Assay of antiseptic agents in cell culture: conditions affecting cytotoxicity.

In-vivo studies suggest that chlorine-releasing antiseptic agents inhibit wound healing. Studies which have used cell culture systems to evaluate cytotoxicity have generated conflicting results for the toxicity of free-chlorine agents relative to other antiseptics. Here we examine the following three factors which may influence the toxicity of individual agents within a cell culture assay: (1) cell number; (2) duration of exposure; and (3) the nature of the antiseptic diluent. Three agents (sodium hypochlorite, chlorhexidine and hydrogen peroxide) were tested on transformed human keratinocytes (SVK 14 cells). It was found that increasing cell number, and using serum or medium as a diluent, reduced the toxicity of all agents but had the greatest effect on sodium hypochlorite. In contrast, increasing the duration of exposure increased the toxicity of all agents but had the greatest effect on hydrogen peroxide. These observations may explain the high toxicity of hydrogen peroxide and relatively low toxicity of sodium hypochlorite which have been observed in vitro and are the reverse of in-vivo findings. Culture systems in which high cell numbers are coupled with an agent diluted in serum or medium, and a long exposure time, seem likely to decrease the toxicity of chlorine-releasing agents relative to hydrogen peroxide.

Hemifacial microsomia, external auditory canal atresia, deafness and Mullerian anomalies associated with acro-osteolysis: a new autosomal recessive syndrome?

We report the combination of hemifacial microsomia, external auditory canal atresia, deafness and acro-osteolysis in several members of a highly consanguineous Asian family. In addition Mullerian anomalies have been found in two female members of the family. The external auditory canal stenosis and Mullerian anomalies in this family are similar to those reported by Winter et al. [(1968) J Pediatr 72 : 88-93] and overlap with those found in Goldenhar syndrome and Mullerian duct/renal aplasia/cervicothoracic somite dysplasia (MURCS), CHARGE and VATER associations. However, to the authors' knowledge, acro-osteolysis has not been reported in patients with any of these conditions. Overall, the findings in this family appear to be unique and the presence of consanguinity suggests an autosomal recessive condition with variable expression.

Non-Hodgkin's lymphoma of the skin associated with chronic limb lymphoedema.

Cutaneous non-Hodgkin's lymphoma developed within a leg affected by chronic lymphoedema. The lymphoedema had followed radiotherapy to bony metastases from a carcinoma of the prostate. Eighteen months after the development of the cutaneous tumours, extracutaneous involvement by the lymphoma became apparent. This is the second report of a non-Hodgkin's lymphoma appearing within a lymphoedematous limb. The possible reasons for such an unusual localization are discussed. Our case report illustrates that cutaneous tumours other than lymphangiosarcomas may localize to a lymphoedematous limb and clinically simulate the Stewart-Treves syndrome.

Facial leiomyomas.

We present a patient with multiple leiomyomas confined to the left cheek, giving rise to an unusual clinical presentation of this condition. The lesions were cosmetically disfiguring and, because of their exposed location, were particularly painful in the winter months. The treatment of this condition is discussed.

Giant solitary trichoepitheliomas located in the perianal area: a report of three cases.

Very large solitary trichoepitheliomas which arose in the perianal region in three patients are described. Although these tumours showed a striking histological similarity to classical multiple or solitary trichoepitheliomas of the face, they differed in their massive size, unusual location and by their involvement of deeper tissue. We suggest that giant solitary trichoepitheliomas is a distinct variant of trichoepithelioma that may have a predilection for the perianal region. At this site this rare tumour must be distinguished from basal cell carcinoma of the perineum and from malignant basaloid (cloacogenic) carcinoma of the anal canal.

Pemphigus vulgaris localized to the vagina presenting as chronic vaginal discharge.

Involvement in pemphigus vulgaris of the female genital tract including the vulva, vagina and cervix has previously been described. In all these cases other cutaneous and mucosal sites have also been affected at some time. We describe a case of pemphigus vulgaris which only involved the vaginal mucosa. The patient presented with a persistent vaginal discharge and examination showed extensive vaginal erosions. Histology of vaginal biopsies was non-diagnostic. The recognition that the vaginal changes may represent an immunobullous disease led to further vaginal biopsies on which direct immunofluorescence studies were performed. These biopsies showed IgG and C3 in the intercellular epidermis, suggesting a diagnosis of pemphigus vulgaris. During the 3-year period that the patient has been under review there have never been any other cutaneous or mucosal lesions. To our knowledge, this is the first case of pemphigus vulgaris localized exclusively to the vaginal mucosa. There was considerable delay in diagnosis and this case highlights how important it is to recognize that chronic mucosal lesions at genital sites may be caused by immunobullous diseases such as cicatricial pemphigoid and pemphigus, and to institute appropriate investigations.

Guidelines for the management of lichen sclerosus.

These guidelines for the management of lichen sclerosus have been prepared for dermatologists on behalf of the British Association of Dermatologists. They present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation.

Recurrent erythema multiforme: clinical features and treatment in a large series of patients.

Recurrent erythema multiforme is an uncommon disorder. We have reviewed the clinical features and treatment of 65 patients with this condition. The mean number of attacks per year was six (range 2-24), and the mean duration of the disease was 9.5 years (range 2-36) reflecting its chronicity. The majority of patients had oral mucous membrane involvement (69%). In 46 patients (71%) the condition was precipitated by a preceding herpes simplex virus infection. Acyclovir was found to be the most useful first-line treatment, with 55% of patients deriving benefit from either continuous oral acyclovir or a patient-initiated 5-day oral course at the onset of herpes simplex virus infection. Of those failing to respond to acyclovir, a small proportion responded to dapsone. The most resistant patients (11) were treated with azathioprine, with complete disease suppression in all cases.

Comparative study of antiseptic toxicity on basal keratinocytes, transformed human keratinocytes and fibroblasts.

The cytotoxic effects of a range of antiseptic agents were examined on cultured human fibroblasts and basal keratinocytes and compared to those on a transformed keratinocyte line (SVK 14 cells). Cells were exposed to chlorhexidine, hydrogen peroxide and sodium hypochlorite for 15 min and cell viability was assessed 24 h later with a colorimetric assay which utilizes the tetrazolium salt 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl tetrazolium bromide (MTT). At concentrations recommended for wound cleansing all agents produced 100% killing of all cell types. The results show that fibroblasts and keratinocytes, cells which are fundamental to the wound healing process are equally sensitive to the effects of the antiseptic agents tested, and are highly susceptible to the effects of free-chlorine containing agents. These observations are of particular importance to the use of cultured keratinocytes (culture grafts) to enhance wound healing; the application of antiseptics to such wounds is contraindicated. All three cell types tested showed similar susceptibilities to the agents tested. These findings suggest that the transformed cell line, which has the advantage of immortality and ready availability, can replace fibroblasts and keratinocytes in studies designed to investigate the adverse effects of antiseptic agents in vitro. Comparison of the ED50 concentration for each agent on all cell types to the standard use concentration produced a ranking order of toxicity which showed chlorhexidine to be the least toxic agent and sodium hypochlorite the most.(ABSTRACT TRUNCATED AT 250 WORDS)

A double-blind, placebo-controlled trial of continuous acyclovir therapy in recurrent erythema multiforme.

Twenty patients who suffered from more than four attacks of erythema multiforme (EM) per year were enrolled in a 6-month double-blind, placebo-controlled trial of acyclovir 400 mg twice daily. Fifteen patients had disease precipitated by recurrent herpes simplex. In the acyclovir-treated group the median number of EM attacks during the treatment period was zero, compared with three in the placebo-treated group (P < 0.0005, Wilcoxon rank sum test). Seven of the 11 patients treated with continuous acyclovir did not have any attacks of EM while taking the drug, and one showed almost complete disease suppression. Following treatment with acyclovir, two patients went into complete remission, whereas all individuals in the placebo group continued to have attacks. In the acyclovir-treated group nine of the 11 patients had herpes simplex-precipitated disease. One of the two patients with idiopathic disease showed complete disease suppression while on acyclovir, lending support to the view that idiopathic recurrent EM may be related to subclinical herpetic infection. In this study, we have shown that continuous acyclovir therapy can completely suppress attacks of recurrent EM and, in some cases, may induce disease remission.

Vesicular Langerhans cell histiocytosis--an uncommon variant.

A case of the congenital self-healing reticulohistiocytosis variant of Langerhans cell histiocytosis is described. The child was born with a widespread blistering eruption, which rapidly resolved leaving papules and erosions. These ultimately healed leaving anetoderma. Congenital self-healing reticulohistiocytosis should be considered in the differential diagnosis of blistering eruptions present at birth.

Identification of the epidermolysis bullosa acquisita antigen by LH 7.2 monoclonal antibody: use in diagnosis.

The sera from two patients with epidermolysis bullosa acquisita were blotted against dermal extracts in comparison with the mouse monoclonal antibody LH 7.2. This antibody reacts with carboxy terminal region of type VII collagen. The epidermolysis bullosa acquisita antisera showed binding to the same molecular weight protein as LH 7.2 confirming that the target antigen for epidermolysis bullosa acquisita antibodies is the carboxy terminal region of type VII collagen. This newly described collagen forms the major component of anchoring fibrils. These findings are consistent with established ultrastructural data which have shown that the epidermolysis bullosa acquisita antigen is located within and below the lamina densa. The monoclonal antibody LH 7.2 provides an internal standard for epidermolysis bullosa acquisita autoantisera activity. The use of immunoblotting of epidermolysis bullosa autoantisera in comparison with the monoclonal antibody LH 7.2 provides definitive investigation for the diagnosis of this disorder.

Natural history, management and complications of herpes labialis.

Infection with herpes simplex virus (HSV) is a common worldwide problem. Primary infection with HSV-1 rarely causes significant problems although widespread involvement in atopic eczema can be life-threatening as may associated encephalitis. Keratoconjunctivitis, pharyngitis and hepatitis can also complicate primary infection. Twenty to 40% of the population at some stage have recurrent orolabial infections with HSV although in only 1% of these cases is this recurrence severe. Recurrent erythema multiforme appears to be associated with HSV-65% of patients are thought to have preceding herpes labialis. Many primary and recurrent infections with HSV-1 require little more than topical antiseptic therapy to control secondary infection. Systemic acyclovir, however, is indicated in various situations including complicated primary infection, infection in neonates, eczema herpeticum, HSV infections in the immunocompromised, and recurrent erythema multiforme. In the latter, prophylactic treatment with 6 months acyclovir appears to be effective.