Atypical naevus spilus: detection by in vivo confocal microscopy.

Naevus spilus (NS) is a naevoid disorder characterized by hyperpigmented macules or papules scattered over a café-au-lait macule. Such café-au-lait macules are often present at birth, and the darker pigmented speckles of NS slowly increase in number and size over a period of several years. NS can therefore be difficult to evaluate clinically for the development of melanoma. In vivo confocal microscopy (IVCM) is a novel method that allows examination at cellular resolution of cutaneous lesions in vivo. IVCM has been shown to have twice the specificity of dermoscopy for the diagnosis of melanoma, with comparable sensitivity. It has been shown to be useful in the detection and grading of dysplastic naevi, which are recognized precursors of melanoma in some cases. In this report, we highlight that IVCM can also be used as a tool complementary to dermoscopy to identify areas of dynamic change in clinically and dermoscopically equivocal lesions. IVCM may thereby assist in the early detection of melanocytic atypia and melanoma arising in NS, in turn leading to excision of melanoma at an early stage, which is associated with a favourable outcome. We also outline some of the difficulties encountered in confocal microscopy and histology when differentiating melanoma from dysplastic naevi.

Localized facial flushing in infancy. Auriculotemporal nerve (Frey) syndrome.

BACKGROUND: Patients with auriculotemporal nerve syndrome (Frey syndrome) have facial flushing, sweating, or both localized to the distribution of the auriculotemporal nerve that occurs in response to gustatory stimuli. In adults, the syndrome usually results from surgical injury or trauma to the parotid gland. The condition is rare in infants, but usually manifests during infancy with the introduction of solid food, thus leading to the misdiagnosis of food allergy by physicians unfamiliar with the syndrome. OBSERVATIONS: We describe 8 children with auriculotemporal nerve syndrome who manifested with flushing only. The reaction was erroneously attributed to food allergy in most cases. Six of the 8 patients were delivered with forceps assistance. The remaining 2 patients, with disease onset during the first 3 months of life, had bilateral involvement without known trauma. CONCLUSIONS: Auriculotemporal nerve syndrome may manifest during infancy as flushing with eating food. In contrast to the syndrome in adults, gustatory sweating is rarely associated. The known use of forceps to assist in the delivery of at least 14 of the 28 previously reported pediatric cases and in 6 of our 8 patients suggests that trauma to the parotid region may be responsible for the condition in most infants, as it is in adults. Auriculotemporal nerve syndrome in infancy should be recognized as a benign condition that often resolves spontaneously. Treatment is ineffective and unnecessary.

The influence of dressings on venous ulcer healing--a randomised trial.

OBJECTIVE: To assess the effect of different dressings on venous ulcer healing. DESIGN: A randomised clinical trial. MATERIALS: Patients were randomised to treatment with one of three dressings: a zinc oxide impregnated bandage, a zinc oxide impregnated stockingette, or an alginate dressing. All patients were treated as outpatients and had compression bandaging with two minimal stretch bandages (Elastocrepe) and a stockingette (Tubigrip) to keep the bandages in place. METHODS: One hundred and thirteen patients (133 ulcerated limbs) with chronic ulceration of the leg due to venous disease alone, and attending Fremantle Hospital Leg Ulcer Clinic, Western Australia were entered into the study. Healing was measured as complete healing of the ulcerated limb or failure of the limb to heal within 9 months. RESULTS: There was no significant difference between the three groups in ulcer size, duration, and other parameters compared. Healing was affected significantly by ulcer size and which leg was ulcerated. There was significantly faster healing with the paste bandage. CONCLUSION: The use of a paste bandage significantly improved the healing of chronic venous ulcers when used in combination with compression bandaging, and compared to an alginate dressing and a zinc oxide impregnated stockingette.

Generalised granuloma annulare successfully treated with pentoxifylline.

Generalised granuloma annulare (GA) is a chronic disease of unknown aetiology and is recalcitrant to many treatment regimes. Some investigators have suggested that an immune medicated vasculitis may be involved in the pathogenesis of GA. We describe a patient with a ten year history of generalised GA, who showed dramatic clearing of the majority of papules after four weeks of treatment with pentoxifylline. This drug has shown promising results in the treatment of many dermatologic disorders including necrobiosis lipoidica diabeticorum, leukocytoclastic vasculitis and Raynaud's phenomenon. Pentoxifylline is thought to reduce blood viscosity via effects on all major blood components, and its clinical effectiveness in generalised GA lends support to a model of immune-medicated vasculitis in the pathogenesis of this disorder. Thus, pentoxifylline offers a well-tolerated and effective alternative to the treatment options available for patients with granuloma annulare.

Dermal myiasis in an Australian traveller.

Myiasis, the infestation of body tissues by the larvae of flies, occurs infrequently in Australian tourists who return from areas where certain species are endemic. Some of these insect species such as Cochliomyia hominivorax and Chrysoma bezziana (New and Old World screw-worms respectively) are responsible for significant disease in livestock as well as in humans. We report a patient who travelled extensively through South America and returned to Australia with a subcutaneous nodule containing a large larva of the species Dermatobia hominis. Because of the risk of travellers introducing unwanted species of flies into our country, it is important for doctors to suspect the possibility of furuncular myiasis, and to obtain accurate identification of the larva.

The effect of bacterial colonization on venous ulcer healing.

To determine the effect of bacterial colonization on venous ulcer healing, 82 patients with 100 venous ulcerated limbs were each studied prospectively for six months. Despite bacteriological swab results, topical or systemic antibiotics were not administered unless cellulitis supervened. Initial ulcer size, length of ulcer history and time to complete healing of colonized and uncolonized ulcers were determined and compared. Organisms were cultured from 83 limbs prior to commencement of treatment, the commonest isolates being Staphylococcus aureaus (48%), mixed coliforms (28%), Pseudomonas aeruginosa (21%) and anaerobes (17%). When compared with ulcers with no bacterial growth, colonized ulcers were of longer duration (p [symbol: see text] 0.01), had a larger initial size (p [symbol: see text] 0.001) and had significantly longer healing time (p [symbol: see text] 0.001). When analysed individually beta-haemolytic streptococci, anaerobes, Staphylococcus aureus and coliforms were associated with delayed healing. Delayed healing was not found with Pseudomonas aeruginosa, although pseudomonas-colonized ulcers were significantly larger and of longer duration than uncolonized ulcers. Bacterial colonization is associated with delayed venous ulcer healing. To further clarify the pathogenicity of colonizing bacteria, however, the effect of their eradiction on healing of venous ulcers needs to be established.

Epidemiology of chronic venous ulcers.

A metropolitan population of 238,000 in Perth, Western Australia, was screened for chronic ulceration of the leg. Patients with a chronic leg ulcer and a venous abnormality comprised 57 per cent of all patients with a chronic leg ulcer, giving a prevalence of 0.62 per 1000 population. There was an increasing prevalence with age; 90 per cent of patients were 60 years and older. This group comprised 16.7 per cent of the population, and had a prevalence of 3.3 per 1000. Although chronic venous ulcers were more common in women there was no difference in age related prevalence. In 36 per cent of patients with a venous abnormality, there was at least one other aetiological factor contributing to chronic ulceration of the leg; 96 per cent had either a history of deep venous thrombosis or a condition known to predispose to deep venous thrombosis.

Outpatient treatment of chronic venous ulcers in a specialized clinic.

Chronic leg ulcers have many different causes and therefore need an accurate diagnosis in order to give the most effective treatment. A specialized clinic was set up in Fremantle Hospital in July 1988 with the aims of performing a thorough clinical and laboratory assessment to establish the cause of ulceration in every patient, and treating patients according to the cause of ulceration. Patients with arterial, neoplastic or dermatological conditions were treated as appropriate for their diagnosis and patients with other chronic ulcers were managed as outpatients where possible. Patients were seen between July 1988 and July 1989. Only 43% had purely venous ulcers, 32.6% had a venous component plus some other abnormality, and 5.2% were purely arterial. Using an outpatient treatment regimen, 67% of all ulcerated limbs and 73.7% of limbs with purely venous ulcers were healed within 6 months. Only 11 patients with venous ulceration (15 limbs) failed on this therapy and required admission during the observation period. The initial ulcer size was shown to influence the time to total healing of the limb. The healing rates achieved compare favourably with studies from other specialized centres and suggest that the majority of patients with chronic leg ulcers can be treated successfully using ambulatory outpatient dressing techniques.

Sporotrichoid cutaneous infection due to Mycobacterium chelonei in a renal transplant patient.

Atypical mycobacterial infections are becoming more common in dermatological practice due to increasing numbers of immunosuppressed patients. A case of cutaneous Mycobacterium chelonei infection with sporotrichoid spread in a renal transplant patient is described, and the current literature regarding clinical spectrum, histopathology and management of infection with this pathogen is reviewed.