Teledermatology in practice.

Teledermatology has been the focus of much interest in recent years. Potential uses include a simple supporting role for primary care, more accurate triage of dermatology patients or an 'advice only' service reducing the need for dermatology patients to attend outpatient clinics. With the current under-provision of dermatology services in the UK and the waiting list targets set by government, teledermatology systems have been proposed as a possible solution. 'Store and forward' teledermatology systems are easy to set up and it has been shown that accurate diagnoses can be made using digital images attached to an E-mailed history. In an area of geographical isolation a store and forward teledermatology system has been used successfully to reduce patient waiting times. In Peterborough we have been using a store and forward teledermatology system for over 4 years. Our experience has demonstrated that for only a small number of selected patients was it possible to provide an advice-only service, but the majority of patients still need to be seen in the outpatient clinic. Despite the technical simplicity of these systems today there is still little evidence that teledermatology will have a significant impact on patient workload in the average dermatology clinic. It must be recognized that teledermatology is potentially a useful communication tool for selected patients in primary care but is unlikely to solve waiting list problems or replace the need for local dermatology services.

Palmar filiform hyperkeratosis (FH) associated with underlying pathology?

We describe two patients with palmar filiform hyperkeratosis, characterized by multiple thin spiny keratotic projections on the palms. The condition has been associated with an underlying malignancy in some cases. One patient has myelofibrosis, an association not previously described. In addition we describe a further patient with filiform hyperkeratoses of both palms and soles with no associated underlying disorder. In view of the relatively high risk of underlying malignancy occurring in patients with filiform hyperkeratosis, these patients should always be investigated fully.

gamma-interferon production in atopic dermatitis shows differential modification by phosphodiesterase and prostaglandin inhibition.

Interferon-gamma (IFN-gamma) production by peripheral blood mononuclear leucocytes (MNL) is reduced in atopic dermatitis (AD) patients. This may be related to abnormalities in second messenger systems, and increased prostaglandin E2 (PGE2) release from monocytes. We compared the effects of manipulating the second messenger activity using the phosphodiesterase (PDE) inhibitor Ro 20-1724, dibutyryl cyclic adenosine monophosphate (cAMP), and cyclooxygenase inhibition of PGE2, on IFN-gamma production by cultured MNL from AD patients (n = 9) and normal controls (n = 10). Ficoll-Hypaque-separated MNL were cultured for 48 h with OKT3 stimulation, and cAMP, Ro 20-1724, or indomethacin. Supernatants were analysed for IFN-gamma by ELISA. Basal IFN-gamma was lower in AD patients, and the increase in IFN-gamma production with OKT3 was 6.5-fold greater in control subjects than patients with AD. Culture with indomethacin significantly enhanced OKT3-stimulated IFN-gamma production in both groups, whereas OKT3-stimulated IFN-gamma production was abolished with dibutyryl cAMP. IFN-gamma production was significantly lower with Ro 20-1742 in AD than in normal controls. We have shown reduced IFN-gamma release from unstimulated and stimulated MNL in AD patients compared with normal controls. The addition of indomethacin increased IFN-gamma production in both groups, although the increase was less in AD patients, suggesting an intrinsic cellular defect. IFN-gamma release from AD MNL was more sensitive to the inhibitory effects of PDE, and this may be due to increased PDE activity, or the hyperdynamic cAMP system present in atopics.

Cutaneous infiltration in T-cell prolymphocytic leukaemia.

T-cell prolymphocytic leukaemia (T-PLL) is an aggressive leukaemia accounting for over 30% of all mature T-cell malignancies. We describe the clinical manifestations and histology of cutaneous involvement in a series of 92 patients with T-PLL. Of the 92 patients, 26 (28%) had cutaneous involvement, and in 23 this was present at the time of the diagnosis of the leukaemia. Skin manifestations included a diffuse infiltrated erythema, infiltration localized to the face and ears, nodules and erythroderma. Histology showed a perivascular and periappendageal dermal infiltrate of lymphoid cells with the morphology of prolymphocytes. An early skin biopsy in these patients should help to reveal the underlying diagnosis.

Are pigmented lesion clinics worthwhile?

To assess the effect of a pigmented lesion clinic on referral patterns and thickness of melanoma at presentation, we have compared data from the centralized pathology services of the adjacent health authorities of Wandsworth, and Merton and Sutton. Both districts were the subject of a CRC public awareness campaign in 1987, but only Wandsworth is served by a pigmented lesion clinic. All patients presenting with malignant melanoma were included; from 1981 to 1990 for Wandsworth, and from 1984 to 1990 for Merton and Sutton. The Breslow thickness and clinic source of all melanomas was documented. Approximately equal numbers of melanomas were seen in the two districts, with no obvious difference in the numbers of thin (< 1.5 mm thick) 'good prognosis' tumours. Both districts saw an increase in the total number of tumours, and the number of thin tumours, after the CRC publicity campaign. However, there was considerable cross-boundary referral to the pigmented lesion clinic in Wandsworth, with 60% of all melanomas coming from outside the district. The presence of a pigmented lesion clinic within a given district confers no obvious benefit with regard to the number of thin, 'good prognosis' melanomas being seen as a whole, but the cross-boundary referral pattern suggests that it fulfils a demand from both general practitioners (GPs) and patients, and it does provide a centralized source for the collection of much-needed data.

Measurement of phosphoinositide-specific phospholipase C activity in mononuclear leucocytes from atopic and normal subjects.

The intracellular inositol pathway is an important route for cell activation and relies on the stimulation of membrane-bound phosphoinositide-specific phospholipase C (PLC). Previously we have shown abnormalities of inositol metabolism in mononuclear cells (MNL) in atopic dermatitis (AD) using an indirect method. We now describe a direct method of measuring PLC activity in membrane and cytosol preparations of MNL in AD. We compare PLC activity in AD with that in normal controls and examine the effect of substrate concentration and nucleotide stimulation on the system. Our findings show increased membrane-bound PLC activity in AD compared with normal controls. Non-specific stimulation of AD PLC activity by nucleotides suggests that the enzyme of atopics is more sensitive to substrate-driven activity than that of non-atopics.

Acquired eruptive haemangiomata with primary biliary cirrhosis and prostatic carcinoma.

We report a male patient with acquired eruptive haemangiomata occurring in association with primary biliary cirrhosis and a carcinoma of the prostate. The possible explanations include an abnormality of sex sterol metabolism associated with his liver disease, secretion of an angiogenic factor by his carcinoma or a combination of the two mechanisms.

Acral persistent papular mucinosis.

The case is reported of a 56-year-old man with an unusual papular eruption on the forearms with deposition of mucin in the dermis. The clinical and histopathological features were consistent with acral persistent papular mucinosis, a recently described focal type of cutaneous mucinosis.

Recognition of two distinct major antigens by bullous pemphigoid sera.

Sera from 17 patients with bullous pemphigoid identified a range of polypeptides of relative molecular mass (Mr) 240,000, 230,000, 190,000, 180,000, 120,000 and 100,000 from extracts of SCaBER cells, cultured human keratinocytes or human epidermis, using an immunoblotting technique. The pattern of polypeptides was characteristic for the patient serum and individual sera identified similar polypeptides from all three substrates. All 17 sera recognized major polypeptides of either Mr 230,000 (11 sera) or Mr 180,000 (seven sera) under the denaturing conditions used for immunoblotting studies. Sera from 12 patients were also examined using an immunoprecipitation technique. Polypeptide(s) of Mr 230,000 were immunoprecipitated from extracts of SCaBER cells by 11 of these sera, despite immunoblotting patterns of Mr 180,000 (or less) for three of the 11 sera. None of the minor polypeptides recognized in immunoblotting studies were immunoprecipitated by these sera. Localization of antigens was determined by binding of sera to intact or permeabilized SCaBER cells in an ELISA. Sera which recognized the Mr 230,000 polypeptide under denaturing conditions also identified an intracellular epitope in SCaBER cells, while sera which identified the denatured Mr 180,000 polypeptide bound to a cell surface epitope. Two distinct major antigens are recognized by bullous pemphigoid sera. These both appear as molecules of Mr 230,000 under non-denaturing conditions, but only one of the molecules is dissociated to produce a Mr 180,000 polypeptide under denaturing conditions. Epitopes on these two major antigens are localized on either side of the cell membrane.

Binding of bullous pemphigoid and pemphigus vulgaris sera to SCaBER cell line in an ELISA.

Specific antibodies present in the sera of patients with bullous pemphigoid or pemphigus vulgaris were detected in an enzyme-linked immunosorbent assay (ELISA) employing a squamous carcinoma cell line, SCaBER, as substrate. Bullous pemphigoid sera bound preferentially to permeabilized cells, suggesting that the antigens are largely intracellular. The assay may prove to be a useful addition to current methods of detecting circulating antibodies in these patients.

Psoriasis, razoxane and a cutaneous B-cell lymphoma.

A woman with a 20-year history of acral pustular psoriasis of Hallopeau and recurrent pustular lesions of the forearms and lower legs, developed a B-cell lymphoma of the lip following 4 1/2 years of treatment with razoxane.

Failure of cimetidine to suppress immunoreactive parathyroid hormone and hypercalcaemia in primary hyperparathyroidism.

Cimetidine has been reported as suppressing the excess parathyroid hormone secretion and hypercalcaemia seen in hyperparathyroidism. A case of primary hyperparathyroidism is described, in which the level of circulating parathyroid hormone and hypercalcaemia remain entirely unaffected by cimetidine. The drug is implicated in the management of primary hyperparathyroidism unsuitable for surgery, but present evidence, as reviewed, is insufficient to recommend the use of cimetidine in this way.