Spontaneous resolution of a giant keratoacanthoma penetrating through the nose.

Although keratoacanthomas are common and spontaneous resolution well recognized, case reports with photographic documentation of resolution are few. The subtype of giant keratoacanthoma (GKA) can give rise to severe cosmetic destruction because of their size and their predilection for cosmetically sensitive areas (nose and eyelids). Spontaneous resolution of GKAs has not been widely reported. We present an impressive series of clinical photographs documenting the spontaneous resolution of a GKS on the nose of a 56-year-old patient.

Topical photodynamic therapy for non-cancerous skin conditions.

Topical photodynamic therapy (PDT) is a non-invasive therapeutic modality which is developing increasing use in dermatology. It is a well established treatment for pre-malignant and malignant skin tumours and over recent years there has also been encouraging evidence for its use in treating benign cutaneous disorders. We review the literature and clinical trials utilising topical PDT for non-cancerous skin conditions. Recalcitrant warts, acne vulgaris and psoriasis have so far been studied in most detail. At present, photosensitisers, light sources and treatment parameters of PDT vary in different clinical trials even for the same conditions. Optimum parameters for PDT need to be established and comparison randomised studies are required to clarify whether PDT for benign dermatoses is significantly superior to existing therapeutic modalities.

Compliance of renal transplant recipients with advice about sun protection measures: completing the audit cycle.

Renal transplant recipients are at increased risk for development of nonmelanoma skin carcinoma, owing to a number of causes, including ultraviolet exposure. It has been shown that, despite education, there is poor compliance by these patients with the advice given for protecting their skin from the sun. This repeat study was conducted to determine whether there had been an improvement in compliance over the last 6 years. Two hundred twenty-seven patients were invited to complete the questionnaire used in the previous study. This questionnaire was designed to establish whether patients understood the need for extra care, whether they recalled any education about protective measures, and what actual measures were taken. There was a significant increase in the proportion of patients taking appropriate precautions. Hence there has been a significant improvement in the compliance of renal transplant recipients in Yorkshire with skin protection measures since this was originally audited in 1998.

An unusual case of a compound depressed skull fracture after an assault with a stiletto heel.

Compound depressed skull fractures occur commonly from assault with various sharp and blunt objects. The use of a stiletto heeled shoe as an offensive weapon has not been reported before as a cause of such an injury. However unusual the history of assault, a clear picture of the mechanism of the injury is vital. Patients with scalp lacerations following a direct blow to the head must be evaluated thoroughly. Early investigation and treatment are necessary to reduce the risk of complications, as illustrated by this case.

The accumulation of protoporphyrin IX in plaque psoriasis after topical application of 5-aminolevulinic acid indicates a potential for superficial photodynamic therapy.

The success reported for the treatment of superficial skin carcinomas by photodynamic therapy with topical application of the photosensitizer precursor 5-aminolevulinic acid has therapeutic implications for the treatment of other skin disorders. This paper describes the accumulation of the photosensitizing agent protoporphyrin IX in areas of plaque psoriasis by monitoring of the fluorescence emission induced by low-intensity laser excitation at 488 nm. We present results from 15 patients with a total of 42 plaques and show that the characteristic fluorescence emission of protoporphyrin IX increases in intensity within the 6-h period following application of 5-ami-nolevulinic acid, suggesting that there is a potential for superficial photodynamic therapy. The rate of increase and maximum intensity of fluorescence emission was not directly related to the applied quantity of the precursor. The variability of the fluorescence intensity was as great between plaques at different sites on the same patient as between different patients. Also, the effect of plaque occlusion following application appeared insignificant. Although there was only limited enhancement of emission from areas of skin surrounding the plaque, a significant buildup of sensitizer was detected after several days in some areas of psoriasis that received no application.

Nutritional factors in diabetics with and without retinopathy.

We used 3-d food-record-keeping techniques to examine nutritional factors in diabetic patients with and without retinopathy. Patients without retinopathy had significantly higher daily intakes of total carbohydrate, water-soluble dietary fibers, insoluble dietary fibers, and glucose than did patients with retinopathy. Also, patients without retinopathy took a significantly lower proportion of their total daily calories as protein.

Register of dietary assessment calibration-validation studies: a status report.

A register of dietary assessment calibration-validation studies was created to improve communication between investigators, avoid duplication of effort, and identify gaps in knowledge. Calibration-validation studies were defined as investigations in which the participants completed at least two different dietary measurements. A questionnaire soliciting descriptive information about such studies was widely distributed. Completed questionnaires were received from October 1993 through September 1994 and the data from them were entered into a computer database. Preliminary individual reports were mailed to all contributors in September 1994 for revision or updating. Responses received by the end of October 1994 were incorporated into the database. A status report was published in December 1994. The report includes descriptions of 84 studies, 15 summary tables, and 6 reference indexes. Of the 84 studies included, 44 (52%) were conducted in North America, 35 (42%) in Europe, 2 (2%) in South America, 2 (2%) in Asia, and 1 (1%) in Australia. Sixty-three of the 84 studies (75%) used food-frequency questionnaires, 52 (62%) used food records, 35 (42%) used one or more dietary recalls, 11 (13%) used biological measures, and 8 (10%) used diet histories. Plans for maintaining and updating the register are being developed.

Baseline fruit and vegetable intake among adults in seven 5 a day study centers located in diverse geographic areas.

OBJECTIVE: To examine baseline rates of fruit and vegetable consumption among adults in the 5 A Day research trials in order to identify any regional and sociodemographic differences associated with daily servings. DESIGN: The main outcome measure was the frequency of fruits and vegetables consumed within 1 month of the baseline survey as assessed by a 7-item food frequency questionnaire (FFQ). SUBJECTS/SETTING: Participants (N = 15,060) were from 7 study centers. Study centers included schools (N = 48), worksites (N = 60), churches (N = 50), or the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics (N = 15) in interventions to increase fruit and vegetable consumption. STATISTICAL ANALYSES: Means and standard errors, adjusting for clusters, were calculated. A mixed linear model analyzed relationships between fruit and vegetable consumption and regional center, gender, age, race, education, income, marital status, food-shopping responsibility, and whether one lives with children. RESULTS: Results indicate an overall mean intake of 3.6 daily servings of fruits and vegetables. Significant differences in mean daily servings were found among the regional study centers (low of 3.0 to high of 4.1). There were significant differences in mean daily consumption by age (< 30 years = 3.7 servings per day; 30 to 49 years = 3.4; > or = 50 years = 3.7), education (> high school = 3.4 servings per day; high school graduate = 3.4; some college = 3.5; college graduate = 3.9), race (black = 3.7 servings per day; Hispanic = 3.0; white = 3.6; other = 3.7), marital status (married = 3.6 servings per day; single = 3.5), and food-shopping responsibilities (little = 3.2 servings per day; about half = 3.6; most = 3.8). Only 17% of respondents ate 5 or more servings of fruits and vegetables per day. CONCLUSIONS: The 7 regions showed significant variability in daily fruit and vegetable consumption, suggesting that a single national message to increase fruit and vegetable consumption may not reach the population segments most in need of changing. It is advisable to spend more time understanding the food consumption habits of the population under investigation to develop messages to foster behavior change.

Association of awareness, intrapersonal and interpersonal factors, and stage of dietary change with fruit and vegetable consumption: a national survey.

PURPOSE: To examine associations of awareness, intrapersonal and interpersonal factors, and stage of change with consumption of fruits and vegetables. DESIGN: Nationally representative, random digit dial survey conducted in 1997 with a response rate of 44.5%. Psychosocial correlates of fruit and vegetable consumption were assessed using regression analyses. SETTING: United States. SUBJECTS: A total of 2605 adults who were 18 years and older. MEASURES: Awareness of the "5 A Day for Better Health" program and its message, along with stage of change; taste preferences; self-efficacy; and perceived benefits, barriers, threats, social support, and norms related to fruit and vegetable consumption. RESULTS: Awareness and intrapersonal and interpersonal factors explained 24% of the variance in fruit and vegetable consumption beyond the 9% explained by demographic characteristics. Knowledge of the 5 A Day message was associated with a 22% increase in fruit and vegetable consumption. Self-efficacy for eating fruits and vegetables and taste preferences (affect) were the factors most consistently and strongly associated with both higher consumption and higher likelihood of being in action or maintenance stages of change. Affect and perceived barriers were more strongly associated with increased vegetables and salad than fruit. CONCLUSIONS: Dietary intervention programs to increase fruit and vegetable consumption should emphasize the 5 A Day message, increased self-efficacy, and ways to make vegetables more palatable and easily accessible. Understanding the factors that influence dietary choices should be used when designing dietary interventions.

Process evaluations of the 5-a-day projects.

Process evaluation is an important, but infrequently conducted, component of evaluating the impact of health promotion interventions. The process evaluation results from the nine 5-a-Day projects were overviewed. Process evaluation helped explain some of the weaker aspects of program performance, process indicators occasionally declined over time and varied by demographic characteristics, and some process measures were related to mediating variables and program outcomes. Future development of process evaluation must include further development of concepts, more consistent and thorough conduct of process evaluation, appropriate methodological work, and assessment of the relations among the process evaluation components and the program mediators and outcomes. Further development in this area promises refinement in understanding how and why interventions achieve their effects, how best to conduct intervention programs to maximize effects, and enhancement of the internal and external validity of the studies.

Histiocytosis: an unusual cause of dysphagia, hoarseness and stridor.

We present a patient with established histiocytosis who developed dysphagia, retching, regurgitation, hoarseness and stridor. These symptoms were managed with carbon dioxide laser vaporization, electively on three occasions, and once as an urgent procedure, while awaiting radiotherapy, to control her airway. Histiocytosis is a rare cause of a number of otolaryngological syndromes, but there has been no previous record of this disease causing laryngopharyngeal symptoms. This paper discusses the classification of histiocytosis, and describes our management of this rare and intriguing case.

Topical photodynamic therapy in the treatment of hidradenitis suppurativa.

Topical photodynamic therapy (PDT) is well established for the treatment of malignant and pre-malignant skin lesions and now it is increasingly used to treat benign dermatological conditions. The studies reporting the use of PDT in hidradenitis suppurativa are reviewed. Though small in number, there is considerable variation in the application of topical photosensitisers, light sources used and treatment regimes. In addition there is often limited information about patient selection in terms of disease severity and measuring precise patient outcome. These issues need to be addressed in future studies in order to accurately determine the role of PDT in this disease.

Microbiological effect of photodynamic therapy (PDT) in healthy volunteers: a comparative study using methyl aminolaevulinate and hexyl aminolaevulinate cream.

BACKGROUND: Acne vulgaris is a common skin problem that affects up to 90% of adolescents. Colonization of the duct with Propionibacterium species is one of the factors implicated in the development of acne. Owing to the increasing incidence of antibiotic resistance, there has been an greater interest in the development of new methods to treat acne. Early studies have shown that photodynamic therapy (PDT) with aminolaevulinic acid (ALA) can lead to prolonged improvement in acne. Newer derivatives of ALA such as methyl aminolaevulinate hydrochloride (MAL) and hexyl aminolaevulinate hydrochloride (HAL) have been developed for use in PDT, with the potential benefits of higher lipophilicity and penetration potential. OBJECTIVES: To determine the microbiological effect and tolerability of a single application of HAL-PDT and to compare it with MAL-PDT in healthy volunteers. METHODS: This was a randomised double-blind study to examine the microbiological effects and safety of a single application of MAL-PDT and HAL-PDT on normal skin in 18 healthy volunteers. Bacterial skin samples for Propionibacterium spp. and Micrococceae were obtained at baseline and 2, 4, 7 and 14 days. RESULTS: Following PDT with MAL and HAL, a statistically significant transient reduction in mean density of Propionibacterium spp. 2 days after treatment using each agent (P < 0.05 for both) was found. There were no significant changes in mean number of Micrococceae for the duration of the study period. Treatment with HAL-PDT and MAL-PDT was well tolerated. Overall, HAL-PDT was associated with fewer side-effects compared with MAL-PDT (P < 0.01) over the 14 day study period. CONCLUSION: HAL-PDT and MAL-PDT transiently reduce density of Propionibacterium spp. density to a similar degree in normal healthy individuals. The transient reduction in Propionibacterium spp. suggests that the prolonged antiacne effect of PDT relies on factors independent of bacterial density. HAL-PDT appears to be better tolerated than MAL-PDT.

Investigation of the use of the pulsed dye laser in the treatment of Bowen's disease using 5-aminolaevulinic acid phototherapy.

BACKGROUND: The use of 5-aminolaevulinic acid photodynamic therapy (ALA-PDT) for the treatment of Bowen's disease is well established. However, treatment with a continuous light source has the disadvantage of prolonged treatment time during which patients often experience significant discomfort requiring the use of local anaesthetic. OBJECTIVES: The aim of this study was to assess the efficacy and safety of the pulsed dye laser (PDL) as the light source for photoactivation of the protoporphyrin IX to treat Bowen's disease by PDT. METHODS: Thirteen patients with a total of 17 patches of histologically proven Bowen's disease were treated with 20% 5-ALA in Unguentum M (Crookes Healthcare, Nottingham, U.K.) under occlusion for 4 h. The patches were then irradiated using a Candela SPLTL-1b (Candela Corporation, Wayland, MA, U.S.A.) PDL using a wavelength of 585 nm, with a 7-mm diameter spot at a fluence of 10 J cm(-2). The spots overlapped by 50% to cover the lesion and extend beyond the clinical margin of the patch of Bowen's disease by 0.5 cm. Patients were then followed up initially at 2 months, then at 3-monthly intervals for a period of 12 months to assess treatment success and recurrence rate. RESULTS: Subjects consisted of 10 females and three males, between 47 and 88 years. The mean area of the patches of Bowen's disease was 315.4 mm(2) (range 36-2464 mm(2)) requiring a median of 32 pulses (range 3-260). Lesions sites were hands (two), foot (one) and lower leg (14). All patients experienced varying degrees of discomfort during treatment but none required the use of local anaesthetic. At 2 months eight treatment sites could not be assessed due to loose overlying crusts and removal of these revealed superficial erosions in seven patients. Of the 17 lesions treated, on follow-up at 1 year, 14 patches (82%) demonstrated a complete clinical response, although one of these had required a second treatment. Two patients with three lesions that would have required further therapy refused a second treatment. Prolonged crusting lasting 8 weeks occurred in eight patches and prolonged discomfort lasting 6 weeks occurred in four patients. CONCLUSIONS: This study has shown that the PDL is an effective light source for ALA-PDT of Bowen's disease. Light source exposure times are shorter, although overall treatment time may not always be significantly reduced for larger lesions. The procedure was well tolerated. However, the post-treatment morbidity was relatively high compared with the more conventional treatment modalities. Further studies are needed to determine whether lower energy fluences can maintain similar efficacy while reducing post-treatment morbidity.