Floor-pattern salt-split skin cannot distinguish bullous pemphigoid from epidermolysis bullosa acquisita. Use of toad skin.

BACKGROUND AND DESIGN: Patients with epidermolysis bullosa acquisita (EBA) and bullous pemphigoid (BP) can present with similar clinical features. These antigens have different phylogenetic origins. It was thought that sodium chloride split-skin immunofluorescence could reliably distinguish between BP and EBA. However, it has now been recognized that both diseases can present with a floor pattern fluorescence on salt-split skin. A simple method is required to distinguish these diseases. RESULTS: Serum specimens from two patients presenting with pruritic blisters showing a floor pattern immunofluorescence on salt-split skin were found to have positive fluorescence on toad skin that has the BP and not the EBA antigen. The diagnosis of BP in these patients was confirmed by a prompt response to treatment with systemic steroids. Electron microscopy showed a split at the lamina lucida. CONCLUSIONS: Bullous pemphigoid can present with a floor pattern immunofluorescence on salt-split skin. The use of the skin from invertebrates like the toad may help in distinguishing BP from EBA.

Leukemia cutis.

Leukemia cutis is an uncommon manifestation of leukemia that is strongly associated with the presence of extramedullary disease at other sites. Patients usually present with leukemia cutis concomitantly with systemic leukemia or after leukemia has been diagnosed. Acute monocytic, myelomonocytic, and the T-cell leukemias show the highest incidence of leukemia cutis. The lesions show varied morphology and can be difficult to distinguish both clinically and histopathologically from nonspecific cutaneous lesions, which occur much more frequently. Immunohistochemistry is useful in making the distinction between them. The prognosis in leukemia cutis is generally poor; the best results have been achieved with a combination of systemic and local therapy.

Effect of sexual practices on T cell subsets and delayed hypersensitivity in transsexuals and female sex workers.

To determine whether ano-receptive unprotected sexual intercourse (SI) practised by transsexuals produces immunological abnormalities we compared delayed hypersensitivity skin tests (DTH) and T cell helper (CD4) and suppressor (CD8) subsets in 57 transsexuals and 69 female sex worker controls. The populations were matched for age, duration of prostitution, number of clients and previous use of antibiotics. Heterosexual males and females and transsexuals who practised protected SI, were also included as controls. All were HIV negative. There were significantly increased absolute CD4 and CD8 counts and decreased DTH and CD4/CD8 ratios in those who practised unprotected ano-receptive SI. These changes were unlikely to be due to any of the microbial agents tested. We conclude that ano-receptive sexual intercourse results in increased immunological abnormalities in these sex workers possibly as a result of rectal exposure to seminal alloantigens. These abnormalities could play an important role as co-factors in disease transmission.

Efficacy of health education programme on awareness of AIDS among transsexuals.

A study of the awareness of Acquired Immunodeficiency Syndrome (AIDS) among Transsexual prostitutes attending the Middle Road Hospital was made. The present study involved 71 subjects of a cohort of 100 who were interviewed a year earlier and had subsequently been given intensive health education. The results show that there was now an increased awareness of AIDS in virtually all the subjects studied. In contrast, there has been no significant change in the use of safe sex practices as a direct consequence of this knowledge. The reasons for this are discussed. There may be a need for more intensive behaviour modification programme in this group of individuals.

PIP: 100 Transsexual prostitutes originally interviewed in 1984 and 1985 were recalled in Singapore and interviewed by questionnaire during 1985 and 1986. 71 completed the health education session. They were given a pamphlet about methods of transmission and measures used to decrease risk. Individual verbal counselling on risk factors, transmission, and the etiology of AIDS was administered by the Epidemiological Counselling Unit (ECU). Condoms and the reduction of exchange of body fluids were recommended to decrease risk. Gonococcal smears were taken every 2 weeks, and syphilis serology was done 3 monthly. There were 35 Chinese aged 20-49, 27 Malays aged 20--55, and 9 Indians aged 24-33. THere was a greater awareness of AIDS in the present cohort of 71 subjects as a result of health education sessions conducted by the ECU. However, there was no significant difference in the sexual practices within the 3 ethnic groups. They continued their high risk sexual practices as before, probably because of their socioeconomic status and their educational level. They were avoiding Caucasians and oral sex, as sources of HIV infection. Condom usage did not change significantly, however, their perception that attendance at the hospital protected them from AIDS dropped from 26 (26%) in 1984-85 to 2 (3%) in 1985-86. THese finding show that although there was in increased awareness of AIDS, there was no significant change in the use of safe sex practices. More intensive but simple behavior modification programs are needed to reduce unsafe sex practices.

Awareness of AIDS among transsexual prostitutes in Singapore.

PIP: A study was conducted on 100 Singapore transsexual prostitutes in an attempt to discover AIDS awareness and any precautions which might have been taken by the prostitutes to limit their exposure to the AIDS virus. The results are as follows: the age, race and educational levels of the transsexuals were recorded. 55% of the transsexuals were Chinese, 36% were Malay, and 9% were Indian. The age range of the transsexuals was 20-55; the mean age of the Chinese transsexuals was 30.9; Malay was 33.1; and Indian was 27.0. 46% of the Chinese transsexuals, 64% of the Malay and 77% of the Indian had received only Primary education or were uneducated. 50% of the Chinese, 30% of the Malay and 23% of the Indians had received Secondary education. 4% of the Chinese and 6% of the Malay had received Post Secondary education. When asked, "Have you heard of AIDS?" 67% of the Chinese, 48% of the Malay and 44% of the Indians replied in the affirmative. When asked, "Has knowledge of AIDS altered your sexual practice?" 67% of the Chinese, 48% of the Malays and 44% of the Indians answered in the affirmative. Safe sex methods reported were: use of condoms, avoidance of Caucasians, checking of genitalia, non-penetration, and cleaning after the act.^ieng

Adjuvant therapy of bullous pemphigoid with mycophenolate mofetil: old drug, new use.

Bullous Pemphigoid (BP) is an autoimmune subepidermal blistering disease appearing predominantly in the elderly. The disease is primarily treated with systemic corticosteroids. However, the treatment can be associated with significant morbidity. Adjuvant corticosteroid sparing therapy can also be associated with significant morbidity. In this study a case of BP which was difficult to control with systemic steroids was successfully treated with mycophenolate mofetil as adjuvant therapy. Mycophenolate mofetil used previously in transplantation, has recently been shown to be useful in autoimmune blistering disorders. Further study to confirm this significant finding and to determine if the long term prognosis of BP can be altered by the drug, is required.

A review of neurological complications in AIDS.

Involvement of the central nervous system is now being recognized as an important aspect of HIV infection. Acting as a sanctuary site, it may pose problems to effective therapeutic strategies. HIV-induced AIDS dementia complex is the commonest mode of presentation. Other causes include opportunistic infections and, more infrequently, malignancies. The precise diagnosis is often difficult to make and requires the judicious use of the CT scan. Treatment has been disappointing and is characterized by frequent relapses.

Current therapy of HIV associated infections and malignancies.

Drug therapy in AIDS is used to prolong life as there are many infections and malignancies which appear as a consequence of the immunosuppression and these can be fatal. Current anti-virals which specifically inhibit HIV replication are being used earlier to extend quality of life, maintain immune status and reduce the prevalence of opportunisitic infections and malignancies. Some infections cannot yet be treated and new therapies are awaited. It is too early in the epidemic for significant drug resistance to emerge. However, this is to be expected in the future. The prevalence of adverse drug reactions is significantly increased and therefore newer alternatives are keenly awaited. Drug treatment of HIV infected individuals is a formidable task requiring skilled multidisciplinary approach. This review summarises the most current treatment modalities for HIV associated infections and malignancies.

Sodium chloride split skin in detecting circulating bullous pemphigoid antibodies.

Sodium chloride split skin is a sensitive and cheap substrate compared to Monkey Oesophagus and cadaveric skin in detecting bullous pemphigoid antibodies. Split skin results in greater exposure of antigen for antibody binding. It is recommended for routine use in immunofluorescence laboratories.

Cutaneous carcinogenesis: a review of recent advances in pathogenesis.

The clinical spectrum of cutaneous carcinogenesis has not changed substantially. New insights into the pathogenesis of ultraviolet induced lesions have resulted in better understanding of the basic biology of cutaneous tumours. This has evolved into the development of 4 stages in skin carcinogenesis. New problems like Human Immunodeficiency Virus (HIV), associated tumours and ozone depletion are emerging, which will require greater research efforts into preventing a further increase in incidence.

Cutaneous angiofibromas: treatment with the carbon dioxide laser.

A keloid-prone young Chinese patient with multiple facial angiofibromas (incomplete form of tuberous sclerosis) who had been previously treated with liquid nitrogen and electrocautery is presented. He was treated with carbon dioxide laser using low irradiance to vapourize most of the lesions. Postoperative progress was uneventful and results after one-year follow-up showed very satisfactory cosmetic results. There was no recurrence or complication on prolonged follow-up. Carbon dioxide laser is advocated as the treatment of choice for angiofibromas.

Immunofluorescence studies of pemphigus and pemphigoid in Singapore.

Immunofluorescence studies (direct and indirect) were done on 48 cases of pemphigus and 55 cases of bullous pemphigoid. All cases of pemphigus had in vivo and in vitro IgG intercellular antibodies except for two patients whose sera were not sent for pemphigus antibodies. 47 (85.4%) of our pemphigoid patients had linear C3 deposits on the basement membrane zone while 29 (52.7%) had IgG deposition. Only 17 (30.9%) patients had circulating pemphigoid antibodies. The results were compared and discussed with those reported by other earlier authors.

Drug-induced purpura simplex: clinical and histological characteristics.

Purpura simplex (PS) is a chronic condition manifesting as purpura, dermatitis and pigmentation. Histologically it is characterised by extravasation of erythrocytes and perivascular inflammation without fibrinoid necrosis. Most cases of PS are idiopathic. In order to determine if PS can be drug induced, a prospective study of 183 patients with PS was carried out. Of these, 27 patients were confirmed to be drug induced, as the purpura cleared on withdrawal of medications within four months. Lesions of drug-induced PS were significantly more generalised as compared to PS patients without a drug history. No epidermal involvement and an absence of lichenoid infiltrate characterised drug-induced as compared to idiopathic PS. NSAIDs, diuretics, meprobamate and ampicillin were the commonest offenders. We conclude that a drug-induced subgroup of PS exists and can be identified by clinical and histological features. Therefore, a careful drug history and skin biopsy are recommended in all cases of PS.

The significance of Candida-specific serum IgE in recurrent vaginal candidiasis.

Total and Candida-specific serum concentrations of IgE were studied in 21 patients who fulfilled the criteria for recurrent vaginal candidiasis, and 45 controls. The candida specific IgE levels were significantly higher in patients with recurrent vaginal candidiasis than the controls. There was no significant difference in the total IgE levels between the patients and the controls. IgE is postulated to inhibit the cellular immune response to Candida and thereby prevent the eradication of the organism. There may be a genetic basis for the increased serum IgE levels. Hyposensitisation may be an effective mode of therapy.

Chronic discoid lupus erythematosus: an immunopathological and electron microscopic study.

We studied 100 cases of chronic cutaneous discoid lupus erythematosus (DLE) to evaluate the diagnostic sensitivity of immunoreactant deposition and its possible role in basement membrane thickening. Histopathology was diagnostic in 71% of cases. Sixty-two percent (41/66) of lesions with thickened and 50% (17/34) with normal basement membrane had immunoreactant deposition. Ultrastructural study of 6 cases (3 with and 3 without immunoreactant deposition) with thickened basement membrane all showed reduplication of the lamina densa. Thickening of the basement membrane appears to be contributed mainly by reduplication of the lamina densa rather than by immunoreactant deposition. The direct immunofluorescence (DIF) test of lesional skin was positive in 58% of patients and was independent of duration of lesion, age and sex. Light microscopy has greater diagnostic sensitivity in confirming DLE lesions than DIF. Direct salt split skin technique did not increase DIF sensitivity. Scalp lesions showed the highest frequency (83%) of immunoreactant deposition. As C1q was the commonest immunoreactant found in our study, we suggest that it should be routinely used when DIF is employed in the evaluation of DLE. DIF is especially helpful in confirming cicatricial alopecia due to DLE.