Anogenital Lichen Sclerosus in Women

A study of 350 women with lichen sclerosus, originally made to elucidate the relationship between lichen sclerosus and autoimmunity, led to the amassing of a considerable amount of clinical material. Our review is confined to those with anogenital lesions (342), supplemented by some new cases (15), giving a total of 357 women with biopsy proven lichen sclerosus. It demonstrates the wide age range of the condition, the association with morphoea and lichen planus and the occurrence of squamous cell carcinoma in some cases. It also shows that inappropriate surgery has continued to be carried out for benign disease.

Bullous subacute cutaneous lupus erythematosus

We describe a 59-year-old woman, with a history of autoimmune disease and disseminated uterine leiomyosarcoma, who developed a photoaggravated, blistering skin eruption. An initial rash, at the outset of treatment with chemo- and radiotherapy, resembled erythema multiforme. Review of the original skin biopsy showed it to be subacute cutaneous lupus erythematosus. There were no systemic symptoms or signs to suggest systemic lupus erythematosus. The much later photoaggravated rash consisted mainly of bullae and eventual epidermal denuding which resembled toxic epidermal necrolysis. We propose that the clinical and histological diagnosis is one of bullous subacute cutaneous lupus erythematosus in a patient with no other features of systemic lupus erythematosus.

The management of psoriasis

Psoriasis is a common condition affecting 1.5-2.0% of Western populations. It occurs equally commonly in men and women. Although it affects mainly the skin, an associated arthritis occurs in approximately 3-4% of those affected. It is rarely life-threatening, but is frequently the cause of significant morbidity, both physical and psychosocial. Management may involve topical treatments, phototherapy or photochemotherapy or systemic agents. The choice of treatment depends on a variety of factors, including the extent and type of the cutaneous lesions, the presence of an associated arthritis and whether the patient has any other intercurrent disease. Patients receiving treatment with systemic agents require careful supervision, as those currently used have potentially serious adverse effects.

Dermatitis herpetiformis and bullous pemphigoid: a developing association confirmed by immunoelectronmicroscopy

We report a case of dermatitis herpetiformis associated with bullous pemphigoid in which the clinical, histopathological and immunopathological findings were corroborated by direct immunoelectronmicroscopy performed on normal and peri-lesional skin biopsies. Western immunoblotting detected the 180 kDa BPAG2 consistent with bullous pemphigoid. HLA-typing confirmed the DR3 DQ2 haplotype associated with dermatitis herpetiformis.

Proximal cutaneous necrosis in association with chronic renal failure

We report two patients with renal failure who developed painful symmetrical ulceration over the proximal thighs and abdominal wall. Histological examination of the ulcerated areas revealed intravascular calcification. This phenomenon has been termed calciphylaxis and is a rare complication of renal failure. The pathogenesis is poorly understood. However, abnormalities of calcium/phosphate metabolism and of coagulation are important.

Acrokeratosis paraneoplastica: Bazex syndrome

Bazex syndrome, or acrokeratosis paraneoplastica, is a cutaneous paraneoplastic syndrome characterized by psoriasiform lesions associated with, usually, a squamous cell carcinoma of the upper aerodigestive tract. We present a case of Bazex syndrome associated with metastatic cervical squamous cell carcinoma with an unknown primary. The features of the condition are discussed in the light of current knowledge.

Symmetrical lymphomatoid papulosis masquerading as pyoderma chancriformis of the eyelids

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Dermatology in the intensive care unit

We report our experience, and review the literature, concerning 'intensive care dermatology'. Over a period of 14 months, 27 patients who had significant cutaneous problems were seen in the intensive care unit. These included primary dermatological conditions, multisystem disorders with cutaneous signs, complications of dermatological therapy, and skin conditions developing as complications of intensive care. We discuss the diagnosis and management of dermatological problems in the intensive care unit.

Chronic verrucous varicella-zoster infection in a patient with AIDS

The expression of herpes varicella zoster virus in patients already infected with the human immunodeficiency virus (HIV) provides the perfect illustration of an opportunist microbe at work. There is an increased incidence of herpes zoster which may be more severe, recurrent or disseminated. Likewise, varicella may be more severe and recurrent. In both patterns of infection atypical lesions in the form of persistent ulcerative or verrucous lesions have been seen. An HIV-positive patient is described who developed verrucous lesions de novo, 4 months after her child had varicella.

Ichthyosis hystrix and skin cancer

Ichthyosis hystrix is a rare genodermatosis characterized by persistent spiny scales which cover a significant part of the skin surface. In many cases it is associated with palmoplantar keratoderma, and occasionally deafness and neurological defects coexist. The case of a man with ichthyosis hystrix is reported who developed skin malignancy and dysplastic keratoses, a complication which has not previously been recorded.

The anticonvulsant hypersensitivity syndrome

Anticonvulsants can cause a characteristic hypersensitivity reaction. This multisystem reaction typically presents as fever, mucocutaneous eruptions, lymphadenopathy and hepatitis. There is cross-reactivity between different anticonvulsants, which complicates subsequent therapy. We report three cases to illustrate both the typical features, and less common complications, of this under-recognized and life-threatening syndrome.

Angioendotheliomatosis associated with Castleman's lymphoma and POEMS syndrome

Castleman's lymphoma, a benign localized lymphoid hyperplasia, has been reported in association with POEMS syndrome, a multisystem reactive disorder that includes several skin manifestations. Benign reactive angioendotheliomatosis is a rare skin disorder that is associated with various systemic disorders. A patient with long-standing Castleman's lymphoma and POEMS syndrome also developed benign reactive angioendotheliomatosis.

HTLV-1-associated cutaneous disease: a clinicopathological and molecular study of patients from the U.K

The clinicopathological features of eight patients with cutaneous disease associated with HTLV-1 infection are reviewed. All were U.K. residents of West Indian extraction, and two are currently alive. Disease remained confined to the skin in two patients. Five patients with a cutaneous prodromal phase developed leukaemia after a median duration of 124 months (3 months-21 years), and in one of these combination chemotherapy produced a sustained clinical remission for 20 months. Two patients developed cutaneous disease after remission of their leukaemia. Cutaneous lesions were heterogeneous and included localized papules, a generalized papulonodular eruption, diffuse and localized erythematous plaques, pompholyx-like lesions on the palms and soles, and tumours. The histology of the skin lesions was also variable, and consisted of a heavy dermal infiltrate with lymphocytes, histiocytes, plasma cells, eosinophils and cytologically atypical mononuclear cells. Epidermotropism was present in biopsies from five patients. Tumour cells with large, densely staining, pleomorphic nuclei, arranged in rows between collagen bundles, were present in the majority of cases. In one patient the infiltrate also consisted of epithelioid cells and multinucleated giant cells. Six cases were classified histologically as pleomorphic T-cell lymphoma, and two as cerebriform or mycosis fungoides type. Molecular studies revealed a clonal T-cell population associated with monoclonal integration of HTLV-1 provirus in tissue DNA from six patients. In two patients HTLV-1 integration was established retrospectively using enzymatic in vitro amplification of a specific HTLV-1 po1 gene sequence in DNA extracted from paraffin-embedded sections. This study indicates that the clinical and pathological features of HTLV-1-associated cutaneous disease are diverse. Patients may have disease confined to the skin for prolonged periods, either at presentation or following clinical relapse--cutaneous adult T-cell lymphoma. Molecular techniques allow distinction from other types of cutaneous T-cell lymphoma, and provide an opportunity for retrospective studies of archival material.

Acrokeratosis Paraneoplasticao of Bazex

Bazex disease is one of the rarer cutaneous paraneo-plastic syndromes. It is characterized by psoriasiform changes on the digits, and in some patients spread to the ears, nose and in later stages to the limbs and trunk. The associated malignancy is typically a squamous cell carcinoma of the upper aerodigestive tract. We review the literature regarding acrokeratosis paraneoplastica of Bazex and report three cases which illustrate both the typical and some of the less common changes that are seen in the condition.

Cutaneous malignant melanoma and human immunodeficiency virus (HIV) infection: a report of three cases

Cutaneous malignant melanoma was diagnosed in three patients suffering from human immunodeficiency virus (HIV) infection. Staging at presentation inversely correlated with absolute CD4 count. In addition, a notably sparse lymphocytic inflammatory response to the melanoma was observed in two cases. Established data on melanoma in non-HIV immunosuppressed patients suggests a poor prognosis for melanoma in HIV disease.

Disseminated granuloma annulare as a presentation of acquired immunodeficiency syndrome (AIDS)

Localized granuloma annulare is the commonest form of a granulomatous dermatosis characterized by flesh coloured or violaceous papules often arranged in rings. Several rare atypical variants are also reported including disseminated or generalized, subcutaneous and perforating types. There is a predilection for females and a documented association with diabetes mellitus in some cases. Recently it has been suggested that atypical variants of granuloma annulare might be associated with the acquired immunodeficiency syndrome (AIDS). We describe a patient presenting with extensive generalized granuloma annulare in whom an underlying diagnosis of Human Immunodeficiency Virus (HIV) disease was confirmed.

Algodystrophy (reflex sympathetic dystrophy) complicating unilateral acrodermatitis continua

A 65-year-old female suffered trauma to her left hand on which acrodermatitis continua (psoriasis of Hallopeau) developed. It is suggested that the persistent pain of this skin condition, its poor response to treatment and her allied mental state led to the development of a severe algodystrophy with marked underlying osteoporosis.

The flow cytometry of melanocytic skin lesions

DNA flow cytometry was performed on formalin fixed, paraffin embedded melanocytic naevi. DNA aneuploidy was detected in all three types of naevus but was significantly more frequent in those naevi accepted as precursors of malignancy: that is, dysplastic and congenital pigmented hairy naevi. It may be that the presence of DNA aneuploidy has prognostic significance in these naevi. Technical problems were encountered in the analysis of data from melanocytic lesions so that caution is recommended in interpretation of studies using formalin fixed tissue.

Lichen sclerosus et atrophicus and autoimmunity--a study of 350 women

A study of autoimmune related phenomena in 350 women with histologically confirmed lichen sclerosus et atrophicus revealed that 21.5% had one or more autoimmune related diseases, 21% had one or more first degree relatives with an autoimmune-related disease, 42% had an autoantibody at a titre greater than 1:20, and 59.5% had one or more of these autoimmune-related phenomena. No statistically significant differences in the natural history of lichen sclerosus et atrophicus were demonstrated between those patients with autoimmune-related phenomena and those without.

A flow cytometric study of the significance of DNA aneuploidy in cutaneous lesions

Aneuploidy has not to date been demonstrated in any entirely benign condition and thus is held to be implicit of neoplasia. DNA flow cytometry can be used to detect DNA aneuploidy rapidly. A technique has been developed to make possible flow cytometric analysis of formalin-fixed skin. The technique was validated by study of benign and pre-malignant dermatoses. Further studies were performed on skin conditions of questionable malignant potential. DNA aneuploidy was demonstrated in lichen sclerosus et atrophicus. Flow cytometry was unable to distinguish keratoacanthomas from squamous cell carcinomas.

Acropustulosis of infancy

Acropustulosis of infancy is a syndrome characterized by recurrent pruritic acral vesicopustules. It occurs primarily in black male infants and hitherto has been described mainly in the North American literature. We describe four cases seen in London. This entity, therefore, should be recognized in the U.K., particularly in the differential diagnosis of infantile scabies.

Aneuploidy in Bowen's disease

Distinct aneuploid clones of keratinocytes were detected in six cases of cutaneous Bowen's disease. As Bowen's disease is an accepted precursor of malignancy, aneuploidy may prove to be a useful indicator of the risk of invasive change in dermatoses questionably pre-malignant.

Familial primary cutaneous amyloidosis

Primary cutaneous amyloidosis is uncommon in Europeans. A British family is described in which an extremely rare variant was inherited as an autosomal dominant. The subtlety of physical signs in this family contrasted with the severity of the associated pruritus. Transepidermal elimination of amyloid was a characteristic histological feature.

Study of psoriatic epidermal cell kinetics and cell death after oral methotrexate

Epidermal cell proliferation in psoriasis was studied after oral methotrexate using tritiated uridine. Psoriatic enteropathy has in the past been reported to reduce the absorption of methotrexate administered orally but this study showed that the onset of inhibition of mitosis and DNA synthesis occurred at the same time as after intramuscular administration of the drug. The cell kinetic data indicate that cells were blocked at the G1/S interface, and the kinetics of inhibition are discussed in terms of their implications for the mode of action of methotrexate in psoriasis. Considerable numbers of dead cells were seen in the epidermis from 6 to 24 h after oral methotrexate. The mode of action of methotrexate in psoriasis is currently unknown but whatever other actions it may have, any global hypothesis of its action will have to incorporate a flux to epidermal cell death.

Fatal toxic epidermal necrolysis associated with Hodgkin's disease

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Mutilating cryoglobulinaemia rapidly improved by plasmapheresis: diagnostic features on blood film

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Basal cell carcinoma of the vulva in association with vulval lichen sclerosus et atrophicus

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Malignant angiosarcoma of the scalp: a case report with immunohistochemical studies

A case of angiosarcoma of the scalp is reported. The histogenesis of this tumour is discussed in terms of the ultrastructural and immunohistochemical findings. This type of angiosarcoma is uncommon and carries a poor prognosis: the therapeutic alternatives are discussed.

Blue naevus associated with trichoepithelioma: a report of two cases

Naevocellular naevi may show considerable histological variation and have often been shown to contain other ectodermal elements, as well as cells of melanocytic origin. Blue naevi are also thought to be of melanocytic origin, and in this report we describe two blue naevi in which trichoepitheliomatous elements were seen. The aetiological implications of this observation are discussed.

Polymorphic eruption of pregnancy with subepidermal vesicles

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