Paraneoplastic pemphigus: an association with fludarabine?

Paraneoplastic pemphigus is a relatively recently described immunobullous disease with characteristic features. We report three cases of paraneoplastic pemphigus in adult men with chronic lymphocytic leukaemia arising within a week of completion of treatment with fludarabine. In all cases, withdrawal of fludarabine and treatment of the blistering was associated with marked cutaneous improvement. Fludarabine, a synthetic nucleoside analogue, which has only been available in Britain since 1994, is known to be associated with autoimmune phenomena and may have been involved in the development of paraneoplastic pemphigus in these cases.

Long-term efficacy and safety of cyclosporin in severe adult atopic dermatitis.

A prospective, open, multicentre study was performed to investigate the efficacy and safety of long-term treatment with cyclosporin in adults with severe atopic dermatitis. Subjects were treated for a maximum of 48 weeks. For the first 8 weeks, cyclosporin was administered at 2.5 mg/kg per day. The dose was then adjusted according to response. Disease activity was monitored using the six-area, six-sign score and the proportion of skin involved. Pruritus and sleep disturbance were assessed using four-point scales. Response was further evaluated on a five-point scale. Adverse events, blood pressure and serum biochemistry were monitored. Tolerability was assessed on a five-point scale. One hundred subjects were enrolled and 65 completed 48 weeks of treatment. Withdrawals occurred due to remission (three), inadequate response (seven), protocol violations (11) and adverse events (14, of which seven were probably treatment related). Cyclosporin produced rapid and highly significant improvements in all indices of disease activity. Sixty-five subjects considered that they had shown a considerable improvement or complete clearance of disease. Most patients relapsed after cessation of treatment, but neither signs nor symptoms had returned to baseline severity 8 weeks later. Blood pressure and serum creatinine levels increased slightly, and in one subject renal impairment was a major factor contributing to withdrawal of the drug. Overall, 85 subjects rated the tolerability of cyclosporin as good or very good. The results indicate that cyclosporin has a place in the long-term treatment of severe atopic dermatitis provided that appropriate patients are selected and careful monitoring is performed.

Subungual keratoacanthoma--a report of four cases and review of the literature.

Subungual keratoacanthoma is a rare benign neoplasm which most commonly occurs in middle-aged Caucasians. It usually presents as a painful, rapidly growing lesion of the terminal phalanx. Radiography consistently demonstrates a well-defined cup-shaped erosion of the underlying bone. Clinically, subungual keratoacanthoma must be distinguished from subungual squamous carcinoma. We report four further cases and discuss the literature.

Evening primrose oil and marine oil in the treatment of psoriasis.

The effect of dietary supplementation with a combination of n-3 (marine oil) and n-6 (evening primrose oil) essential fatty acids in the treatment of chronic stable plaque psoriasis was observed. Thirty-seven patients in a double-blind parallel trial were studied. There was no significant improvement in clinical severity of psoriasis or change in transepidermal water loss.

The effect of essential fatty acids on epidermal atrophy due to topical steroids.

The effect of topical n-6 essential fatty acids in the form of evening primrose oil on the epidermal atrophy caused by a potent topical steroid was studied in 24 normal volunteers by measuring epidermal thickness and cross-sectional area and by histological examination. Epidermal thickness and cross-sectional area were significantly lower in normal forearm skin treated with 0.1% betamethasone valerate twice daily without occlusion for 3 weeks when compared with placebo-treated skin. The addition of evening primrose oil to the topical steroid did not prevent steroid-induced epidermal atrophy suggesting that steroid-induced epidermal atrophy is not mediated by the inhibition of essential fatty acid release from cell membranes.

Levels of essential and other fatty acids in plasma and red cell phospholipids from normal controls and patients with atopic eczema.

Blood samples were collected from 48 atopic eczema patients and 33 normal subjects in Bristol, and from 434 normal individuals worldwide. In the plasma phospholipids in the atopic eczema patients, the concentrations of linoleic acid and the ratio of linoleic acid to its metabolites were significantly elevated as compared with both sets of controls. In the atopic eczema patients there were major abnormalities in the red cell phospholipids with saturated and monounsaturated fatty acids being significantly elevated and the concentrations of most essential fatty acids being significantly reduced. Patients with atopic eczema thus show abnormalities related both to desaturation of essential fatty acids and to their incorporation into red cell membranes.

Oral albendazole for the treatment of cutaneous larva migrans.

Cutaneous larva migrans is becoming more common in the U.K. with the popularity of tropical countries as holiday destinations. We describe the increasing use of a new benzimidazole derivative, albendazole, which is very effective in the treatment of cutaneous larva migrans. In contrast to thiabendazole, it is virtually free from side-effects and should, we feel, become the treatment of choice for this condition.