Primary cutaneous Hodgkin's lymphoma.

Cutaneous involvement in Hodgkin's lymphoma is an uncommon but well-recognized condition that usually occurs with advanced-stage disease. Primary cutaneous Hodgkin's disease (PCHD) is exceedingly rare, with only a few reported cases. We report a case of a man treated with combination systemic chemotherapy for PCHD, and review the available literature.

Porokeratosis and Crohn's disease.

We report the cases of three patients with Crohn's disease in whom porokeratosis developed. Disseminated superficial actinic porokeratosis developed in two patients. In one of these patients, the skin lesions arose during an exacerbation of the bowel disease. In the third patient, who had congenital linear porokeratosis, the disseminated superficial form of the disorder developed during the first severe exacerbation of Crohn's disease. A family history of porokeratosis was present in one patient, but no relatives of any of these patients were known to have Crohn's disease. In all three patients, Crohn's disease was limited to the colon.

Detection of human papillomavirus DNA in skin warts from immunocompromised patients but not in semen from men whose wives have abnormal cervical cytology.

The epidemiology of human papillomaviruses (HPV) was studied in 61 immunocompromised patients (e.g. renal and cardiac transplants; Bowen's disease; genital cancer) undergoing therapy at the University Hospital of Wales at Cardiff U.K. Warts from various sites of these patients were studied for the presence of HPV types 6, 11, 16 and 18 using the dot-blot DNA hybridization technique. Four HPV-16 and one HPV-11 was detected. The presence of HPV-16 in our study is quite significant since it suggests the potential occurrence of genital HPV types in skin warts in immunocompromised patients and hence the need for screening such patients against HPV types. HPV, mainly types 16 and 18 are usually associated with genital cancer, cervical malignancies and cervical intraepithelial neoplasia. The semen of the husband of 30 women with cervical abnormalities and the semen of 30 husbands (control) of wives with normal cervix were tested for HPV-6, 11, 16 and 18. No HPV-DNA could be detected in all of the 60 specimen. This suggests that specimens were either truly negative for any of those types or because virus DNA could present in a small amount less than 5 pg/microliters in some patients. Whether semen plays a role in transmitting HPV is still controversial.

Psoriasis consultation audit: a two-centre study.

The adequacy of hospital note-keeping in 100 patients presenting with psoriasis at two teaching hospitals has been assessed. The criteria used were defined in consultation with a peer group of 60 British dermatologists. The pattern of record keeping was similar in both centres. Where differences existed between consultant (C) and non-consultant (J) staff, non-consultant staff completed the records more fully. There were differences between centres in the recording of patients' symptoms and disability, psoriasis type, and in the number of visits before discharge to general practitioners care. Both centres had a poor record of communication to general practitioners following patient default from the clinic. In both centres, the patient had only a one in 8 chance of subsequently being seen by a consultant if at the first visit they had been seen by a non-consultant. This simple case-note audit has highlighted the similarity of practice in the two centres and has resulted in practical improvements in record keeping.

A study of etretinate alopecia.

Twenty-two patients receiving etretinate were studied in an attempt to clarify the changes in hair cycle dynamics responsible for etretinate alopecia. Shed hair counts and telogen counts on samples of plucked hair were performed prior to therapy and after 6 and 12 weeks' treatment with etretinate. No evidence of anagen effluvium was found. In two individuals there were findings compatible with a classical telogen effluvium, but these had atypical features. The main finding in the study was an increase in the plucked telogen count, maximal at 12 weeks. As an arrest in the onset of anagen could produce only a comparatively small telogen increase, the predominant cause of this increase was a decrease in the duration of anagen. In two subjects there was also evidence of a telogen anchorage defect.

Purpura and dermal thinning associated with high dose inhaled corticosteroids.

OBJECTIVE: To assess the effect of high dose inhaled corticosteroids on skin. DESIGN: Cross sectional study of patients receiving treatment for chest diseases. SETTING: Outpatient chest clinic in a teaching hospital. PATIENTS: 68 Patients divided into four groups of similar age--namely, 15 receiving long term oral prednisolone, 21 receiving high dose inhaled corticosteroids, 15 receiving low dose inhaled corticosteroids, and 17 controls. MAIN OUTCOME MEASURES: Skin thickness at three sites measured by A scan ultrasound and clinical assessment of purpura. RESULTS: Compared with controls patients in both the oral prednisolone treated group and the high dose inhaled corticosteroid treated group had significantly thinner skin at all three sites (group median thicknesses: prednisolone treated group 28-33% less than controls; high dose inhaled corticosteroid treated group 15-19% less than controls). Differences in skin thicknesses between the low dose inhaled corticosteroid treated group and the controls were trivial. The prevalence of purpura was significantly greater in patients receiving oral prednisolone (12/15 patients) and high dose inhaled corticosteroids (10/21) than in controls (2/17). CONCLUSION: Skin thinning and purpura represent further evidence of systemic effects of high dose inhaled corticosteroids.

A localized, recurrent pustular eruption following amoxycillin administration.

An unusual localized pustular reaction to amoxycillin is reported. Although the rash was recurrent and localized to the identical site on each occasion, the clinical and histological appearances were not those of a typical fixed drug eruption.

Cutaneous cryptococcosis: treatment with oral fluconazole.

A case of cutaneous cryptococcosis is described in an immunocompromised patient. The initial lesion developed on the dorsum of the hand following trauma and was initially thought to be neoplastic. Satellite subcutaneous lesions developed in a 'sporotrichoid' pattern along the forearm. Treatment with oral fluconazole resulted in the complete resolution of the lesions. This is the first published report of the use of fluconazole in the treatment of cutaneous cryptococcosis.

Dermatophyte onychomycosis in children.

Four-hundred and ninety-four schoolchildren and 200 children attending a paediatric medical out-patient clinic were screened for clinical evidence of dermatophyte onychomycosis. Only one case was found and mycological investigation showed this to be due to Trichophyton rubrum. The overall prevalence of dermatophyte onychomycosis in the prospective survey of schoolchildren was 0.2%, confirming that this type of infection is very uncommon in children. Seven further cases of nail infection occurring in children under the age of 12 years are reported. These represent all cases collected by our laboratory over a 3-year period. In six cases where culture of nail was positive, the causative organism was T. rubrum. In four cases at least one parent was also found to have dermatophyte onychomycosis; again, T. rubrum was the causative organism in all cases. Dermatophyte onychomycosis in children appears to be of low infectivity, (in contrast to viral wart infection), and a parental source should be suspected and sought.

Epidermal dysplasia and cyclosporine therapy in renal transplant patients: a comparison with azathioprine.

The prevalence of dysplastic cutaneous lesions was determined in a group of 68 renal transplant patients whose immunosuppressive therapy included cyclosporine but not azathioprine. The mean age of the patients was 41 years (range 17-67), and the mean transplant time was 44 months (range 24-75). Dysplastic cutaneous lesions were found in 14 out of 68 patients, a prevalence of 20.6%. Although the lesions arose on sun-exposed sites, there was no apparent correlation with previous sun-exposure. The cumulative prevalence of dysplastic cutaneous lesions in 64 patients who had received cyclosporine for between 24 and 72 months was compared with 33 renal transplant patients who had been treated with azathioprine over a similar period of time. The overall prevalence of cutaneous dysplasia was 22% in the cyclosporine group and 9% in the azathioprine group. The cumulative prevalence of cutaneous dysplasia in the cyclosporine group was greater at all time points studied. In contrast to previous reports, we have found no evidence that the risk of cutaneous malignancy in patients treated with cyclosporine is less than that found in patients maintained on azathioprine.

Assessment of disease progress in psoriasis.

Effective methods of recording and measuring progress of the signs of psoriasis are essential and central to the accurate assessment of therapy. Currently there is wide variation in assessment methods used, and even well-designed clinical assessment techniques have a wide observer error: objective assessment methods may have advantages. The clinical assessment techniques used in 30 clinical trials of treatment in chronic plaque psoriasis in 1985 and 1986 were reviewed and a detailed analysis is presented. In only 18 trials were individual regions assessed, and widely differing methods of scoring signs were used. Reproducibility of the assessment by clinicians of area of skin involvement by psoriasis was studied. Ten patients with chronic plaque psoriasis had standardized photography, and four clinicians assessed area of involvement from the photographs. The clinicians significantly differed in their rank ordering of the area of psoriatic skin involvement. Area of involvement by psoriasis in the same photographs was assessed objectively using computer-assisted planimetry. Although the clinicians' assessment did not differ randomly from the objective measurement, the accuracy of subjective area assessment is not the same for all clinicians. As even experienced clinical observers show wide variation when attempting to record clinical severity of psoriasis, there is clearly a need for better objective measures of psoriasis severity.

Relief of experimentally induced pruritus with a novel eutectic mixture of local anaesthetic agents.

The effectiveness of a eutectic mixture of the local anaesthetics lignocaine and prilocaine (EMLA cream) in relieving artificially induced pruritus was examined in 20 volunteers. The study was conducted in two parts. In part one, the effect of EMLA on the threshold concentration of histamine necessary to induce pruritus was assessed by a double-blind placebo controlled method. In part two, the effect of EMLA on the perception of pruritus induced by the artificial pruritogens cowhage and papain was assessed by a single blind method. Some subjects were less sensitive to histamine after placebo cream treatment, but all subjects showed a marked reduction in sensitivity to histamine after EMLA treatment. The difference between EMLA and the placebo treatment was statistically significant. The EMLA preparation was found to be effective in alleviating pruritus induced by cowhage and papain and this effect was also statistically significant. Thus, EMLA cream was found to be effective in reducing experimentally induced pruritus and, therefore, may be useful in some clinical circumstances where persistent itch is a distressing symptom.

Treatment of cutaneous neoplasia with etretinate in renal transplant recipients.

Six patients who had developed neoplastic and pre-neoplastic cutaneous lesions following a successful renal transplant were treated with etretinate, 1 mg/kg/day, for six months. In four cases there was almost complete resolution of the lesions; one patient had only a partial response, and one patient developed further lesions whilst on treatment. Patients were observed for six months after treatment was discontinued. Two patients in the group that had responded well to treatment developed further lesions. No deterioration in renal function, as measured by serial serum creatinine concentrations and creatinine clearance, occurred in any of the patients treated. In-vivo measures of the cutaneous cell-mediated immune response were unaltered, but cell kinetic studies demonstrated an increase in proliferative activity in sun-exposed skin during treatment, suggesting that the anti-tumour effect of etretinate is not due to a cytostatic action, and does not require an intact immune system. On the basis of our observations, we feel that further studies are warranted with larger numbers of patients.

Hyperimmunoglobulin E syndrome: treatment with isotretinoin.

A patient with hyperimmunoglobulin E syndrome is described. Recurrent cutaneous staphylococcal abscesses were a prominent feature and had been resistant to treatment with antibiotics and surgical drainage. Following a 4-month course of treatment with isotretinoin, he developed no further abscesses over a 6-month follow-up period. Detailed immunological investigations were undertaken before and after treatment and no change was found to account for his improvement. We consider that the beneficial effects of isotretinoin in this situation are likely to be due to a reduction in sebaceous gland size and activity, rather than to any effect on the underlying disorder.

Cutaneous fungal infection following renal transplantation: a case control study.

The prevalence of cutaneous fungal infection was studied in 72 patients who had undergone renal transplantation and compared with a group of age and sex matched controls. Samples were obtained from toe nails, toe webs, and the upper back; clinically suspicious lesions from other areas were also examined. A total of 576 sites were sampled (288 in each group). Pathogenic fungi were identified from 44 sites (15%) in the renal transplant (RT) group compared with 26 sites (9%) in the control group, (P less than 0.05). However, site-specific differences were less marked; no difference was found between the RT group and controls when the results from the toe nails and toe webs were analysed separately. Trichophyton mentagrophytes was the most common species isolated from both groups. Colonization of the back with Pityrosporum yeasts was significantly more common in the RT group, but few patients in either group had tinea versicolor. 'Mixed infections', with more than one species of fungus isolated in an individual, were only found in the RT group. We also examined the relationship between the presence of fungal infection and the presence or absence of cutaneous malignancy in the renal transplant group. No increase in the prevalence of fungal colonization was found in those patients who had developed cutaneous malignancy compared with those who had not.