False-negative rate of intraoperative frozen section margin analysis for complex head and neck nonmelanoma skin cancer excisions.

INTRODUCTION: Intraoperative frozen section analysis (IFSA) is traditionally performed for complex and high-risk non-melanoma skin cancer (NMSC) resections, particularly when surgery under a general anaesthetic and a complex reconstruction is required, and where Mohs micrographic surgery (MMS) is not available. METHODS: A retrospective audit of 253 cases between 1999 and 2009 was undertaken, investigating the accuracy and efficacy of IFSA for the treatment of NMSC in our tertiary skin tumour unit based in a university hospital setting. RESULTS: The combined incomplete and very narrow (<1 mm) excision margin rates were 28.7% and 27.5% for basal cell and squamous cell carcinoma, respectively. Unrepresentative sampling of the excision margins intraoperatively was the overwhelming cause of error (94%). CONCLUSION: After a thorough audit of our data, IFSA has been abandoned for the treatment of NMSC in our unit. MMS is practised intraoperatively, even in advanced cases. We believe that IFSA no longer has any role in our complex, multidisciplinary skin cancer practice.

Severe lower limb cellulitis is best diagnosed by dermatologists and managed with shared care between primary and secondary care.

BACKGROUND: Cellulitis is responsible for over 400,000 bed days per year in the English National Health Service (NHS) at the cost of £96 million. OBJECTIVES: An audit following transfer of care of lower limb cellulitis managed in secondary care from general physicians to dermatologists. METHODS: Review of patient details and work diaries from the first 40 months of implementation of the new model of care. RESULTS: Of 635 patients referred with lower limb cellulitis 33% had other diagnoses which did not require admission. Four hundred and seven of 425 patients with cellulitis were managed entirely as outpatients, many at home. Twenty-eight per cent of patients with cellulitis had an underlying skin disease identified and treated, which is likely to have reduced the risk of recurrent cellulitis, leg ulceration and lymphoedema. Only 18 of 635 patients referred with lower limb cellulitis required hospital admission for conventional treatment. CONCLUSIONS: This new way of managing suspected lower limb cellulitis offered substantial savings for the NHS, and benefits of early and accurate diagnosis with correct home treatment for patients.

A comparison of narrowband (TL-01) UVB-induced erythemal response at different body sites.

In most dermatology centres where phototesting is performed, the starting dose is calculated as a proportion of the minimal erythema dose (MED). Previous studies have found significant differences in MED readings between forearm and back skin with both broadband and narrowband (NB) UVB. Our objective was to compare MEDs obtained from three body sites, the forearm, back and abdomen, to see if there was a significant difference in individuals. We recruited 20 healthy volunteers who were exposed to our standard dose series for phototesting with NB-UVB to three body sites: forearm, back and abdomen. MEDs were assessed 24 h post exposure. The median MED for the abdomen was 0.79 J/cm2, the back 0.95 J/cm2 and the arm 1.11 J/cm2. Friedman's analysis of variance by ranks showed that these differences were significant (P = 0.003). There was no correlation between skin type and MED for any of the three anatomical sites. Our results support phototesting for all patients prior to treatment with NB-UVB. Furthermore, we have shown that the abdomen is the anatomical site of choice for phototesting, as this will result in a reduced risk of burning episodes.

A near fatal case of the dapsone hypersensitivity syndrome in a patient with urticarial vasculitis.

Dapsone (4,4'-diaminodiphenyl sulphone) is used for a variety of dermatological conditions including immunobullous diseases and urticarial vasculitis. Side-effects are common and include lethargy, headaches, methaemoglobinaemia and haemolysis. Severe adverse effects are rare but the dapsone hypersensitivity syndrome is well recognized. Symptoms include fever, haemolytic anaemia, lymphocytosis and hepatitis. We report a near fatal case of the dapsone hypersensitivity syndrome in a patient with urticarial vasculitis. This diagnosis should be remembered in any patient who becomes unwell whilst taking dapsone.

Focal dermal hypoplasia: report of a case with cutaneous and skeletal manifestations.

Focal dermal hypoplasia is a rare genodermatosis characterized by developmental defects of the skin, resulting in widespread linear lesions of dermal hypoplasia with adipose tissue in the dermis. We describe a 13-year-old girl who has typical cutaneous lesions which have been present since birth; she also has some of the associated dental, nail and skeletal abnormalities, while an X-ray of the long bones osteopathia striata is visible, a feature seen in a high proportion of cases of focal dermal hypoplasia. Eighty-eight per cent of the case reports in the literature are of females and X-linked dominance is the likely mode of inheritance. It has also been proposed that the condition is lethal in homozygous males and the high frequency of miscarriages on the maternal side of this patient's family is consistent with that lethality in males. The literature, particularly with regard to pathogenesis and inheritance, is discussed.

Absence of toxicity of oats in patients with dermatitis herpetiformis.

BACKGROUND: People with gluten sensitivity should avoid foods containing wheat, rye, and barley, but there has been debate about whether they should avoid oats. Although patients with celiac disease have recently been shown to tolerate oats, less is known about the effects of oats on patients with dermatitis herpetiformis. METHODS: We studied seven men and three women (mean age, 58 years) with biopsy-confirmed dermatitis herpetiformis. They had followed a strict gluten-free diet for a mean of 15.8 years, which controlled their rash and enteropathy. The patients added oats that were not contaminated with gluten to their diets for 12 weeks (mean [+/-SD] daily intake, 62.5+/-10.8 g). RESULTS: None of the patients had any adverse effects. Serologic tests for antigliadin, antireticulin, and antiendomysial antibodies were negative before oats were introduced into the diet and after they were discontinued. Villous architecture remained normal: the mean (+/-SE) ratio of the height of villi to the depth of crypts was 3.59+/-0.11 before the diet and 3.71+/-0.09 afterward (normal, 3 to 5), and the mean enterocyte heights were 31.36+/-0.58 microm and 31.75+/-44 microm, respectively (normal range, 29 to 34). Duodenal intraepithelial lymphocyte counts all remained within normal limits (mean, 13.8+/-1.03 per 100 enterocytes before the diet and 14.2+/-1.2 per 100 enterocytes afterward; normal range, 10 to 30). Dermal IgA showed no significant changes. CONCLUSIONS: Patients with dermatitis herpetiformis can include moderate amounts of oats in their gluten-free diets without deleterious effects to the skin or intestine.

T-cell receptor V beta expression is restricted in dermatitis herpetiformis skin.

An infiltrate of T-cells is found in lesional dermatitis herpetiformis skin, but the role of these cells in the pathogenesis of the skin lesions is unknown. The purpose of this study was to examine T-cell receptor V beta expression in skin biopsies taken from patients with dermatitis herpetiformis. Expression of eleven T-cell receptor V beta families in biopsies obtained from 10 patients was examined by immunoperoxidase staining and compared simultaneously with peripheral blood lymphocytes. Over-representation of V beta 2 (p < 0.02), V beta 5.2/5.3 (p < 0.01) and V beta 5.3 (p < 0.05) was found in lesional dermatitis herpetiformis skin compared with peripheral blood lymphocytes. These results suggest that recognition of an antigen(s) or superantigen is involved in the pathogenesis of dermatitis herpetiformis skin lesions.

Differential T-cell reactivity to the round and oval forms of Pityrosporum in the skin of patients with psoriasis.

Pityrosporum yeasts have been implicated as a trigger for the initiation of scalp lesions in psoriasis. To determine whether Pityrosporum-reactive T cells are present in lesional psoriatic skin. T-cell lines (TCL) were cultured from the scalps of nine patients with psoriasis and seven with alopecia areata (disease controls), and from non-scalp lesions from six of the psoriatic patients. The psoriatic skin TCL were stained for CD3, CD4, CD8 and TCR alpha beta expression and tested in a proliferation assay with Candida albicans and purified protein derivative (PPD), and cytoplasmic and cell-wall extracts of P. ovale (oval) and P. orbiculare (round). The proliferative responses of corresponding peripheral blood mononuclear cells (PBMC) were also determined. All the PBMC samples responded to the Pityrosporum extracts to variable extents, but no significant difference in the response of the group to the two different forms of yeast was observed. The response was mediated by CD4+ T cells and inhibited by the addition of anti-HLA-DR antibody. In addition, all nine psoriatic scalp TCL, which were predominantly CD3+, CD4+ TCR alpha beta(+), responded to the cytoplasmic, and five of nine TCL to the cell-wall extract of P. orbiculare. In contrast, only three of the nine TCL proliferated to either extract of P. ovale. This difference was significant for both the cytoplasmic (P < 0.01) and cell wall (P = 0.01) extracts. Similarly, the TCL cultured from non-scalp psoriatic lesions also showed a more marked response to the P. orbiculare extracts (P = 0.05). Furthermore, four of seven and two of seven scalp TCL from lesions of alopecia areata responded to the P. orbiculare and P. ovale extracts, respectively; these responses did not differ significantly from those of the psoriatic scalp TCL. None of the skin TCL responded to either Candida albicans or PPD. These findings demonstrate that T cells with differential reactivity to the round and oval forms of Pityrosporum are present in, but are not specific for, psoriatic skin lesions. A role for these cells in the pathogenesis of psoriasis remains speculative.

Induction of cutaneous lymphocyte-associated antigen expression by group A streptococcal antigens in psoriasis.

The cutaneous lymphocyte-associated antigen (CLA) has been proposed as a homing receptor for the selective migration of memory T cells into the skin. To investigate the effect of group A streptococci (GAS) on the migration of T cells in psoriasis, CLA expression was assessed by double-staining for CD3 and the HECA-452 epitope on peripheral blood T cells from 13 patients with psoriasis, 10 patients with other inflammatory skin diseases and 12 normal controls before and after 7 days culture with a GAS sonicate, Candida albicans (control antigen) or medium. In addition, CLA+, and CLA-, CD3+ CD45RO+ subsets were isolated from individuals in each group and V beta 2 expression and proliferation to GAS studied. Mean CLA expression by freshly isolated T cells was almost identical in the three groups. After culture with GAS, T cells from the psoriatic patients and control showed a significant increase in mean percentage CLA+ expression compared to medium (P < 0.002, P < 0.05, respectively). This induction was inhibited by the addition of anti-IL-12 antibody. However, in psoriatic patients, but not in controls, the GAS-induced increase was significantly greater than that of C. albicans (P < 0.002) and was accompanied by a decrease in T cells positive for the peripheral lymph node homing receptor, L-selectin (P < 0.05). The percentage of V beta 2+ T cells was markedly higher in the CLA+ than in the CLA- T-cell subset in psoriatic patients (P < 0.01) and controls; both subsets proliferated to GAS, in each group. These findings suggest a differential modulation of specific tissue homing receptors on T cells by GAS in psoriasis.

Autoimmune haemolytic anaemia associated with dermatomyositis.

We report the case of a female patient who at presentation fulfilled the diagnostic criteria of dermatomyositis and also had an autoimmune haemolytic anaemia. Although autoimmune haemolysis is a well recognized feature of a number of autoimmune disorders, it has not previously been described in association with dermatomyositis.

Protective effect of gluten-free diet against development of lymphoma in dermatitis herpetiformis.

A retrospective study of 487 patients with dermatitis herpetiformis showed that lymphoma developed in eight patients, the expected incidence being 0.21 (standardized registration ratio 3810). All lymphomas occurred in patients whose dermatitis herpetiformis had been controlled without a gluten-free diet (GFD) or in those who had been treated with a GFD for less than 5 years. The results are suggestive of a protective role for a GFD against lymphoma in dermatitis herpetiformis and give further support for advising patients to adhere to a strict GFD for life.

Cytokine expression in psoriatic skin lesions during PUVA therapy.

To determine whether an improvement in skin lesions as a result of PUVA therapy may be correlated with changes in cytokine patterns, RT-PCR amplification was used to compare the levels of IL-2, IL-6, IL-8, IL-10, TNF-alpha and IFN-gamma cytokine mRNA expression in serial biopsies from three chronic plaque psoriatic patients. In each case, 3-mm punch biopsies were taken from lesional skin before and during 2-28 days of treatment with PUVA. Total mRNA was extracted from each biopsy, cDNA synthesized, and then amplified by 35 cycles of PCR using cytokine-specific primers. The specificity of the PCR products was confirmed by the Southern blot technique. Substantial levels of specific mRNA for each of the cytokines studied was present in the lesions prior to treatment. In two of the three patients who responded well to PUVA, a reduction in all the cytokines including IL-10 was observed compared with baseline levels. In contrast, PUVA proved to be ineffective in clearing the psoriasis of the third patient whose skin lesions worsened during the course of treatment. This was accompanied by an increase in IFN-gamma but not of the other cytokines investigated, above the pretreatment level. This study showed an association between PUVA-induced resolution and decreases in the levels of various cytokines highly expressed in psoriatic lesions.