The profile of dermatological problems in primary care.

BACKGROUND: Cutaneous disease is thought to account for 10-15% of patient consultations with general practitioners, but relatively little is known about the demography of dermatological conditions in primary care. AIM: To assess the proportion and diagnostic profile of dermatological conditions seen in primary care in the southeast of Scotland, and to draw comparisons with secondary dermatological care. METHODS: General practitioners in 13 general practices were asked to note all skin-related consultations during a 2-week period. The case notes of these patients were reviewed, and diagnosis and treatment was recorded. Patients who had consulted for the same skin disorder on >or= 3 occasions during the previous year were invited for assessment by a consultant dermatologist. Where possible, the case notes from 10% of all consultations during the 2-week study period were examined to assess accuracy of recording. RESULTS: The percentage of consultations relating to cutaneous disorders varied between practices, ranging from 3% to 18.8%, with a mean of 8.4%. Eczema accounted for 22.5%, infections 20.3% and benign tumours for 11.4% of consultations with a dermatological basis. In contrast, in secondary care, benign tumours accounted for 23.8%, malignant tumours for 16.4% and eczema for 16.3% of dermatological consultations. CONCLUSIONS: Dermatological disorders make up a significant proportion of general practitioners' workload. The diagnostic profile of primary-care dermatology differs markedly from that of hospital practice. General practitioners may benefit from training specifically tailored to the common primary-care dermatological conditions.

Physiological effects of pneumoperitoneum in laparoscopic pyloromyotomy.

A retrospective analysis comparing intraoperative physiological variables during laparoscopic and open pyloromyotomies was undertaken during an 18-month period at our institution. Fifty cases were examined (22 laparocopic and 28 open). Operative time, temperature change, end-tidal CO2, heart rate, and blood pressure were examined and compared. No significant differences were found in operative time, temperature change, heart rate, and blood pressure. As anticipated, in laparoscopic procedures there was a statistically significant increase in end-tidal CO2, although none of the end-tidal CO2 values rose above 6 kPa. It is concluded that laparoscopic pyloromyotomies undertaken in small infants with insufflation pressures of 8-10 mm Hg are without significant adverse physiological effects and are no slower to perform than open procedures.

Retrospective analysis of the impact of a low glycaemic index diet on hospital stay following coronary artery bypass grafting: a hypothesis.

OBJECTIVE: Glucose tolerance and insulin resistance influence medical outcome in subjects with coronary artery disease, these metabolic parameters also influence general perioperative surgical outcome. We hypothesize that glucose tolerance and insulin resistance can be favourably modified by reducing the glycaemic index of the diet. DESIGN: The present study is a retrospective analysis of a low and high glycaemic index diet on glucose tolerance, insulin resistance and perioperative outcome, as assessed by the length of hospital stay following coronary artery bypass surgery. Thirty-five adults awaiting bypass surgery were randomized, for the 4 weeks prior to surgery, to either a low glycaemic index diet (17 subjects) or high glycaemic index diet (18 subjects). Glucose and insulin responses during a 75 g oral glucose tolerance test were assessed before and after dietary intervention and insulin-mediated glucose uptake was assessed in isolated adipocytes obtained at surgery. RESULTS: The patients who consumed a low glycaemic diet had improved glucose tolerance and significantly greater in vitro adipocyte insulin sensitivity at the time of surgery compared with the high glycaemic diet group (78.87 +/- 10.64% versus 41.11 +/- 7%, respectively). The total length of stay in the patients on the low glycaemic diet was less than patients consuming the high glycaemic diet (7.06 +/- 0.38 days versus 9.53 +/- 1.44 days, P < 0.5). CONCLUSION: This study provides further support that carbohydrate and fat metabolism influence cardiac outcome and provides new evidence that dietary modification prior to coronary artery bypass surgery can shorten hospital stay.

Prevalence of temporomandibular dysfunction in a group of scuba divers.

BACKGROUND: Temporomandibular dysfunction (TMD) has been reported to be a common problem in divers, with a prevalence of up to 68%. No evidence for this is available. OBJECTIVE: To investigate the prevalence of TMD in divers. METHOD: Sixty three subjects were asked to retrospectively complete a questionnaire on symptoms of TMD after diving in warm and cold water areas and in daily life. RESULTS: The prevalence of TMD was greater in female divers. The prevalence of TMD while diving was about 26%, comparable to that experienced in daily life. CONCLUSION: Improvements in mouthpiece design and lighter demand valves mean that TMD is now probably exacerbated by diving rather than caused by it.

Epidermal Langerhans cell apoptosis is induced in vivo by nonanoic acid but not by sodium lauryl sulphate.

Exposure to irritants may cause chronic irritant contact dermatitis (ICD), characterized by irregular epidermal thickening and a predominantly dermal mononuclear cell infiltrate. The mechanisms involved, and why only certain individuals are affected, are not clearly understood. Different irritants may trigger different cellular and molecular interactions between resident skin cells and recruited inflammatory cells. In some individuals these interactions may become self-perpetuating resulting in persistent inflammation in the absence of continued exposure. This study examined Langerhans cell (LC) density in clinically normal skin of 46 patients with chronic ICD and 10 healthy individuals, and compared the action of the two irritants nonanoic acid (NA) and sodium lauryl sulphate (SLS) on the LCs and keratinocytes of clinically normal skin in patients with chronic ICD. There was a higher number of LCs/mm basement membrane in patients compared with controls, although there was no difference in the number of dendrites/LC nor in dendrite length. SLS induced keratinocyte proliferation after 48 h exposure, had no effect on LC number or distribution, and induced keratinocyte apoptosis after 24 and 48 h exposure. In contrast, NA decreased keratinocyte proliferation after 24 h exposure but this returned to basal levels after 48 h, and induced epidermal cell apoptosis after only 6 h exposure. NA dramatically decreased LC number after 24 and 48 h exposure, which was accompanied by basal redistribution and decreased dendrite length. Most significantly, NA induced apoptosis in over half of the LCs present after 24 and 48 h exposure.

Paget's disease of the scrotum: a case exhibiting positive prostate-specific antigen staining and associated prostatic adenocarcinoma.

A 75-year-old man with carcinoma of the prostate presented with a pruritic, erythematous plaque involving the scrotal skin. Histological examination revealed extramammary Paget's disease. The intraepidermal tumour cells expressed prostate-specific antigen in keeping with a prostatic origin.

Atopic and non-atopic individuals react to nickel challenge in a similar way. A study of the cytokine profile in nickel-induced contact dermatitis.

The influence of atopy on delayed-type hypersensitivity remains unclear. The expression of cytokine mRNA was assessed by reverse transcription-polymerase chain reaction (RT-PCR) in biopsy skin taken 24 h after the application of a 5% NiSO4 patch to five patients with atopic dermatitis and seven non-atopic subjects with previously proven contact allergy to nickel. Control specimens were obtained from untested and vehicle-tested skin from the same individuals. There was a significant increase in the mRNA expression for interferon-gamma (IFN-gamma), interleukin (IL)-2 and IL-4 together after nickel challenge in both patients (analysis of variance P = 0.007) and non-atopic-individuals (P = 0.005). In contrast, IL-10 mRNA increased in the non-atopic group only. These results show that atopic patients and normal subjects have a similar immunological reaction to nickel challenge. Moreover, it is suggested that both Th1- and Th2-type cytokines are involved in the immunopathogenesis of contact dermatitis.

Leukaemia inhibitory factor: induction in the early phase of allergic contact dermatitis.

It has been suggested that leukaemia inhibitory factor (LIF), may be involved in the pathogenesis of cutaneous inflammation. In 5 patients with previously proven contact allergy to nickel, LIF mRNA and protein expression were assessed by reverse transcription-polymerase chain reaction and immunohistochemistry in 5% nickel sulfate patch test biopsies 24 h after application of the patch. Control specimens were obtained from non-tested and vehicle-tested skin from the same individuals. LIF mRNA expression was significantly increased in nickel-tested skin compared with both vehicle-tested (p = 0.045) and non-tested skin (p = 0.041). All biopsies showed similar patterns of LIF immunoreactivity, with no significant differences between nickel-tested, vehicle-tested and non-tested skin. Immunostaining was cytoplasmic and was present in the epidermis and hair follicles. No dermal staining was observed. This study suggests that LIF may play a role in the early phase of allergic contact dermatitis.

Urinary glycosaminoglycans excretion in Graves' disease.

Urinary excretion of glycosaminoglycans was measured in 10 patients with pretibial myxoedema, 7 of whom also had thyroid-associated ophthalmopathy, and in 3 additional patients with ophthalmopathy but no skin changes. Total uronic acid excretion was raised above control levels in only 2 patients, who had both eye and skin disease of recent onset. In these patients excretion was initially three times the control level but declined sharply in subsequent months. This decline was in the absence of effective treatment or spontaneous improvement and would appear to reflect the natural history of the disease. These data show that although glycosaminoglycans excretion may be disturbed in Graves' disease, it provides an unreliable reflection of clinical status and of the effectiveness of treatment.

Epidermal keratinocyte production of interferon-gamma immunoreactive protein and mRNA is an early event in allergic contact dermatitis.

Previous work has indicated the importance of cytokine cascades in the induction of contact dermatitis, but there is little information on the cellular localization of cytokines in human skin, particularly during the early phases of the inflammatory response to contact allergens. Using in situ hybridization for mRNA and immunocytochemistry on biopsies from a series of 16 patients with known allergic contact dermatitis, we examined the kinetics of early cytokine production after challenge with relevant or irrelevant antigen. We show that epidermal keratinocytes from patients challenged in vivo with allergen, but not irrelevant antigen, rapidly synthesize (within 4 h) mRNA for interferon-gamma and produce immunoreactive interferon-gamma. Interleukin-1alpha and interleukin-8 mRNA were also detected but showed no correlation with relevant antigen challenge. This study demonstrates that keratinocytes can produce interferon-gamma and that this production is linked to challenge with relevant antigen in allergic contact dermatitis. These findings indicate that keratinocytes may amplify allergen-specific T-lymphocyte-triggered interferon-gamma dependent responses and might partially explain the speed of reaction in this common disease and other delayed hypersensitivity reactions involving the skin.

Sensitivity to sternotomy wires may cause postoperative pruritus.

An eczematous eruption developed on the anterior chest of a 58-year-old woman with known nickel sensitivity after the insertion of nickel-containing sternotomy wires. Her wound was revised with removal of the wires to give immediate and sustained relief from the itch. The electron microscopy and parasternal biopsy histology demonstrating a sarcoidal reaction are discussed.

Changes in skin pH after the use of baby wipes.

We recently made a double-blind safety-in-use comparison of four different brands of baby wipes using a panel of 302 infants over a period of 10 weeks. For the first two weeks, only soap and water was used to clean the babies' skin after each diaper change, and then for the eight-week test phase each baby was allocated one or other of the products for normal home use. The wipes differed in cleansing lotion formulation (emollients, preservative, pH) and fibrous composition. There were no clinically detectable differences in the effects of the wipes in terms of erythema, frequency of rashes, edema, and desquamation, but we recorded significant changes in the pH of pubic and buttock skin inside the diaper area. In particular, the brand of wipes with the lowest pH (2.8) in the lotion reduced the mean skin pH from 5.6 to 5.0 (p < 0.01), and those with a pH of 5.5 had no significant effect. Wipes of intermediate pH (3.7) gave a final skin pH of 5.4-but the downward trend was not statistically significant. These data indicate that skin pH can be depressed by such topical application, although the trial lasted only a fraction of the total time wipes might be used on each infant. Further research is necessary to evaluate the implications of these findings.

Skin fibroblast activity in pretibial myxoedema and the effect of octreotide (Sandostatin) in vitro.

The accumulation of glycosaminoglycans in the skin in pretibial myxoedema appears to be a response by local fibroblasts to a stimulating factor in the patient's serum, but the identity of the factor, its ability to stimulate skin fibroblasts as opposed to cultured thyroid cells, and the specificity of its effect to pretibial skin fibroblasts, are all controversial. We have studied fibroblasts cultured from the lesional skin of two women with pretibial myxoedema, and compared their proliferation and secretion of glycosaminoglycans with those of fibroblasts from the patients' forearms and from the forearm skin of two normal subjects. We found that in the presence of the patients' sera all six lines of fibroblasts secreted more glycosaminoglycans [205 +/- 21% (SD)] than with normal human sera (147 +/- 19%), or fetal calf serum (100%). Fibroblast proliferation showed the same pattern of differences: patients' sera 142 +/- 22%; normal human sera 116 +/- 9%, and fetal calf serum 100%. These experiments confirm the presence of a serum factor in pretibial myxoedema which is capable of stimulating the activity of skin fibroblasts in vitro, and show that its effects are not restricted to fibroblasts from pretibial skin or to those grown from the skin of the patients. Proliferation of normal fibroblasts cultured in medium supplemented with fetal calf serum was reduced by Sandostatin (octreotide), but it failed to inhibit their secretion of glycosaminoglycans. In contrast, secretion of glycosaminoglycans by a patient's pretibial skin fibroblasts was almost completely inhibited by 1 mM minoxidil. In the presence of patients' sera Sandostatin (0.1-10 micrograms/ml) reduced secretion of glycosaminoglycans by about 50%.(ABSTRACT TRUNCATED AT 250 WORDS)

Changing forms of juvenile pityriasis rubra pilaris--a case report.

Pityriasis rubra pilaris (PRP) is a rare disease affecting both males and females. The aetiology is unknown, but it has an ill-defined relationship with psoriasis. Within the spectrum of PRP certain disease patterns are recognized, and regarded by many as helpful prognostic indicators. Griffiths has suggested a clinically based classification based on a series of 98 patients seen at St John's Hospital, London between 1950 and 1972 (Table 1). Classical type 1 PRP is an erythematous squamous disorder typically showing follicular hyperkeratosis, perifollicular erythema and sharply demarcated islands of unaffected skin. The palms and soles become hyperkeratotic and often exhibit a characteristic orange hue. Type III PRP is the juvenile counterpart of classical type I PRP. The following case report describes a patient who presented with type III PRP but later went on to develop the type IV or circumscribed, juvenile onset PRP.