Papulonecrotic tuberculide and stenosis of the abdominal aorta.

Papulonecrotic tuberculide (PNT) is a rare form of skin tuberculosis affecting predominantly young adults, with a history of immunity to Mycobacterium tuberculosis. We report a case of a young Caucasian female with PNT who was also documented to have a stenotic segment in the abdominal aorta. The difficulty in clarifying and treating the primary disease and the association between a tuberculous infection and Takayasu's arteritis are discussed.

Childhood vulval pemphigoid: a clinical and immunopathological study of five patients.

We describe five girls with vulval pemphigoid: two had bullous pemphigoid confined to the vulva and three had cicatricial pemphigoid. They demonstrate a spectrum of severity from localized disease to extensive vulval scarring necessitating long-term immunosuppressive therapy and surgical correction. The age at onset of their disease ranged between 6 and 13 years. All presented with vulval discomfort and erosions. Three had oral lesions, two perianal and one eye and cutaneous involvement. Two girls with only vulval lesions and one with vulval and oral lesions responded well to topical steroids. In two, systemic treatment with prednisolone and dapsone or azathioprine was required. The diagnosis was made on the basis of histology and immunofluorescence (IF). All had positive direct IF with IgG and C3. Indirect IF demonstrated circulating IgG binding to the basement membrane zone in four, with dermal or epidermal binding on salt-split skin substrate. Immunoblotting revealed antibodies to the BP230 and BP180 antigens. Immunoelectron microscopy in the child with dermal binding IgG and BP180 and BP230 on immunoblotting showed labelling at the lamina densa-lamina lucida interface adjacent to hemidesmosomes.

The under-reporting of skin disease in association with squamous cell carcinoma of the vulva.

Histology sections from 61 cases of squamous cell carcinoma (SCC) of the vulva presenting after 1988 were reviewed for evidence of associated epithelial abnormality. Of the 50 patients with epithelium adjacent to the tumour, 24 had histological evidence of lichen sclerosus (LS), 20 of severe vulvar intraepithelial neoplasia (VIN 3), 22 of human papilloma virus (HPV) infection and three of lichen planus (LP). The clinical records and the original histology report were also subsequently reviewed and with the exception of VIN 3, these disorders were poorly reported by both clinicians and pathologists. Lichen sclerosus was diagnosed clinically in only two of the 36 hospital records available for inspection. Old terminology was used to describe some patients with epithelial disease (erythroleucoplakia in one patient with LS, leucoplakia in two patients with LS and one with LP). This study demonstrates the need to adopt standard nomenclature and increase the awareness of epithelial disease associated with SCC of the vulva among clinicians and pathologists.

Occupational contact sensitization to the stabilized chlorinated paraffin fraction in neat cutting oil.

Twelve men developed contact sensitization to a neat cutting oil to which they were occupationally exposed in the same factory. Serial patch testing ultimately showed strong positive reactions to the chlorinated paraffin fraction of the oil in all 12 patients, whereas negative results were obtained in all 25 controls. Patch testing to pure chlorinated paraffin, on the other hand, gave negative results. Unexplained positive patch test reactions to epoxy resin from the standard series were elicited in half of the cases, suggesting that an epoxy stabilizer within the chlorinated paraffin fraction was the most likely sensitizer responsible for the outbreak of dermatitis. Because of insufficient manufacturer cooperation, we were not able to specifically identify the sensitizer. A number of deficiencies in the work practice, which accounted for the relatively large size of the sensitized group, were identified.

Effect of lichen sclerosus on sexual function and parturition.

Women attending a dermatologic vulvar clinic were asked to reply by mail to an anonymous questionnaire asking simple questions about sexual function and pregnancy following the development of lichen sclerosus. Additional comments were invited from respondents. The majority of women of all ages reported that lichen sclerosus had a detrimental effect on sexual function, with problems including dyspareunia, apareunia and difficulty achieving orgasm. The symptoms may relate to continuing inflammatory disease as well as to anatomic changes and scarring from long-standing active disease. Disease-suppressing therapy should be instituted at the earliest opportunity, and surgery to reverse the effects of scarring should be considered.

Bacitracin: a significant sensitizer in leg ulcer patients?

We report the results of patch testing 85 patients with either long-standing venous ulceration or eczema complicating their leg ulcers. As previously reported, lanolin and its derivatives and topical antibiotics were the most frequent sensitizers. However, unlike previously published data, we found bacitracin to be the most potent sensitizer of all topical antibiotics tested. There were no positive reactions in a control group of patients, although we were unable to repeat the patch tests in patients with a positive reaction to bacitracin. In the past 10 years, our department has used a proprietary mixture of polymyxin and bacitracin in treating infected leg ulcers and other dermatoses. It is therefore possible that chronic usage of topical bacitracin on leg ulcers carries a significant risk of contact sensitization.

Long-term control of vulval lichen sclerosus after treatment with a potent topical steroid cream.

Super potent topical steroids are an effective treatment for many patients with vulval lichen sclerosus, but concerns exist about their long-term safety. Review of 12 women up to 39 months following a course of super potent topical steroids shows that subsequent control of disease activity and symptoms is much easier than before therapy, with most patients requiring only small amounts of moderate potency topical steroid. Apart from a background erythema no long term cutaneous side effects were observed.

Acrodermatitis continua responding to cyclosporin therapy.

A 69-year-old man with painful, recalcitrant, localized acrodermatitis continua developed widespread pustulation which was resistant to high-dose methotrexate therapy. Low-dose cyclosporin induced a rapid and persistent remission.

Aspects of cutaneous ageing.

'Ageing is a multistep, multifaceted, time-dependent phenomenon characterized by the decreased ability of a system to respond to exogenous and endogenous stress from either physical, chemical or biologic agents'. Cutaneous ageing provides a visible model of the interaction between endogenous (intrinsic) factors and exogenous (extrinsic) factors. In skin, the principal extrinsic-factor is ultraviolet light (UV) which is responsible for the constellation of changes termed photoageing. In recent years, much interest has been directed towards defining the ageing processes in skin and excellent comprehensive reviews have been compiled. This review aims to highlight several areas of developing knowledge, and focuses on the potential importance of environmental changes as they influence skin ageing and carcinogenesis. Repeated reference to the effects of UV on the skin are inevitable in any review of skin ageing and this is scarcely surprising as the skin contains many cells as well as subcellular and extracellular chromophores which are capable of absorbing energy within the UV spectrum. Cellular chromophores include among others keratinocytes, melanocytes, Langerhans cells, dermal fibroblasts and mast cells. Subcellular chromophores include keratin, melanin, collagen, elastin and a number of proteins, lipids and steroids (such as vitamin D). Urocanic acid, a photoisomerization product of the amino-acid histidine, may provide some limited photoprotection and some believe it to be important in UV induced immunosuppression. Understanding events at the molecular and biochemical level has unfortunately not been paralleled by clinical advances and the common, troublesome skin-problems of old age such as cancer, xerosis and pruritus remain a major cause of morbidity and yet are poorly explained.

The treatment of vulval lichen sclerosus with a very potent topical steroid (clobetasol propionate 0.05%) cream.

The clinical and histological response to 12 weeks of treatment with a very potent topical fluorinated steroid was studied in 15 patients with vulval lichen sclerosus (LS) who were treated with twice daily applications of clobetasol propionate 0.05% cream (Dermovate, Glaxo U.K.). Thirteen patients completed the study and all showed a marked clinical improvement. Histological measurements of skin biopsies taken before and after treatment showed a significant reduction in the characteristic features of LS. One patient developed contact sensitivity to clobetasol propionate. There was no evidence of infection or skin atrophy during the study. Patients completing the study have been followed up for up to 22 months and have been maintained in remission with moderately potent topical steroids which had previously been ineffective.

Elastic fibre damage induced by low-dose D-penicillamine.

We have studied 23 patients receiving penicillamine for the treatment of rheumatoid arthritis to determine the prevalence of penicillamine-induced elastosis. One female patient had pseudoxanthoma elasticum-like skin changes and bramble-bush elastosis without calcification in the involved skin. Penicillamine elastosis was present in the joint capsule in 62% of eight patients or 64% of II joints examined and was detected in joint capsules after as little as I year of treatment.

Tufted folliculitis. A specific bacterial disease?

Residual groups of hair follicles and unusual "tufts" of multiple hairs emerging from single follicular openings have been described in scarring alopecia associated with staphylococcal infection. Various mechanisms have been proposed to explain these findings. Histological study of four cases suggests that retention of telogen hairs through several hair cycles may be responsible for this phenomenon.

Nail dystrophy in cutaneous T-cell lymphoma.

A case is reported of cutaneous T-cell lymphoma in an elderly woman. Dystrophy of all 20 nails was caused by a lymphomatous infiltrate of the nail apparatus.

Mycosis fungoides with oral involvement. A case report and literature review.

Mycosis fungoides, also known as T-cell lymphoma, is a low-grade malignant lymphoma predominantly affecting the skin. Intraoral manifestations are infrequently seen clinically. A case of mycosis fungoides with oral involvement and a review of the literature is reported.

The site of protein loss in Schönlein-Henoch purpura.

Schönlein-Henoch purpura may be complicated by hypoproteinaemia, which in most patients is due to the development of nephrotic syndrome. However, in some proteinuria is insignificant and enteric protein loss has been suggested as the cause. A case with supportive evidence for this is reported.