Sunlight exposure behaviour and vitamin D status in photosensitive patients: longitudinal comparative study with healthy individuals at U.K. latitude.

BACKGROUND: Low vitamin D status is prevalent in wintertime in populations at northerly latitudes. Photosensitive patients are advised to practise sun avoidance, but their sunlight exposure levels, photoprotective measures and resulting vitamin D status are unknown. OBJECTIVES: To examine seasonal vitamin D status in photosensitive patients relative to healthy individuals and to assess quantitatively behavioural and demographic contributors. METHODS: This was a longitudinal prospective cohort study (53·5°N) examining year-round 25-hydroxyvitamin D [25(OH)D] levels, sun-exposure behaviour and oral vitamin D intake in photosensitive patients diagnosed at a photoinvestigation unit (n = 53), compared with concurrently assessed healthy adults (n = 109). RESULTS: Photosensitive patients achieved seasonal 25(OH)D variation, but insufficient (< 20 ng mL(-1); 50 nmol L(-1)) and even deficient (< 10 ng mL(-1); 25 nmol L(-1)) levels occurred at the summer peak in 47% and 9% of patients, respectively, rising to 73% and 32% at the winter trough. Adjusting for demographic factors, the mean values were lower than for healthy volunteers by 18% [95% confidence interval (CI) 4-29] in summer (P = 0·02) and 25% (95% CI 7-39) in winter (P = 0·01). Behavioural factors explained 25(OH)D differences between cohorts. Patients demonstrated lower weekend ultraviolet B doses (P < 0·001), smaller skin surface area exposure (P = 0·004) and greater sunscreen use (P < 0·001), while average oral vitamin D intake was low in both groups (photosensitive: 2·94 µg per day). Supplementation and summer surface area exposure predicted summer peak and winter trough 25(OH)D levels. A 1 µg per day increment in supplementary vitamin D raised summer and winter 25(OH)D by 5% (95% CI 3-7) and 9% (95% CI 5-12), respectively (both P < 0·001). CONCLUSIONS: Photosensitive patients are, through their photoprotective measures, at high risk of year-round low vitamin D status. Guidance on oral measures should target this patient group and their physicians.

Delta 9-tetrahydrocannabinol inhibits electrically-evoked CGRP release and capsaicin-sensitive sensory neurogenic vasodilatation in the rat mesenteric arterial bed.

BACKGROUND AND PURPOSE: Calcitonin gene-related peptide (CGRP) is a sensory neurotransmitter in the rat mesenteric arterial bed. Certain cannabinoids can inhibit, via CB(1) receptors, vasorelaxant responses to electrical field stimulation (EFS) of sensory nerves in the rat mesentery, but the mechanism of the inhibitory effect of the cannabinoid delta 9-tetrahydrocannabinol (THC) is unclear. This study assessed directly the effect of THC on EFS-induced release of CGRP from sensory nerves in the rat mesenteric bed and investigated the possible involvement of cannabinoid receptors and transient receptor potential (TRP) ion channels. EXPERIMENTAL APPROACH: Rat mesenteric beds were perfused with physiological salt solution. Sensory nerves were stimulated electrically and perfusate levels of CGRP measured by immunoassay. The effects of THC on EFS-induced CGRP release and vasorelaxant responses to sensory nerve stimulation were investigated in the absence and presence of cannabinoid antagonists and TRP channel blockers. KEY RESULTS: EFS evoked a release of CGRP and vasodilatation of the mesenteric beds. THC inhibited the electrically-evoked release of CGRP and sensory neurogenic vasorelaxation. The effect of THC was unaffected by the CB1 antagonist AM251, the CB2 antagonist AM630 or the TRPV1 receptor antagonist capsazepine, but was blocked by the TRP channel blocker ruthenium red. CONCLUSIONS AND IMPLICATIONS: THC inhibits the EFS-induced release of CGRP (and subsequent vasorelaxation), from capsaicin-sensitive sensory nerves in the rat perfused mesentery. The effect of THC was not mediated by CB1, CB2 or TRPV1 receptors, but was sensitive to ruthenium red, suggesting a possible involvement of TRP ion channels.

Selective expression of immune-associated surface antigens by keratinocytes in irritant contact dermatitis.

The expression of three immunoregulatory surface antigens by epidermal keratinocytes was studied in irritant contact dermatitis (ICD), in order to assess whether keratinocytes have a modulatory role in the pathogenesis of this disorder. Biopsies were taken from 48-h patch test reactions to six structurally unrelated irritants, and frozen sections immunolabeled with monoclonal antibodies to the major histocompatibility complex class II antigen, HLA-DR, intercellular adhesion molecule-1 (ICAM-1), and the 88-Kd glycoprotein CD36 (OKM5), as well as to the CD3 (T cells) and CD11a (lymphocyte function associated antigen-1, LFA-1) antigens. We found that there was very limited expression of HLA-DR by keratinocytes, with no correlation between the extent of HLA-DR positivity and the degree of T cell infiltration into the epidermis and dermis, suggesting that interferon gamma may not be a significant mediator of ICD at 48 h. In contrast, keratinocytes showed extensive upregulation of ICAM-1, with an excellent spatial association between ICAM-1 expression and LFA-1 positive leucocytes in the epidermis. This indicates that keratinocyte ICAM-1 induction is not restricted to diseases in which antigen presentation is pivotal, but that it has a generalized role in cutaneous inflammatory reactions, promoting the infiltration of leucocytes into the epidermis. Immunolabeling with OKM5 revealed that CD36 is present to a variable degree on keratinocytes in normal skin. Differential changes in the pattern of keratinocyte expression occurred between irritants, in a manner that suggested that the CD36 antigen does not act as an adhesion molecule in ICD, but rather that its expression is related to the proliferative state of the epidermis. The results of this study demonstrate that immune-associated antigens are selectively expressed on the surface of keratinocytes in 48-h ICD biopsies, implying that these cells play an important regulatory role in the development of the inflammatory response to irritant chemicals.

Differential effects of structurally unrelated chemical irritants on the density of proliferating keratinocytes in 48 h patch test reactions.

Alterations in the proliferative capacity of human epidermis following topical exposure to structurally unrelated chemical irritants were investigated, with the aim of improving our understanding of the cellular changes that take place during the development of irritant contact dermatitis (ICD). Healthy volunteers were patch tested for 48 h with the following six irritants and their appropriate vehicle and occlusion controls: 5% sodium lauryl sulphate (SLS), 0.5% benzalkonium chloride, 80% nonanoic acid (NAA), 0.02% dithranol, 0.8% croton oil, and 100% propylene glycol (PG). After the degree of inflammation induced was visually graded, biopsy samples were removed and the dividing keratinocytes were identified immunocytochemically by using the monoclonal antibody Ki-67, with quantification being performed on the basis of the number of positive cells/100 basal keratinocytes. Statistically significant increases in the density of proliferating cells occurred in the reactions to SLS, NAA, and PG, whereas, in contrast, dithranol caused a marked decrease in the number of dividing keratinocytes. Overall, the density of proliferating keratinocytes did not show a linear relationship with the visually assessed intensity of inflammation, indicating that the changes observed were related to the chemical nature of the individual irritants and their specific biochemical interactions with the keratinocytes, rather than being the consequence of a generalized inflammatory response. Differential release of epidermal cytokines and mediators by the six irritants may account for these varying states of keratinocyte proliferation. Application of the Spearman rank coefficient of correlation revealed that the changes in mitotic activity of keratinocytes were unrelated either to the total density of leukocytes infiltrating the epidermis and dermis, or to the individual densities of the major phenotypic classes of inflammatory cells present. This makes it unlikely that the localized release of cytokines by infiltrating leukocytes is, by itself, the primary factor in the alteration in epidermal cell kinetics seen in ICD. Our results provide a further demonstration of the diverse actions of different chemical irritants on human skin and emphasize the need to regard ICD as a heterogeneous disorder.

Differential patterns of epidermal leukocyte infiltration in patch test reactions to structurally unrelated chemical irritants.

In previous studies, we showed that a number of aspects of the histopathology of irritant contact dermatitis are profoundly influenced by the chemical nature of the irritant applied. We report here that this phenomenon also extends to the infiltration of leukocytes into the epidermis. Healthy volunteers were patch tested with the following irritants and their appropriate controls: benzalkonium chloride, sodium lauryl sulphate, croton oil, dithranol, nonanoic acid, and propylene glycol. After visually grading the intensity of the resulting inflammation, biopsies were removed and the major phenotypic classes of leukocytes identified immunocytochemically. Dermal and epidermal cell densities were determined, and the expression of several activation/proliferation antigens studied. We found a similar pattern of cellular infiltration in the dermis of all irritant groups; the densities of most of the cell types rising in line with the intensity of inflammation. Within the epidermis, however, there were marked differences in the patterns of cellular infiltration between the irritant groups, leading to poorer correlations between leukocyte density and visual grading. The greatest disparity occurred between croton oil and nonanoic acid biopsies, the former being characterized by the influx of large numbers of leukocytes, the latter showing remarkably little exocytosis. Infiltration of neutrophils occurred to varying degrees with all irritants, but a disproportionately large number were present in sodium lauryl sulphate biopsies. All control groups showed a rise in CD4+ cells, with distilled water also producing increases in CD11c+ cells and neutrophils. A selective influx of CD25+ cells occurred in the epidermis of both irritant and control groups. Our observations further highlight the heterogeneous nature of irritant contact dermatitis, and confirm previous findings that visually negative control patch tests show marked cellular reactivity.

Epidermal damage induced by irritants in man: a light and electron microscopic study.

Irritant contact dermatitis may be induced by many chemicals and has a far greater incidence than allergic contact dermatitis. Despite this, it receives relatively little attention and its pathogenesis remains poorly understood. To gain a greater understanding of the interaction of irritants with the skin, we investigated the histopathological changes resulting from the topical application of a series of structurally unrelated irritants. Human volunteers were patch-tested with appropriate concentrations of nonanoic acid, sodium lauryl sulphate, dithranol, benzalkonium chloride, croton oil, and propylene glycol, which produced generally mild to moderate responses. Biopsy specimens were taken after 48 h and examined by light and electron microscopy. Spongiosis and the infiltration of predominantly mononuclear cells were observed in the epidermis of the majority of biopsy specimens, and were particularly pronounced and extensive in croton oil reactions. In addition, several irritants induced distinct and characteristic patterns of keratinocyte damage. Nonanoic acid and sodium lauryl sulphate caused morphologic changes indicative of disturbances in keratinocyte metabolism and differentiation, giving rise to dyskeratosis and parakeratosis respectively, while dithranol induced marked swelling of keratinocytes in the upper epidermis. The results suggest that there is a diversity and specificity in the histopathology of irritant contact dermatitis, reflecting the different ways in which chemicals may interact with components of the skin.

Differential effects of structurally unrelated chemical irritants on the density and morphology of epidermal CD1+ cells.

In order to gain a greater insight into the complex mechanisms of action of different irritant chemicals on the skin, we have studied the behavior of epidermal CD1+ cells in experimentally induced irritant contact dermatitis. Healthy, human volunteers were patch tested for 48 h with the following six chemically unrelated irritants and their appropriate vehicle controls; benzalkonium chloride, sodium lauryl sulphate, dithranol, nonanoic acid, croton oil, and propylene glycol. After visually assessing and grading the resulting inflammatory reactions, punch biopsies were taken and the morphology and density of CD1+ cells in the epidermis studied using immunocytochemical techniques in combination with image analysis and electron microscopy. Statistically significant decreases in the epidermal density of CD1+ cells occurred in the responses to dithranol (p less than 0.05) and nonanoic acid (p less than 0.01). Importantly, these changes in density were not simply due to variations in the intensity of inflammatory response (r = 0.1157). Alterations in the length of the dendritic processes of CD1+ cells were also induced, and semi-quantitative analysis revealed significant decreases in dendrite length in the reactions to sodium lauryl sulphate (p less than 0.05), nonanoic acid (p less than 0.001), croton oil (p less than 0.05), and dithranol (p less than 0.005). Unlike epidermal density, however, this effect on cell morphology was directly related to the severity of inflammation (r = -0.74, p less than 0.01). Morphologic evidence of cellular injury to Langerhans cells was seen by electron microscopy in the majority of biopsies, although relatively few cells were affected in sodium lauryl sulphate and propylene glycol reactions. Benzalkonium chloride, unlike the other irritants, also induced a state of metabolic activation in a high proportion of epidermal Langerhans cells. Lymphocyte/Langerhans cell apposition was observed in most samples, but was particularly prevalent in the reactions to dithranol. The results of this study demonstrate that significant changes in the morphology and density of Langerhans cells occur in irritant contact dermatitis, some of which are directly influenced by the chemical nature of the irritant.

Long-stay pediatric intensive care unit patients: outcome and resource utilization.

Outcome, resource utilization, and health care characteristics of patients staying in a multidisciplinary pediatric intensive care unit (PICU) for more than 13 days (long-stay patients) were analyzed. Of 647 children admitted consecutively, 46 were long-stay patients. Compared with short-stay patients, long-stay patients were significantly younger and sicker and had a higher incidence of chronic disease. Most important, long-stay patients had significantly higher PICU mortality rates (17.4% v 7.3%, P less than .05) and hospital mortality rates (23.9% v 8.7%, P less than .01) than short-stay PICU patients. Although only 7.1% of the patient sample, long-stay patients consumed approximately 50% of all PICU resources. One-year follow-up on those long-stay patients surviving their hospitalization revealed that 58% had died or were severely disabled. Long-stay patients had relatively poor prognoses and consumed health care resources in excess of their numeric proportions.

Comparison of gastric intramucosal pH and standard perfusional measurements in pediatric septic shock.

OBJECTIVE: To examine the utility of gastric tonometry as an early indicator of morbidity and mortality in pediatric patients with septic shock. DESIGN: Prospective clinical study. SETTING: Multidisciplinary pediatric ICU. PATIENTS: Eight critically ill pediatric patients with septic shock and with pulmonary artery and gastric tonometry catheters in place. INTERVENTIONS: Standard perfusional data including cardiac index, oxygen content (arterial, mixed venous), oxygen delivery, oxygen consumption, urine output, capillary refill, and lactate value were measured every 4 h. Intramucosal pH (pHi) was calculated from simultaneous tonometric measurements of gastric intramucosal PCO2 (PiCO2). Mean pHi values were compared between survivors and nonsurvivors. Tonometric data were compared with standard perfusional data by regression analysis. Low pHi values (< 7.35) were temporally compared with occurrence screens for adverse clinical events, (cardiopulmonary arrest, acute hemorrhage, and significant hypotension or dysrhythmias). MEASUREMENTS AND MAIN RESULTS: Sets (n = 108) of paired data were collected from 8 patients (age 7 to 168 months) representing 4 deaths. The mean pHi in nonsurvivors (7.32 +/- 0.18) was significantly lower than that in survivors (7.48 +/- 0.07). Both pHi and PiCO2 were correlated with urine output by regression analysis. The pHi, but not PiCO2 correlated with extraction ratio and lactate level. There were no other significant correlations noted. Analysis of the ability of pHi values to predict adverse clinical events revealed that pHi less than 7.35 accurately predicted 26 of 39 concurrent or subsequent adverse clinical events. However, 24 of 50 pHi values less than 7.35 showed no association with similar adverse events, either concurrent or subsequent. The pHi had a sensitivity of 67%, a specificity of 74%, a positive predictive value of 52%, and an efficiency of 72% in predicting these adverse events. CONCLUSION: Use of gastric tonometry in pediatric septic shock patients appears to distinguish survivors from nonsurvivors. However, in general, tonometric assessment of splanchnic perfusion correlates poorly with standard clinical, hemodynamic, oxygen transport, or metabolic measurements of perfusion. Low pHi measurements are not predictive of concurrent or subsequent adverse clinical events.

Comparisons of French and U.S.A. pediatric intensive care units.

Consecutive admissions to two pediatric intensive care units (PICUs) in France (n = 93) and the United States (n = 248) were compared using admission demographics, and daily therapeutic and severity of illness data. Analysis of the major demographic characteristics revealed that patients in the French PICU were younger (median age; 3 months vs. 31 months, P less than 0.001), and more commonly admitted for emergency reasons (92% vs. 66%, P less than 0.05). General resource utilization was similar in both units. However, important differences in the incidences of use of individual monitoring and therapeutic modalities were present. The United States PICU had higher incidences of invasive monitoring modalities (arterial catheters, 66% vs. 4%, P less than 0.001; central venous catheters, 38% vs. 11%, P less than 0.001; pulmonary artery catheters, 8% vs. 1%, P less than 0.01), while the French PICU had higher incidences of labor-intensive monitoring modalities (strict input/output, 75% vs. 47%, P less than 0.0001; greater than 3 stat blood studies/shift, 69% vs. 45%, P less than 0.0001). Patients in France were more likely to receive mechanical ventilation (81% vs. 56%, P less than 0.0001) and nutritional support (40% vs. 7%, P less than 0.05). Mortality rates in both PICUs were similar and accurately predicted by admission-day severity of illness scores. We conclude that differential resource utilization, possibly arising from different care philosophies, may result in equivalent care.

The acquired immunodeficiency syndrome: impact on the pediatric intensive care unit.

Increasing numbers of infants and children with AIDS are being admitted to the PICU, especially in certain geographic areas. Clear diagnostic criteria are available to aid in the diagnosis. As many as 50 per cent of these patients may be first diagnosed with AIDS during their PICU stay. Most patients are admitted because of ARF, but septic shock and CNS disorders are also common. Acute PICU mortality is in excess of 80 per cent, and presently the long-term mortality for this syndrome stands at 100 per cent. The economic impact of this epidemic is enormous and may become catastrophic if a national strategy to deal with these costs is not developed promptly. The PICU has an important role both in terms of resource use and cost containment. Awareness of unique stresses on medical and nursing staff caring for these children, as well as the unique psychoemotional needs of the patients themselves, is vital. Specific infection control, nutritional, and medical-legal strategies will facilitate safe, effective delivery of care to these infants and children in the PICU. The appropriate long-term role of the PICU in the care of children with an ultimately terminal disease has yet to be determined.

Immunocytochemical demonstration of reduced Cu,Zn-superoxide dismutase levels following topical application of dithranol and sodium lauryl sulphate: an indication of the role of oxidative stress in acute irritant contact dermatitis.

Oxidative stress is known to be implicated in the inflammation induced by the anti-psoriatic irritant, dithranol. In this study, we wished to investigate whether this is reflected in the levels of the antioxidant enzyme, Cu,Zn-superoxide dismutase, as detected by quantitative immunocytochemistry, and whether similar changes also occur following exposure to an irritant not normally associated with reactive oxygen species generation, namely sodium lauryl sulphate. Analysis of biopsies from patch test sites revealed that significant reductions in the epidermal levels of Cu,Zn-superoxide dismutase were induced by both dithranol and sodium lauryl sulphate, although the time course of diminished activity was different for each irritant. Our findings suggest that oxidative stress plays a general role in the pathophysiology of acute irritant contact dermatitis.

Reduced levels of glutathione S-transferases in patch test reactions to dithranol and sodium lauryl sulphate as demonstrated by quantitative immunocytochemistry: evidence for oxidative stress in acute irritant contact dermatitis.

There is increasing evidence that oxidative stress plays a role in the pathogenesis of acute irritant contact dermatitis. As part of on-going studies into the effect of irritant chemicals on the anti-oxidant enzyme systems in the skin, we have examined the changing levels of two classes of glutathione S-transferase in patch test reactions to dithranol and sodium lauryl sulphate, using quantitative immunocytochemistry. Although no changes were evident after 6 hrs, significant reductions in the density of staining for glutathione S-transferase alpha were seen with both irritants after 48 hrs and 96 hrs. Glutathione S-transferase pi levels were reduced to a lesser degree, reaching significance for dithranol at the 96 hrs time point only, and for sodium lauryl sulphate at 48 hrs only. The results support the hypothesis that oxidative stress plays a role in chemically-induced inflammation, not only in the case of irritants such as dithranol which are known to directly generate reactive oxygen species, but also with chemicals not generally associated with free radical generation.

The injured child. An approach to care.

Injury is the leading cause of childhood death and disability in this country and has been for over a decade. Examination of the current injury statistics clearly demonstrates the failure of our present prevention strategies. Unless definitive steps are undertaken to initiate a comprehensive national injury prevention program, this tragic impact upon children will continue. To ensure that optimal care for injured children is provided, several criteria must be met. Seriously injured children require skillful assessment by clinicians experienced in pediatric trauma and rapid evacuation to a regional pediatric trauma center when appropriate. Their care is best provided by a multidisciplinary team including intensivists, surgeons, and rehabilitation specialists, all thoroughly familiar with the types of injuries children sustain. In the ICU, careful monitoring of circulatory, respiratory, renal, and neurologic status combined with early intervention for physiologic derangements maximizes the injured child's chances for recovery. Finally, it is important to understand that care for the injured child spans a continuum beginning with prevention, continuing through acute care, and ending only after rehabilitation and reintegration into the community is complete, and that each component is no less important than another. Only through these efforts can the loss of our nation's most precious resource be avoided.

Metal sensitivity in patients undergoing hip replacement. A prospective study.

A prospective study of allergic contact dermatitis after metal-on-plastic total hip replacement was undertaken in 69 patients, of whom 54 were available for review after operation. Before operation six patients were metal sensitive, but only one remained so afterwards; this patient had given a clear history of metal sensitivity and a titanium prosthesis had therefore been used. In all six patients the result of the operation was good and no case of loosening occurred. Sixty-three patients had negative patch tests before operation; in none of these was metal sensitivity detected after operation. Cutaneous sensitivity to various metals is well documented after the insertion of metal-on-metal prostheses and in failed prostheses. We have not found any such increased sensitivity after metal-on-plastic hip replacement. There is little evidence of a direct causal relationship between metal sensitivity and subsequent loosening. The cutaneous sensitivity may be the consequence of loosening rather than its cause. Our results suggest that, providing metal-on-plastic prostheses are used, routine patch testing before hip replacement is no longer required.

Medicinal cannabis: is delta9-tetrahydrocannabinol necessary for all its effects?

Cannabis is under clinical investigation to assess its potential for medicinal use, but the question arises as to whether there is any advantage in using cannabis extracts compared with isolated Delta9-trans-tetrahydrocannabinol (Delta9THC), the major psychoactive component. We have compared the effect of a standardized cannabis extract (SCE) with pure Delta9THC, at matched concentrations of Delta9THC, and also with a Delta9THC-free extract (Delta9THC-free SCE), using two cannabinoid-sensitive models, a mouse model of multiple sclerosis (MS), and an in-vitro rat brain slice model of epilepsy. Whilst SCE inhibited spasticity in the mouse model of MS to a comparable level, it caused a more rapid onset of muscle relaxation, and a reduction in the time to maximum effect compared with Delta9THC alone. The Delta9THC-free extract or cannabidiol (CBD) caused no inhibition of spasticity. However, in the in-vitro epilepsy model, in which sustained epileptiform seizures were induced by the muscarinic receptor agonist oxotremorine-M in immature rat piriform cortical brain slices, SCE was a more potent and again more rapidly-acting anticonvulsant than isolated Delta9THC, but in this model, the Delta9THC-free extract also exhibited anticonvulsant activity. Cannabidiol did not inhibit seizures, nor did it modulate the activity of Delta9THC in this model. Therefore, as far as some actions of cannabis were concerned (e.g. antispasticity), Delta9THC was the active constituent, which might be modified by the presence of other components. However, for other effects (e.g. anticonvulsant properties) Delta9THC, although active, might not be necessary for the observed effect. Above all, these results demonstrated that not all of the therapeutic actions of cannabis herb might be due to the Delta9THC content.

Comparison of patch test results in two adjacent areas of England-I. (Industrial allergens).

A 3-year study of patch test reactions to the Standard European Battery has been carried out in two adjacent areas of S. E. England with the same climatic and cultural background. The source of materials and method of testing were identical; both observers had worked together in the same Contact Dermatitis department and the interpretation of reactions can therefore be considered to be consistent. The main differences between the two areas lay in the pattern of employment and of local medicament prescribing. The first only is examined here. One area was dominated by the automobile industry, the other by the furniture industry, with important subsidiary rubber, foam and electronics factories. The pattern that emerges shows that patch test reactions to the Standard European Battery were more likely to be related to environmental allergens and medicament usage than to industrial hazards. Chrome dermatitis was less common than elsewhere in Europe but nickel sensitivity showed the same pattern. Rubber chemical sensitivity reflected industrial, as well as domestic usage. Colophony and formaldehyde appeared to have less industrial significance than we expected. Special additional industrial allergens are not considered here but were of particular importance in the furniture industry. Although the numbers analysed were relatively small, we believe that they reflect the pattern to be expected in areas of relatively low industrial risk in Great Britain at the present time.

Topical methoxsalen photochemotherapy in the treatment of palmoplantar pustulosis and psoriasis.

Topical methoxsalen photochemotherapy has been assessed in 22 patients suffering from recalcitrant palmoplantar pustulosis or psoriasis predominantly involving the hands and feet. Although 20 out of 22 patients improved and good results were obtained in exactly half of those treated, only 4 patients were classified as being "clear" or "minimally involved" at the end of 12 weeks. Two patients have shown no improvement at all. Minor local side effects were relatively common and included symptomatic erythema, blistering and local pigmentation. The histological findings in post PUVA treated skin are discussed and the pros and cons of topical photochemotherapy in this group of diseases is reviewed.

Multiple familial trichoepitheliomas.

We present the case of a 28-year-old woman with multiple familial trichoepitheliomas, characterized by the presence of many small tumors occurring predominantly on the face. This condition constitutes a genodermatosis that follows an autosomal dominant mode of inheritance. These lesions can lead to marked facial disfigurement, and treatment is generally disappointing.