Contact sensitivity to the amide anesthetics lidocaine, prilocaine, and mepivacaine. Case report and review of the literature.

Multiple sensitivities to amide local anesthetics occurred in a 70-year-old woman following dental treatment. Soft-tissue swelling of the cheek was the clinical presentation. Patch testing confirmed type IV hypersensitivity to lidocaine, prilocaine, mepivacaine, and dibucaine. We review the classification of local anesthetics and the literature relating to contact sensitivity to the amide group.

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.

Accuracy in clinically evaluating pigmented lesions.

OBJECTIVE: To determine the ability of three doctors experienced in managing melanocytic lesions to diagnose correctly melanoma, dysplastic naevi, and various benign pigmented lesions. DESIGN: Independent clinical evaluation and histopathological assessment. SETTING: Pigmented lesion clinic, which patients attend without an appointment for early diagnosis of melanoma. PATIENTS: 86 Patients with lesions that were judged to be benign by at least one of the three doctors. INTERVENTIONS: The lesions were excised under local anaesthesia and sent for histopathological examination in coded bottles without clinical details. MAIN OUTCOME MEASURE: Comparison of clinical with histopathological diagnosis for each lesion. RESULTS: A total of 120 lesions were evaluated by at least two of the three doctors. The histopathological diagnoses were made by the same pathologist. The overall sensitivity (diagnostic accuracy) for the three doctors for all types of lesion was 50%. Of the 39 dysplastic naevi, only 19 were identified correctly by all observers, and a further 24 banal lesions were wrongly diagnosed as dysplastic by at least one doctor. Particular difficulty was experienced with small (less than 5 mm), flat lesions, which can be banal or potentially malignant. CONCLUSIONS: Critical diagnosis and management decisions concerning pigmented lesions should always be based on a combination of clinical and histopathological assessments and the history of the patient.

Steroid-resistant bullous pemphigoid treated with cyclosporin A.

A 70-year-old woman with steroid-resistant bullous pemphigoid, severe osteoporosis, and several crush fractures was given cyclosporin A at a dose of 5 mg/kg/day. Considerable improvement was evident within 4 weeks, and control has been maintained over a period of 14 months allowing reduction of her steroid dose to 4 mg on alternate days.

Cutaneous gangrene secondary to focal thrombosis--an important cutaneous manifestation of ulcerative colitis.

We describe a patient who developed cutaneous gangrene secondary to microvascular thrombosis, an uncommon complication of inflammatory bowel disease with potentially serious manifestations.

Pseudoainhum in chronic psoriasis.

Pseudoainhum is a term used to describe the presence of constricting bands of the extremities due to a variety of underlying causes. Progression of the lesions can cause irreversible damage and autoamputation of the affected digit. This report documents a rare association of pseudoainhum and psoriasis and emphasizes the importance of recognizing this condition.

Cutaneous abscesses due to systemic nocardiosis--a case report.

We report a patient with systemic nocardiosis who developed cutaneous abscesses following haematogenous spread from a primary infection in the lung. This case is unusual; first in that the organism assumed a granular form on histological section, and secondly that the patient was not immunocompromised, emphasizing the need to consider nocardiosis in any patient with pleuropulmonary infection and cutaneous abscesses.

Melanocytic lesions and melanocyte populations in human epidermis.

Basal melanocytes were counted and atypia assessed on an arbitrary scale in punch biopsies from the sun-exposed extensor aspect of the forearm of normal skin and from the covered skin of the buttock of patients with pigmented naevi and control subjects. The difference in melanocyte counts and in the presence of atypia between sun-exposed and covered skin was statistically highly significant. The only other difference was between melanocyte counts in covered skin from those with multiple atypical naevi and all other groups; the counts in the former were greater than those in the latter. No further difference was attributable to sun exposure, skin type or diagnostic group. Some degree of melanocyte atypia was seen in approximately half of the biopsies of sun-exposed skin, but atypia was seen in only six of 84 biopsies of covered skin. In each case atypia was present in the corresponding forearm biopsy and all six subjects had pigmented lesions (four with melanoma and two with multiple atypical naevi). It seems possible that while increased melanocyte counts in covered skin could correlate with the presence of atypical naevi, atypia of covered epidermal melanocytes could possibly relate to melanoma risk.

Pyoderma gangrenosum treated with cyclosporin A.

A 49-year-old woman with a 14-year history of pyoderma gangrenosum unresponsive to a variety of systemic and topical treatments was given oral cyclosporin A (CyA), a potent immunosuppressive agent widely used in organ transplantation for the prophylaxis of acute graft-versus-host disease. Improvement and subsequent healing of the lesions was evident within 3 weeks of starting treatment and has continued for the duration of treatment (12 months).

Papular acantholytic dyskeratosis of the vulva.

We describe two patients with unusual asymptomatic, papular lesions on the vulva, clinically resembling lichen planus, the histology of which revealed unexpected findings of suprabasilar clefting, acantholysis and dyskeratotic cells giving rise to corps ronds and grains together with hyperkeratosis and parakeratosis, features originally associated with a diagnosis of Darier's disease. Focal acantholytic dyskeratosis has been described in a wide variety of inflammatory and neoplastic processes including those involving mucous membranes and has been attributed various diagnostic labels. We feel that the findings in our patients are consistent with a diagnosis of papular acantholytic dyskeratosis of the vulva, a rare condition, which was first described in 1984.

Screening for skin cancer: experience of an occupational health screening programme.

A skin cancer screening programme involving 2150 employees based at the head office of a large UK retailer resulted in the detection of four melanomas at an early curable stage. In addition, three other malignant and three potentially malignant tumours were discovered, and individuals at greater risk of developing melanoma were identified and counselled accordingly.

Beta 2 microglobulin expression in keratoacanthomas and squamous cell carcinoma.

The cell surface expression of beta-2-microglobulin (beta 2 M) was investigated in 33 keratoacanthomas (KA) and 58 squamous cell carcinomas (SCC) to determine whether this antigen was expressed to a different extent in these two conditions and, thus, whether this constitutes a reliable and practical test for distinguishing them. Loss of beta 2 M expression was not a reliable feature for distinguishing between KA and SCC and seemed to be related more to the degree of cellular differentiation and maturation, than to malignancy as such.

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.

Effect of incisional biopsy on subsequent histology of melanocytic naevi.

We examined the effect of incisional biopsy on the subsequent histology of 15 benign melanocytic naevi. In all cases the histology of the residual lesion within the second specimen was unchanged apart from the presence of a surgical scar, and in general the definitive excision specimen showed a reduction in melanocytes at the dermo-epidermal junction overlying the scar. In no case were there any features suggestive of melanoma.

Delayed patch test reactions at days 7 and 9.

403 consecutive patients were examined on days 2, 4, 7, and 9 following application of patch tests. Late positive reactions, i.e., those which manifested after day 4, were seen in 29 patients (7.2%). The allergens which most commonly produced late positive reactions were neomycin (7), potassium dichromate (4), and cobalt (3). Paired patch test readings on days 4 and 7 were more reliable than those on days 2 and 4. If only 1 patch test reading were performed, a single reading on day 4 would have been most useful. The reading on day 9 proved to be of limited value. Of 11 patients who were retested after an interval of more than 6 months, 7 showed earlier eliciting reactions, which may have been due to active sensitization.