Treatment of gastrointestinal symptoms associated with methotrexate therapy for psoriasis.

BACKGROUND: The conventional treatments for gastrointestinal symptoms associated with methotrexate therapy for psoriasis are unsatisfactory. OBJECTIVE: Our purpose was to determine the frequency, severity, and dose-relationship of gastrointestinal symptoms induced by methotrexate therapy for psoriasis and the response to folate supplementation. METHODS: Seventy-eight patients with psoriasis receiving low-dose, once-weekly oral methotrexate therapy were studied for the development of gastrointestinal symptoms. The effect of supplementation with folic acid, 5 mg daily, on gastrointestinal symptoms was examined. RESULTS: Gastrointestinal symptoms occurred in 32% of patients; nausea accounted for 80% of symptoms. The onset and severity of symptoms were related to the weekly dose of methotrexate but not to the cumulative dose or to the duration of methotrexate therapy. The symptoms were eliminated by folate supplementation; this did not interfere with the therapeutic effect of methotrexate. CONCLUSION: Gastrointestinal symptoms occur frequently with methotrexate therapy for psoriasis and can be adequately controlled with folate supplementation, apparently without compromising the therapeutic efficacy of methotrexate.

Thyroid function tests in amyloid goitre.

We present two patients with amyloid goitre due to primary systemic amyloidosis which was confirmed at post-mortem. Both were clinically euthyroid but had hyperthyroxinaemia and other thyroid function tests suggestive of thyrotoxicosis.

Perianal streptococcal cellulitis with penile involvement.

Perianal streptococcal cellulitis is described occurring in a 5-year-old boy. The condition also involved the penis and presented as a possible case of sexual abuse. The correct diagnosis was established by culturing beta-haemolytic streptococci group A from the penile and perianal skin.

Prolonged survival in metastatic malignant melanoma associated with vitiligo.

A metastatic malignant melanoma presenting with axillary lymphadenopathy and without a detectable primary lesion is described in a 66-year-old woman. Extensive vitiligo developed 6 years after this diagnosis. There has been no recurrence of melanoma for 10 years following surgical resection of the lymph nodes. The significance of vitiligo and an elusive primary lesion to the favourable prognosis in metastatic malignant melanoma is discussed.

Cryotherapy for multiple trichoepithelioma.

Multiple trichoepithelioma is an uncommon disorder for which treatment is usually bedeviled by the recurrence of tumors. A case of multiple trichoepithelioma is described occurring in the retroauricular area; the condition cleared completely and without relapse following cryotherapy.

Metastatic Crohn's disease responding to metronidazole.

Metastatic Crohn's disease is a rare cutaneous manifestation of intestinal Crohn's disease, for which existing treatment is unsatisfactory. We report a case of perianal and vulval Crohn's disease which cleared completely on a 4-month course of metronidazole without adverse effects. The patient remained in remission I year later. The merits of long-term treatment with metronidazole are discussed.

Paracetamol-induced fixed drug eruption with positive immunofluorescence findings.

A 93-year-old woman with an 8-year history of episodes of fixed drug eruption due to paracetamol is described. The rash was characterized by bullae, crusted lesions, hyperpigmented and erythematous patches as well as lesions resembling toxic epidermal necrolysis. Direct immunofluorescence revealed deposition of IgG and C3 in the epidermal intercellular cement substance of lesional skin only; the pathogenetic significance of this finding is discussed.

Linear IgA disease with haemorrhagic pompholyx and dapsone-induced neutropenia.

A case of haemorrhagic pompholyx occurring in a 29-year-old man with linear IgA disease is described. There were several features in our patient that are usually seen in chronic bullous disease of childhood. Treatment with dapsone cleared the eruption but induced a progressive yet reversible neutropenia.

Basal-cell carcinoma complicating a port-wine stain.

A rare radio-resistant basal-cell carcinoma is described which presented as a recently enlarged non-ulcerated nodule on a port-wine stain. The literature on basal-cell carcinoma occurring on a port-wine stain is reviewed, and the aetiological significance of thorium-X, sun-exposure and vascular changes in the development of malignancy on this type of haemangioma is discussed.

Occupational dermatitis from Synacril Red 3b liquid (CI Basic Red 22).

A carpet factory worker, exposed to a number of different dyes, developed a severe hand dermatitis. The handling of warm, wet and freshly-dyed yarn with unprotected hands was thought to have caused the onset of dermatitis. Patch testing indicated that the patient was sensitive to only one of the dyes handled, namely Synacril Red 3B liquid, which is based on the single dyestuff Basic Red 22 (CI 11055). Chemical analysis revealed the dyestuff to be of high purity (greater than 95%), suggesting that sensitization was caused by the Basic Red 22 dyestuff itself and not by an avoidable impurity.

Discoid lupus erythematosus associated with hereditary angioneurotic oedema.

A female patient developed discoid lupus erythematosus 6 years after the onset of hereditary angioneurotic oedema. Treatment with danazol for 18 months cleared both conditions and was well tolerated.

Bleomycin-induced flagellate erythema.

A 56-year-old woman who developed widespread pruritus and flagellate erythema after attempted pleuredesis with bleomycin is described. The raised linear lesions of flagellate erythema could not be reproduced by scratching, and histopathological examination revealed a lymphocytic vasculitis. The rash faded spontaneously over several weeks to leave streaks of post-inflammatory melanoderma which remained for 6 months. The role of scratching and dermographism in the pathogenesis of the bleomycin-specific eruption is discussed.

Chylous ascites, intestinal lymphangiectasia and the 'yellow-nail' syndrome.

In 1964 Samman and White described 13 patients with lymphoedema of the lower extremities associated with an unusual dystrophy of the finger and toe nails: this they termed the 'yellow-nail' syndrome. Affected nails were thickened, excessively curved along both axes, very slow growing and of yellowish-grey hue; cuticle and lunula were usually absent and onycholysis was frequently evident. Lower limb lymphangiography in most individuals revealed hypoplasia, or aplasia of the lymphatics, similar to that occurring in primary lymphoedema: other patients also developed pleural effusions of high protein content or ascites suggestive of a more generalised disorder of the lymphatic system. Here we describe a patient in whom the classical 'yellow-nail' syndrome was associated with intestinal and chylous ascites.

Intestinal folate absorption in methotrexate treated psoriatic patients.

Thirty-one psoriatic patients 14 of whom were being treated with methotrexate (MTX), participated in a controlled study to evaluate the influence of MTX therapy on the intestinal absorption of folate. Low serum and red cell folate levels in the MTX treated group confirmed previously reported findings. However, analysis of the intestinal absorption profile yielded no significant difference between the two groups. It was concluded that MTX therapy for psoriasis does not adversely affect the intestinal absorption of folate and the observed low body folate status is probably mainly the result of enhanced renal excretion.