Acral pseudolymphomatous angiokeratoma of children (APACHE)-like eruption in adult identical twins.

Acral pseudolymphomatous angiokeratoma of children (APACHE) is a condition that was first described in 1990 in a group of children, but has since been described in adults. We present the cases of identical twin patients aged 40 years. The first brother presented with an 8-year history of itchy lesions over the left ankle and the insteps of both feet. After a diagnostic biopsy, he was treated with potent steroids under occlusion for 8 weeks, which resulted in flattening of the lesions and resolution of the pruritus. The second twin had a 20-year history of a very similar presentation but the lesions were less pronounced; he chose not to have treatment. No other family members were affected. Skin biopsies from both patients showed similar changes. Within an overall hyperkeratotic and acanthotic epidermis, there were focal areas of lichenoid change and epidermal thinning. Beneath these areas, there was oedema and nodular aggregates of dense inflammatory cell infiltrate, predominantly lymphocytic infiltrate. APACHE has not been previously described in twins.

Diffuse dermal angiomatosis: a contributory factor to ulceration in a patient with renal transplant.

We present the case of a 54-year-old patient with renal transplant who developed unusual vascular changes on the forearm distal to a functioning arteriovenous fistula, as well as a painful ulcerated lesion on her anterior abdominal wall. We believe that the diffuse dermal angioendotheliomatosis variant of reactive angioendotheliomatosis had a role in the pathogenesis of this patient's lesions.

The use of imiquimod in the treatment of periocular tumours.

PURPOSE: To review our experience with 5% topical Imiquimod in the treatment of periocular tumours. METHODS: Imiquimod, an imidazoquinoline, is an immune response modifier which has been shown to have potent anti-viral and anti-tumour activity. We present a retrospective case series of 5 patients who received topical Imiquimod for various eyelid tumours. Two patients were diagnosed with basal cell carcinoma of the eyelid, one patient with actinic keratosis, one with intraepidermal squamous cell carcinoma (Bowen's disease) and one patient had concomitant squamous cell carcinoma and intraepidermal squamous cell carcinoma. RESULTS: All 5 patients, with various eyelid neoplastic/pre-neoplastic pathology, responded well with clinical resolution, to treatment with topical Imiquimod. There were few adverse reactions to periocular use of 5% Imiquimod, with only 1 patient developing a chemical conjunctivitis which resolved on dose reduction. CONCLUSIONS: There is limited experience and published literature on the use of topical 5% Imiquimod in the treatment of periocular tumours. In our experience, it is a safe and effective treatment for periocular lesions, including actinic keratosis, intraepidermal squamous cell carcinoma, basal cell carcinoma and squamous cell carcinoma. To our knowledge, this is the first published description of the successful use of 5% Imiquimod in treating moderately differentiated squamous cell carcinoma of the eyelid.

Control of head lice with a coconut-derived emulsion shampoo.

OBJECTIVE: To evaluate a novel coconut-derived emulsion (CDE) shampoo against head lice infestation in children. DESIGN: A school trial in which pupils were treated on days 0 and 7 and checked on days 8 and 15 and a family trial where product was applied by parents three times in 2 weeks or used as a cosmetic shampoo and checked on days 14 and days 70. SETTING: UK schools in Bristol and Western-super-Mare and families in Northern Somerset. MAIN OUTCOME MEASURE: Numbers of children free from infestation after treatment. RESULTS: In the school trial, percentage cures at day 8 were 14% (permethrin, n=7) and 61% (CDE, n=37). In the family trial where all family members were treated, cure rate was 96% (n=28), and if the shampoo was subsequently used as a cosmetic shampoo, only 1 of 12 children became re-infested after 10 weeks. CONCLUSION: CDE shampoo is a novel effective method of controlling head lice and used after treatment as a cosmetic shampoo can aid in the reduction of re-infestation.

Association of parental eczema, hayfever, and asthma with atopic dermatitis in infancy: birth cohort study.

OBJECTIVE: To evaluate the association of parental history of atopic disease with childhood atopic dermatitis, and to examine the relative strength of associations with maternal and paternal disease. DESIGN: Mothers were recruited to the Avon longitudinal study of parents and children (ALSPAC) from the eighth week of pregnancy. Before parturition, both parents were asked, separately, to report their lifetime history of eczema, asthma, and hayfever. Parents reported symptoms of atopic dermatitis in their children at ages 6, 18, 30, and 42 months. RESULTS: Of 8530 children with complete information on rash at ages 6, 18, 30, and 42 months, 7969 had complete information on maternal atopic disease and 5658 on maternal and paternal atopic disease. There was a strong association between parental eczema and childhood atopic dermatitis: odds ratio 1.69 (95% confidence interval, 1.47 to 1.95) for maternal eczema only, 1.74 (1.44 to 2.09) for paternal eczema only, and 2.72 (2.09 to 3.53) for eczema in both parents. Associations with parental asthma or hayfever were attenuated after controlling for parental eczema. There was no evidence that associations with maternal atopy were stronger than with paternal. CONCLUSIONS: Associations between parents' atopic disease and the risk of atopic dermatitis in offspring vary according to the type of atopic disease in the parents, but not according to parental sex. These results are at variance with previous studies reporting stronger associations with maternal than paternal atopy, and suggest that there is no "parent-of-origin" effect in atopic dermatitis. Parental eczema may be a better marker than parental asthma/hayfever in predisposing to childhood eczema.

A prospective study of the prevalence and incidence of atopic dermatitis in children aged 0-42 months.

BACKGROUND: There is strong evidence that the incidence and prevalence of atopic diseases is increasing. However, estimates of the prevalence of atopic dermatitis (AD) have varied greatly in the U.K. and most parts of the developed world. OBJECTIVES: The aim of the study was to estimate the prevalence and incidence of AD between the ages of 0 and 42 months in children born in the 1990s in a defined population in the U.K. DESIGN: We used data from the Avon Longitudinal Study of Pregnancy and Childhood (ALSPAC), a large population-based study in the U.K. that enrolled all pregnant mothers who were resident in Avon and had their delivery date falling between 1 April 1991 and 31 December 1992. Since then ALSPAC has collected a wide range of data from the newborns and their parents. Data reported here were collected at 6, 18, 30 and 42 months using parental reports in a postal questionnaire. Of the 14 009 children originally enrolled 8530 provided information on AD in each of the four follow-up questionnaires. We defined AD as a report of rash in at least two of the four questionnaires. Incidence risk was defined as the percentage of new cases of AD between follow-up questionnaires, out of the total number of children whose parents had not reported that they had AD by the time of the previous follow-up. RESULTS: Period prevalence of 21.0%, 25.6%, 23.2% and 19.9% were observed at ages 0-6, 6-18, 18-30 and 30-42 months, respectively. The corresponding incidence risks were 21.0%, 11.2% and 3.8%, at 0-6, 6-18 and 18-30 months, respectively. There were no gender differences in either the incidence or prevalence of the disease. CONCLUSIONS: Results from this large, prospective study are consistent with recent reports of increased incidence and prevalence of AD. Health planners can use our estimates of incidence and prevalence to project the number of children likely to suffer from AD during infancy and early childhood, and thus to determine the human and financial resources required.

Acute and maintenance treatment of atopic dermatitis in children - two comparative studies with fluticasone propionate (0.05%) cream.

BACKGROUND: Two multicentre, randomised, parallel group, double-blind, comparative studies in children (2-14 yr) evaluated fluticasone propionate (FP) 0.05% cream for both acute and maintenance treatment of moderate to severe atopic dermatitis (AD). METHODS: One study compared FP with hydrocortisone (HC) 1% cream (FP 70, HC 67) and the other with hydrocortisone butyrate (HCB) 0.1% cream (FP 67, HCB 62). Treatments were applied twice daily, for 2-4 weeks until the AD was stabilised, and thereafter intermittently ('as required') for up to 12 weeks. RESULTS: The primary outcome measure, Total AD Score, recorded at the end of the acute and maintenance phases, was significantly lower (indicating improvements in disease severity) following treatment with FP compared with either HC or HCB (acute phase difference vs. HC, -2.39, 95%CI -3.47, -1.31; p<0.001 and vs. HCB, -1.25, 95%CI -2.46, -0.05; p=0.042) and (maintenance phase difference vs. HC, -1.88, 95%CI -3.20, -0.56; p=0.006 and vs. HCB, -1.39, 95%CI -2.72, -0.05; p=0.042). In both studies treatments were equally well tolerated with no visible signs of skin atrophy. CONCLUSION: In both the acute and longer term management of AD in children, FP demonstrated a high level of efficacy and maintenance of disease control with a tolerability similar to HC 1%, a lower potency corticosteroid.

Idiopathic hypereosinophilic syndrome associated with cutaneous infarction and deep venous thrombosis.

We report a case of idiopathic hypereosinophilic syndrome (HES) presenting with cutaneous infarction and subsequent extensive deep vein thrombosis. The eosinophilia improved dramatically with systemic corticosteroid therapy. A variety of skin disorders have been associated with HES, although there are no previous reports of HES associated with cutaneous infarction. HES is a rare disorder characterized by a sustained overproduction of eosinophils and multisystem disease. The aetiology of the eosinophilia remains uncertain but clonal populations of abnormal T-cells producing interleukin 5 may be implicated.

Cutaneous recall reactions with systemic fluorouracil.

5-Fluorouracil is used extensively to treat actinic keratoses as there is selective excessive uptake of 5-fluorouracil in rapidly dividing cells, thus causing inflammation in lesional skin. We report 2 cases of inflammation occurring on clinically normal skin after fluorouracil had been administered parenterally for carcinoma of the oesophagogastric junction and lower third of the oesophagus, respectively. In the first case, actinic keratoses had previously been treated with topical fluorouracil and in the second case, although there were no previous actinic keratoses, there was a high degree of previous solar exposure of the affected areas. In each case, there was a good response to topical steroid application. No recurrence was experienced on further doses of systemic fluorouracil when the skin was treated prophylactically with topical steroids. Recognition of these reactions is important if unnecessary discontinuation of chemotherapeutic drugs is to be avoided as a result of fear of allergic drug reactions.

Twice-daily vs. once-daily inpatient dithranol for psoriasis.

The aim of this study was to compare the efficacy and tolerability of twice-daily vs. once-daily regimes of dithranol (anthralin) in Lassar's paste. Over a 4-year period, 61 inpatients with stable plaque psoriasis gave informed consent and entered a randomized controlled trial, having twice or once-daily application of dithranol in Lassar's paste as part of otherwise standard Ingram's regime. Primary outcome measurements were time required in hospital, nursing time, changes in total body surface area affected by psoriasis and thickness of a target plaque and in some patients, an assessment of the recurrence of psoriasis. Doctors were blinded as to the regime being used. At entry, mean patient age, lesional surface area and target plaque thickness were comparable in both groups and no patient had received systemic therapy in the preceding 3 months. Forty-two patients completed the study, two (11%) in the twice-daily group withdrawing due to skin irritation or 'burning'. Mean lesional surface area and target plaque thickness were similar in both groups at hospital discharge. Mean (+/- SD) time spent in hospital was not significantly different in each group, being 13.3 (+/- 6.2) days and 13.9 (+/- 4.5) days for the twice-daily and once-daily groups, respectively (P = 0.36). Duration of hospitalization did not correlate with surface area or plaque thickness on admission. Mean (+/- SD) nursing time spent on treatment was significantly greater in the twice-daily group, at 0.82 (+/- 0.33) hours per day compared with 0.51(+/- 0.25) hours per day in the once-daily group. Relapse rate at 6 months was not different between the two groups.