 4. There were no significant carry-over effects. Blood tests for hematologic, renal and liver functions were all normal throughout the trial. Conclusions Zemaphyte® did not seem to benefit Chinese patients with recalcitrant atopic dermatitis in our study. Further research is required to evaluate its efficacy.

The cosmetic uses of Botulinum toxin type A

Abstract: One of the telltale signs of aging is increased wrinkling of the face. This can occur naturally over time and is identified by certain biochemical, histologic, and physiologic changes that are enhanced by environmental exposure.1 There are other secondary factors that can cause characteristic folds, furrows, and creases of the face.2 These include the constant pull of gravity, frequent and constant positional pressure on the skin of the face (e.g. during sleep), and repeated facial movements caused by the contractions of the muscles of facial expression.2 Movement of the mimetic muscles of facial expression can contribute to the outward manifestation of a person’s inner emotions. Therefore, not only can wrinkles of the face bear witness to the stress of the environment, the aging process, and the persistent forces of body position and gravity, but they can also exhibit outward expressions of inward and, at times, secretive emotions, whether or not they are an accurate reflection of the sentiment felt by a person at a particular time. For example, someone in a pensive or inquisitive mood can appear to be angry or disgusted if mid-forehead frowning occurs. A negative signal is conveyed, and the true nature of the person’s emotion is lost (Fig. 1a,b). In an attempt to mollify these telltale signs of aging, stress, gravity, and negative emotions, injections of Botulinum toxin type A have been used to diminish the undesirably negative and expressive rhytides of the face by producing a reversible weakness of the hyperfunctional mimetic muscles of facial expression. The pharmacophysiology, preparation, recommended handling, and administration of Botulinum toxin type A, i.e. BOTOX®, will be reviewed subsequently.

Linear IgA Bullous Dermatosis

Abstract: Linear IgA bullous dermatosis (LABD) is a unique autoimmune blistering disease which can present both in children and adults. There are various clinical presentations of the disease which can involve both cutaneous and mucosal tissues. LABD has been reported to be associated with medications, ulcerative colitis, and malignancies. This chapter will discuss the diagnosis, current therapies, and possible treatment algorithms for managing LABD patients.

Detection of Mycobacterium tuberculosis DNA using polymerase chain reaction in cutaneous tuberculosis and tuberculids.

Abstract: Background The objective of this study was to explore the role of the polymerase chain reaction (PCR) for the detection of Mycobacterium tuberculosis DNA as a diagnostic aid in cutaneous tuberculosis, using routinely processed skin biopsy specimens. Methods and results A wide range of clinical specimens representing different forms of cutaneous tuberculosis and so-called tuberculids were studied. A sensitive and specific PCR assay targeting the sequence IS6110 of Mycobacterium tuberculosis complex was used. The specimens were categorized as follows. 1 Acid-fast bacilli (AFB) positive on biopsy (nine specimens from seven patients who were immunocompromised). PCR was positive in five specimens. Of these, one specimen was culture positive and three specimens were culture negative. 2 AFB negative on biopsy: (a) tuberculosis verrucosa cutis (23 specimens); (b) lupus vulgaris (three specimens); (c) cutaneous tuberculosis clinically suspected (six specimens). PCR was negative in all specimens. 3“Tuberculids.” (a) erythema induratum/nodular vasculitis (20 specimens); (b) papulonecrotic tuberculid (two specimens); (c) erythema nodosum (20 specimens). PCR was negative in all specimens. Conclusions The role of PCR in clinical dermatologic practice, at this stage, may be in differentiating between cutaneous tuberculosis and atypical mycobacterial infections in the context of an immunocompromised patient where AFB can be demonstrated on biopsy and cultures may be negative. In this clinical situation, PCR allows the prompt diagnosis and early institution of appropriate therapy. We have not found PCR to be a useful complement to the clinical and histologic diagnosis of “paucibacillary” forms of cutaneous tuberculosis.

Pityriasis rubra pilaris

Abstract: Pityriasis rubra pilaris (PRP) is an idiopathic, papulosquamous disease which has remained enigmatic for more than one and a half centuries after its first description. A review of the clinical features, histopathologic findings, classification, and treatment is presented. Subjects of recent focus in the literature are discussed, including the occurrence of PRP in patients with human immunodeficiency virus (HIV), speculation that PRP may result from an abnormal immune response to antigenic stimulation, and additions to the histopathologic descriptions of the disease.

Molluscum contagiosum: its clinical, histopathologic, and immunohistochemical spectrum

Abstract: Although molluscum contagiosum virus (MCV) is considered by some as an unclassified poxvirus, others consider it a member of the orthopoxvirus genus, family Poxiviridae. It is a large double-stranded DNA virus that has a worldwide distribution. With the eradication of small pox, variola virus (VAR), MCV remains by far the most common pox viral pathogen for humans.1–6 Lesions of MCV occur almost exclusively in the skin, and only rare reports have referred to mucous membrane lesions.1–3 Lesions of MCV are most commonly seen in young children, sexually active adults, and in some immune suppressed patient populations (Figs 1–5). Although MCV infections are highest in warm moist climates, and in populations where personal hygiene is difficult to maintain, they have a worldwide distribution.1–3 In children, MCV has a diffuse distribution and may occur on the face, trunk, and extremities, as well as in the genital area (Fig. 1).1–4 In young adults, sexual contact is probably the most common mode of transmission, and genital lesions are common (Fig. 2).1–4 In human immunodeficiency virus type 1-positive (HIV-11) patients, widespread lesions do occur, but head and neck lesions are most common, followed by genital involvement.1–4,7,8 Although the typical umbilicated papules occur in all patient populations, in HIV-11 patients, verrucous, warty papules, as well as giant molluscum greater than 1 cm in diameter, are also seen (Figs 3–5).1–4,7,8 In patients without severe immune suppression, lesions produced by MCV typically regress spontaneously usually within months, rarely years.1–6,9 MCV cannot be grown in tissue culture cells and does not infect animals; however, it has been replicated in human skin grafted to immune deficient mice.5,6,9 MCV is only distantly related to VAR, and lacks DNA cross-hybridization or immunologic cross-reactivity.5,6,9 Four major subtypes of MCV have been defined by recent work, including three MCV-1 variants and MCV-2, MCV-3, and MCV-4 subtypes.9 MCV-1 subtypes dominate worldwide and, in one report, MCV-1 subtypes occurred exclusively in children under the age of 15 years;2,3,10 however, there is evidence that other MCV subtypes are more common in the HIV-11 patient population.3,11 In the light of the new molecular information available on MCV, we returned to review the clinical and histologic features seen in both HIV11 and HIV-1– individuals.

Recombinant human granulocyte‐macrophage colony‐stimulating factor applied locally in low doses enhances healing and prevents recurrence of chronic venous ulcers

Abstract: Background Chronic venous leg ulcers have a major medical and economic impact on the elderly worldwide. Healing of the large ulcers (>10 cm2 ) occurs only in two-thirds of the patients and reulceration of healed ulcers recurs in one-third within 1 year. Because both healing and relapse rate influence greatly a patient’s quality of life and the overall cost of treatment, every effort should be made to improve these two parameters. Objective To determine the safety and efficacy of topical low-dose recombinant human granulocyte-macrophage colony-stimulating factor (rhu GM-CSF) for the treatment of venous ulcers, and to document any improvement in healing rates. Methods Thirty-eight patients (29 women, 9 men; median age, 74 years) with chronic venous insufficiency were treated with topical rhu GM-CSF (5 μg/mL 0.9% sodium chloride solution), followed by application of a compression dressing. All subjects were treated as outpatients. Results Complete healing was observed in 47 of the 52 ulcers (90.4%). The average healing time was 19 weeks. No systemic or local side-effects from the therapy were observed. Nine chronic ulcers, previously refractory to conventional treatment (pretreatment for more than 46 weeks), showed the same response rate (9/8, or 88.9%) and healing time (mean, 19 weeks). After 40 months, no reulceration of the healed ulcers was observed, but two patients developed new ulcers on the same leg. Healing remained stable, with excellent cosmetic results. Conclusions In this first study, topically applied low-dose rhu GM-CSF was a safe treatment for chronic venous leg ulcers. Healing rates were significantly increased and relapse rates were minimal.

Modified technique of suction blistering for epidermal grafting in vitiligo.

Abstract: Background Suction blister epidermal grafting is a useful modality of treatment of resistant and stable vitiligo; however, it requires expensive and heavy suction apparatus. This study is an attempt to develop a cheap and small apparatus which can be assembled in the physician’s own office. Patients and methods The method was tried in 22 vitiligo/leukoderma patients. The apparatus consisted of a cylindrical funnel connected with a three-way tap , and suction was given by a 50-mL syringe. The pressure inside the suction cup was retained by changing the position of lock of the three-way tap. The pressure was measured by connecting the three-way tap to a vacuum gauge. The apparatus remained adhered to the donor area because of negative pressure. The blister was formed in about 1.5 h. The roof of the blister was grafted onto the dermabraded recipient site. Results The pigmentation was complete in 20 out of 22 patients. There were no complications. Conclusions The technique is inexpensive and easy and obviates the need of cumbersome and heavy equipment.

Current therapies for wound healing: electrical stimulation, biological therapeutics, and the potential for gene therapy.

Abstract: It has long been known that dermal wounds may show The healing of wounds results from a number of temporally impaired healing in patients with peripheral arterial occlusco-ordinated processes that involve several events driven ive disease (PAOD), deep vein thrombosis (DVT), and by locally released mediators.1–11 The first event is immedidiabetes. For example, wounds in diabetic patients heal ate and consists of the activation of the coagulation cascade very slowly or not at all when compared with wounds and the production of a blood clot. After several minutes, in nondiabetics. Despite intense investigation, the precise an acute inflammatory response ensues. Subsequently, molecular mechanisms associated with impaired healing in leukocytes clear the wound of debris and release growth this patient group are poorly understood. A number of factors to initiate the healing process. Then follows the laboratories have shown reductions in the levels of growth first stage of collagen repair involving deposition and the factors and their receptors. These include PDGF recepformation of granulation tissue which becomes a new and tors,20 IGF-I and IGF-II,21 keratinocyte growth factor temporary weak tissue. The third and final process is the (KGF),22 TGFβ and IGF-I,23 TGFβ1,2,3 and receptors.24 second phase of collagen repair resulting in extracellular Consistent with these findings, several groups have shown matrix remodeling, angiogenesis, and the reproduction of that the application of growth factors may induce the full strength tissue comparable to the original skin. Much acceleration of cutaneous wound healing in murine models of the normal healing process is driven by growth factors. of diabetes. These studies are described later. In addition to their role in blood clot formation, platelets generate a number of growth factors that are found in wound fluid, including transforming growth factor α Healthcare burden for the treatment of (TGFα), platelet-derived growth factor (PDGF), epidermal chronic wounds growth factor (EGF), vascular endothelial growth factor (VEGF), transforming growth factor β (TGFβ), and insulinUlcers associated with pressure and arterial and venous like growth factor I (IGF-I).12–15 In the inflammatory diseases response, neutrophil migration is induced by PDGF, Dermal ulcers are a common complication and frequent interleukin 1α (IL1α), IL8, tumor necrosis factor α (TNFα), cause of hospital admission for many patients suffering granulocyte macrophage colony-stimulating factor with diabetes. In 1992, in the UK, 2% of the diabetic (GM-CSF), and granulocyte colony-stimulating factor population were documented as having ulcer history with (G-CSF).16–19 Thus, multiple growth factors and cytokines approximately 0.5% having active ulcers at any one time.25 There is a marked increase in dermal ulcer prevalence play a major role in wound healing. 808

Leprosy: pathogenesis updated

Abstract: Leprosy is a chronic infectious disease caused by Mycobacterium leprae, which can express itself in different clinico-pathologic forms, with a Mitsuda reactiondependent bipolar distribution. A spherical model of leprosy (Fig. 1) shows two hemispheres and an equatorial zone. The tuberculoid hemisphere, with variably positive Mitsuda reaction, includes polar (TT) and subpolar (Tt) tuberculoid leprosy, and macular (Tm), maculoanesthetic (Mal), and low resistant (Lrtl) tuberculoid leprosy. The lepromatous hemisphere, with negative Mitsuda reaction, includes polar (LL) and subpolar (sLL) lepromatous leprosy. At the equator, intermediate variants may develop: Mitsuda-positive borderline tuberculoid (BT), Mitsudanegative borderline lepromatous (BL) and borderline borderline (BB) leprosy. Histopathologically, at the tuberculoid hemisphere, cellmediated immunity prevails and epithelioid granulomas with scarce or no bacilli predominate. At the lepromatous hemisphere, a specific inflammation represented by lepromatous granulomas or virchowcytic granulomas, containing modified macrophages called lepra cells or virchowcytes, is seen. In borderline leprosy, both types of granulomas may coexist, not infrequently with modified epithelioid or lepra cells. Indeterminate leprosy (IL) reveals lymphocytic infiltrates, perhaps related to immune mechanisms that precede the development of tuberculoid granulomas and epidermal lichenoid reactions, or the appearance of only a few lepra cells, with no epidermal lesions; both types of indeterminate leprosy are associated with perineuritis. This thorough classic classification (Fig. 1) has been replaced by a simpler and briefer one that considers two polar (TT, LL) and several borderline forms. Since then, the spectrum of leprosy as a continuum, with transitions in either direction, has been accepted.1–5 The notion of a

Immunology of the cutaneous disorders of pregnancy.

Abstract: maintained during gestation, human circulating leukocytes Pregnancy is an immunologic state where a natural show a lower cytotoxic activity against fetal cells, but homeostasis exists between antigenically different tissues.1 selective suppression of cellular immunity may occur in A fetus can be compared with a grafting of tissues attached response to specific antigens according to Feinberg and to an individual of the same species, but genetically differGonik.1 ent; this phenomenon is also known as an allograft. In general, we can say that normal pregnancy is characterPregnancy is therefore a phenomenon whereby a natural ized by a lack of strong maternal cell-mediated antifetal allograft exists without a state of immunosuppression, as immunity and a dominant humoral immune response.6 the mother must also maintain immunocompetence against The peripheral total number of T cells in pregboth pathogenic and neoplastic invasion during gestanant women does not vary a great deal in the three tion.1–4 trimesters according to our experience and that of other At this point, not all the mechanisms that make possible authors.1,3,7–9 The percentage of B and T lymphocytes is the tolerance during pregnancy are well known. The main not altered during pregnancy, and there is no consistent objective of this review is to gather updated information alteration in their performance.3 about the immunologic mechanisms known in pregnancy, There is no specific maternal cellular response against the immunologic basis of certain dermatologic diseases fetal (paternal) human leukocyte antigens (HLAs) and present during gestation, and the influence of pregnancy the trophoblast in vitro is resistant to cellular immune on different diseases that are immunologically mediated. destruction.1,10 The decidua, the name for the endometrium We begin by discussing what happens to humoral and during pregnancy, is an immunologically active immunocellular immunity in pregnancy. The data reviewed here regulatory tissue that plays a key role in pregnancy outcome. come from humans as well as from murine models. For instance, natural killer (NK) cell activity is depressed

Cutaneous manifestations due to Pseudomonas infection.

Abstract: Pseudomonas aeruginosa (PA) is a Gram-negative bacillus capable of producing infections, which mainly affect patients with immunosuppression, and usually occur in a hospital environment. PA can produce infections in many different organs, including the skin and soft tissue. The cutaneous manifestations of PA infection represent a wide spectrum of pathologic entities, ranging from minor skin lesions in healthy patients involving the external auditory canals, nails, and toeweb spaces to formidable skin signs of potentially life-threatening Pseudomonas septicemia in immunocompromised patients.1 PA infections have become more common. This increasing prevalence has been caused by a number of factors, including antimicrobial selection pressures, the wide use of immunosuppressive treatments, the higher survival rate of immunocompromised patients, endemic hospital reservoirs, invasive procedures that allow the organism to penetrate the host, and changes in lifestyle (saunas, jacuzzis, contact lenses, etc.).2–4

Congenital self-healing histiocytosis (Hashimoto-Pritzker).

Abstract: Background Congenital self-healing Langerhans cell histiocytosis (CSHLCH) is a rare condition, initially seen at birth or in the neonatal period, with generalized papules, vesicles, or nodules. Affected infants are otherwise well and the skin lesions tend to involute spontaneously within weeks to months. Methods Twelve patients with CSHLCH were seen from 1989 to 1998. Results Eight patients were girls and four were boys and all presented with lesions at birth which disappeared 1–3 months later. The lesions consisted of numerous brownish-red papules, papulovesicles, crusts, and nodules distributed on the face, limbs, palms, and soles. Two patients had oral mucosal lesions, and one had ulcerated lesions that evolved leaving hypochromic macules. Light microscopy showed a histiocytic infiltrate in the papillary dermis with epidermotrophism. Two cases were studied by electron microscopy: the Langerhans cells showed Birbeck granules and laminated corpus in their cytoplasm. Immunomarking with S100 protein was performed in all 12 patients and was positive. CD1 was also tested in four cases and was positive. Conclusions Because CSHLCH is a rare condition, we emphasize that, although it is usually a benign, self-limited entity, careful evaluation for systemic disease must be performed and long-term follow-up must be carried out to detect evidence of relapse or progression of the disease; this is essential when treating these patients.

Myiasis: a successful treatment with topical ivermectin.

Abstract: A67-year-oldmansufferedacerebrovascularstrokeleadingtohemiparesisanddysarthriain1987.Duringthepast2years, he had developed a tumoral lesion on the rightauricleandperiauricularulceration,forwhichnopreviousmedical therapy had been performed. He was seen onconsultationin theemergencyroom complainingofa 7-dayhistoryofedema,erythema,andseverelefthemifacialpain. On physical examination, he disclosed a grayishmembrane covering the ulcerated area, which, uponremoval,revealedapproximately100livelarvae(Fig.1).

Mucocutaneous manifestations of HIV infection: a retrospective analysis of 145 cases in a Chinese population in Malaysia.

Abstract: Background Mucocutaneous lesions directly related to human immunodeficiency virus (HIV) infection usually present as initial manifestations of immune deficiency. The most common mucocutaneous lesions are Kaposi’s sarcoma, histoplasmosis, oro-esophageal candidiasis, oral hairy leukoplakia, and, in Asia, Penicillium marneffei infection. Non-HIV-related skin lesions, such as psoriasis, seborrheic dermatitis, and nodular prurigo, may be the initial presentation among HIV infected patients attending outpatient clinics. Methods A retrospective analysis was performed on 145 HIV-positive Malaysians of Chinese descent from two centers at the University Hospital Kuala Lumpur (UHKL) and the General Hospital Kuala Lumpur (GHKL) from March 1997 to February 1998. Demographic data and clinical data were analyzed. Results The analysis showed that 104 out of 145 patients had mucocutaneous disorders (71.7%). In the study, there were 100 men (96.2%) and four women (3.8%). The majority of patients were in the age group 20–50 years. The patients who presented with mucocutaneous disease also had low CD4+ T-lymphocyte counts and most had acquired immunodeficiency syndrome (AIDS) defining illness. The number of cases with generalized hyperpigmentation was very high in the group (35.9%), followed by nodular prurigo (29.7%) and xerosis (27.6%). Seborrheic dermatitis was seen in 20.7% of cases, with psoriasis in 8.3%. The most common infections were oral candidiasis (35.9%), tinea corporis and onychomycosis (9.7%), and herpes infection (5.5%); however, mucocutaneous manifestations of Kaposi’s sarcoma were rare. Conclusions The results suggest that mucocutaneous findings are useful clinical predictors of HIV infection or signs of the presence of advanced HIV infection.