Superficial granulomatous pyoderma treated preoperatively with infliximab.

We report a case of superficial granulomatous pyoderma (SGP) treated successfully with infliximab. A 71-year-old woman developed erythema, erosions and cribriform scarring in the right periorbital area following enucleation of the right eye. Histology showed three-layered granulomas typical of SGP. The patient's disease was unusual in that it failed to respond to a wide variety of immunosuppressants and this condition is rarely reported to affect the face. Eventually she was treated successfully with infliximab, enabling her to undergo extensive surgery despite the fact that her disease was pathergic in onset.

Porokeratosis in association with lymphoedema.

We describe four patients in whom porokeratosis coexisted with lympoedema of the legs. A possible pathogenetic link between the two disorders is discussed, as well as the therapeutic implications and the novel physical sign of lymphoedema bulging through the porokeratotic lesions.

Vitiligo in association with human immunodeficiency virus infection.

Autoimmune disorders such as vitiligo have been previously reported in patients with human immunodeficiency virus (HIV) infection. We describe a case of vitiligo in association with HIV where a rising CD4 lymphocyte count due to highly active antiretroviral therapy (HAART) closely correlated with changes in the skin. This effect, to our knowledge, has not been previously observed.

The relation between mortality from malignant melanoma and early detection in the Cancer Research Campaign Mole Watcher Study.

Between 1987 and 1989 the Cancer Research Campaign funded a health education programme for the early detection of cutaneous malignant melanoma in the general population in 6 health districts of England and 1 health board in Scotland (population of 3 million). The intervention was evaluated by studying its effects on annual and cumulative mortality rates for melanoma. Population-based data on mortality from melanoma were collected in the intervention areas, the health regions covering those areas, and 5 other health regions of England from 1981 to 1996. Deaths from melanoma in cases diagnosed after the start of the intervention were used to study cumulative mortality rates. The annual mortality rates for melanoma, 1981 to 1996, showed no significant difference in their trends between the intervention areas, and other areas of England and Wales. After adjustment for pre-intervention rates, there was also no significant reduction in cumulative mortality from melanoma in the intervention areas compared with the non-intervention areas: rate ratio 1.2 (95% Cl 0.9-1.7) in men, 0.9 (95% Cl 0.7-1.3) in females. The lack of a significant reduction in melanoma mortality associated with the intervention raises questions about this approach to early detection and emphasises the need for new strategies.

A randomized comparison of 4 weeks of terbinafine vs. 8 weeks of griseofulvin for the treatment of tinea capitis.

BACKGROUND: Tinea capitis is a common childhood infection that has recently become more frequent in urban areas in Europe and the U.S.A. The current licensed treatment in children is griseofulvin 10 mg kg(-1) daily, which is usually given for 6--8 weeks. OBJECTIVES: To compare this treatment with a 4-week course of oral terbinafine. METHODS: Terbinafine was given at the following doses: in children weighing < 20 kg, 62.5 mg daily; 20--40 kg, 125 mg daily; > 40 kg, 250 mg daily. Two hundred and ten children aged 2--16 years, with mycologically confirmed tinea capitis, were randomized to 4 weeks treatment with terbinafine or 8 weeks with griseofulvin, and followed for a total of 24 weeks to determine the difference between treatments with respect to short- and long-term efficacy and tolerability. RESULTS: One hundred and forty-seven patients were evaluable (terbinafine 77, griseofulvin 70). Although the 4-week course of terbinafine resulted in a trend to more rapid clearance of tinea capitis, there were no statistically significant differences between the two drugs in terms of overall outcome or tolerability, apart from in a subgroup of patients with Trichophyton infections, and weighing > 20 kg, who responded better to terbinafine than to griseofulvin at 4 weeks. By contrast, there was a better response to griseofulvin than to terbinafine in patients with Microsporum audouinii infections. CONCLUSIONS: Overall, the study showed that 4 weeks of treatment with oral terbinafine has similar efficacy to 8 weeks of treatment with griseofulvin for the management of tinea capitis in children.

Split skin grafts in the treatment of pyoderma gangrenosum. A report of four cases.

BACKGROUND: Pyoderma gangrenosum (PG) is an uncommon necrotising, non-infective ulceration of the skin. The management of PG is aimed at limiting tissue destruction, promoting the healing of the wound, and providing an acceptable cosmetic result. However, skin grafting is normally avoided because of the potential risk of pathergy-the localization of skin damaged by trauma. REPORT: We describe the use of split skin grafts in the management of ulcerative pyoderma gangrenosum in 4 patients. RESULTS: Our cases demonstrate that split skin grafts are a useful treatment modality in patients with ulcerative PG, producing a good cosmetic result. One case illustrates the importance of ensuring the disease is quiescent prior to grafting, to avoid pathergy. The other cases emphasise the need for prolonged immunosuppressive therapy to minimise the chance of reactivation of the disease process. CONCLUSION: Our preliminary experience of 4 cases of ulcerative PG indicates that split skin grafts have a role to play in its management. The ultimate cosmetic result is considered to be superior to allowing the wound to heal by secondary intention. To limit the risk of pathergy developing, our experience suggests a role for prolonged courses of immunosuppressive therapy. The most effective dose and duration of immunosuppressive therapy in patients with PG treated with split skin grafts remains to be determined. A controlled study would be of benefit to compare it with other current treatment options.

Melanoma yield, number of biopsies and missed melanomas in a British teaching hospital pigmented lesion clinic: a 9-year retrospective study.

The demand for pigmented lesion clinics (PLCs) is increasing in view of improved skin cancer awareness following public health education campaigns. These clinics offer an effective way of screening a large number of patients. However, there is no evidence, as yet, that they have an impact on mortality due to malignant melanoma. With the lack of follow-up inherent to these busy screening clinics, there is some concern that melanomas may be missed. This study reports on 7874 patient visits to a PLC in a teaching hospital between 1985 and 1994. In total, 1705 biopsies were performed over the 9-year period. Lesions were more likely to be biopsied in men compared with women. The yield for picking melanomas was one in 36 patient visits. The mean age of patients attending the PLC was 10 years less than the mean age for population-based melanomas. Melanoma thickness did not significantly change over the 9-year period. Only 0.2% of patients (14 cases) re-presented to the PLC for a second or third visit with a final diagnosis of melanoma, but for five of these patients, the interval between the two visits was over 2 years. Most of these 're-attending' melanomas were early lesions. PLCs offer a fast, safe and efficient service for the screening of pigmented lesions but their role in reducing mortality due to malignant melanoma remains to be established. It is likely that these clinics have an important role in terms of public health education regarding sun avoidance and early recognition of skin cancer.

Screening for malignant melanoma using instant photography.

OBJECTIVE: To assess the use of instant photography, in addition to clinical grading, as a method of screening for malignant melanoma during routine health examinations. SETTING: A health screening clinic with an average throughput of about 12,000 patients a year. METHODS: Suspicious pigmented skin lesions were judged clinically using the revised seven point checklist scoring system. They were then photographed with a Polaroid camera and the prints were graded independently by two consultant dermatologists with a special interest in malignant melanoma. A copy of the print was also given to the patient to keep for observation of any change in the lesion. RESULTS: Over a 45 month period 39,922 patients of both sexes were screened and 1052 skin lesions were clinically assessed and photographed. Fourteen malignant melanomas were diagnosed--all, except one, were thin lesions with a good prognosis. CONCLUSIONS: The clinical opinions of non-dermatologists using the revised seven point checklist proved disappointing in screening because of the large number of benign lesions that were given high scores. Photography, on the other hand, detected 11 melanomas and succeeded in separating the majority of banal lesions from potentially malignant ones, thus greatly reducing the need for specialist referral. Nevertheless, three melanomas were missed on purely photographic grading, which emphasises the danger of placing too much reliance solely on a two dimensional image. Finally, the possession of a personal copy of the photograph by the patient proved popular and led to a diagnosis of melanoma in two instances. This procedure merits further study.

Axillary acne agminata (lupus miliaris disseminatus faciei).

Acne agminata is a papulo-pustular eruption typically affecting the face of young adults and characterized histologically by the presence of caseating granulomata in the dermis. We now describe two adults who developed the condition in the axillae.

Bullous pemphigoid and epidermolysis bullosa acquisita: presentation, prognosis, and immunopathology in 11 children.

The immunobullous diseases bullous pemphigoid (BP) and epidermolysis bullosa acquisita (EBA) are very rare in childhood. Although case studies have been detailed, there are no reports of a large series of patients documenting the effectiveness of treatment and long-term prognosis. We report the clinical presentation, immunopathologic features, disease course, and long-term prognosis of BP and EBA in a series of 11 children. The initial diagnoses based on clinical features were BP (5), EBA (3), and chronic bullous disease of childhood (CBDC) (3). These were subsequently revised from BP to EBA (2), CBDC to BP (2), and CBDC to BP or EBA (1) following the results of direct and indirect immunofluorescence and immunoblotting. Analysis of IgG subclasses in eight cases showed that the predominant subclasses were IgG1 (8) and IgG4 (6). The clinical features appeared to be highly variable, and in patients presenting with inflammatory blistering, laboratory studies were required in order to differentiate between BP and EBA. All patients improved on treatment with corticosteroids and/or sulfones, although treatment regimens showed wide variation. Their diseases tended to remit within 2 years, and their long-term prognosis was good.

Pyoderma gangrenosum in a child with congenital partial deficiency of leucocyte adherence glycoproteins.

Congenital deficiency of beta 2 integrin leucocyte adhesion molecules is a rare immunodeficiency and is often fatal. Neutrophils are unable to bind to ligands on the endothelium, and so cannot leave the circulation during inflammation or infection. When leucocyte adhesion deficiency (LAD) is caused by abnormally low expression of beta 2 integrins, it is termed LAD type 1. We describe a 5-year-old girl with a history of recurrent bacterial infections since early childhood who developed necrotic skin ulcers resembling pyoderma gangrenosum and a persistent circulating neutrophilia. Histologically, the lesions showed deep ulceration with a diffuse lymphohistiocytic infiltrate, but with a relative sparsity of neutrophils. Subsequent investigation revealed a complete absence of CD11a/CD18 beta 2 integrins on the surface of the patient's neutrophils, confirming the diagnosis of LAD type 1. The ulcers responded to treatment with oral prednisolone and colchicine.