Integrated multidisciplinary approach to hidradenitis suppurativa in clinical practice,

Background

The European hidradenitis suppurativa (HS) guidelines recommend a multidisciplinary approach for patients with HS and management of comorbidities.

Objective

We aimed to describe the organization of a multidisciplinary HS program and characterize the patient population.

Methods

We conducted a retrospective study of patients with HS undergoing prospectively defined multidisciplinary work-up including examinations by a dermatologist, plastic surgeon, smoking specialist, and nutritionist in our outpatient unit between October 2015 and January 2017.

Results

The study included 49 patients with a sex ratio of 1:1. A total of 73.4% of patients were smokers, 20.4% were overweight, 48.9% were obese, and 30.6% had symptoms of depression. The mean Sartorius score was 30.4 (±17.6). The outcome of plastic surgery consultation was as follows: 16 patients had operations, 5 were excluded based on medical history, 9 refused surgery, and 16 remained undecided. The refusal rates for consulting with the smoking cessation and nutrition specialists were 55.8% and 69.5%, respectively. Twelve patients received antibiotics, 9 received biologics, 9 underwent medico-surgical treatment, 9 underwent surgery, and 10 were lost to follow-up. The mean visual analogue scale score for satisfaction was 8.3 (±1.6; n = 28).

Conclusion

An integrated multidisciplinary care model for HS is associated with high patient satisfaction. Adherence to the proposed comorbidity management was higher in female patients and related to empathetic interactions with physicians.

Extracorporeal Photopheresis: An Efficacious and Well-Tolerated Treatment for Cutaneous and Oral Mucosal Chronic Graft-versus-Host Disease

BACKGROUND

Extracorporeal photopheresis (ECP) is a second-line therapy for steroid-refractory chronic graft-versus-host disease (cGVHD).

OBJECTIVE

We describe the long-term efficacy and tolerability of ECP according to the cutaneous phenotype of cGVHD and report on the reduced need for immunosuppressant drugs in this setting.

PATIENTS AND METHODS

Fourteen patients (8 females) with cutaneous and/or mucosal cGVHD, treated with ECP between October 2010 and May 2016 within a single center, were included. Final analyses included patients who had received ECP for at least 12 months. We prospectively evaluated the efficacy of ECP using lesion-specific clinical scores and by recording changed doses of systemic immunosuppressants.

RESULTS

Of the 14 patients, sclerotic skin lesions were present in 10 (71%). The mRODNAN score decreased in all patients from month 9 onwards, with 40 and 77% reductions at 12 and 36 months, respectively. Six patients (43%) presented with cutaneous lichenoid lesions: this score was reduced in all patients by month 3, reaching a 93% reduction by month 12. Five patients (36%) experienced oral mucosal lichenoid lesions: these scores were decreased by 55% at month 12 and by 100% by month 33. The use of systemic immunosuppressants was reduced in all patients; 4 patients could stop all immunosuppressant drugs after 2 years. ECP was stopped in 3 patients after a complete response. No major ECP-associated adverse effects were observed.

DISCUSSION AND CONCLUSION

ECP was an effective long-term therapy for oral and cutaneous cGVHD: consequently, dose levels of therapeutic immunosuppression could be reduced.

Purpuric lesions induced by UVA1 spectrum (340-400 nm) phototesting in an adult with persistent and severe hydroa vacciniforme

A 28-year-old man had presented a severe photosensitivity since his infancy. In March 2008, the clinical examination showed large crusts on the dorsum of his hands, on the edge of his ears with destruction of the underlying cartilage, and on his nose and cheeks. He also presented erythematosus fibrous scars on the temples. The diagnosis of hydroa vaccinforme was made. Phototesting including repeated UVA1 phototest was strongly positive with purpuric lesions from day 7 to day 10 and hypertrophic scars at day 67. A sequential histological study of the UVA1 triggered lesions was performed and showed bullous cleavage, dense inflammatory infiltrate in the whole dermis with numerous neutrophilic cells, nuclear dusts, superficial focal thrombosis of small blood vessels at day 10. We report an unusual case of hydroa vaccinforme with purpuric lesions leading to fibrous scars and with important infiltration of neutrophils in the dermis of the photoinduced lesions.

Intracellular sequestration of amiodarone: role of vacuolar ATPase and macroautophagic transition of the resulting vacuolar cytopathology

BACKGROUND AND PURPOSE

Tissue deposits of the anti-arrhythmic drug amiodarone are a major source of side effects (skin discoloration, etc.). We addressed the mechanism of the concentration of amiodarone in cells, and characterized the resulting vacuolar cytopathology and its evolution towards macroautophagy.

EXPERIMENTAL APPROACH

Sequestration of amiodarone in human cells (macrophages, smooth muscle cells, HEK 293a cells) was evaluated using its violet fluorescence and cytopathology using GFP-conjugated subcellular markers. Autophagic signalling was probed by immunoblotting for the effector protein LC3. A patient biopsy of amiodarone-induced blue-gray skin discoloration was investigated for the presence of macroautophagy (immunofluorescence for LC3).

KEY RESULTS

Most of the amiodarone (1-20 microM, 4-24 h) captured by cultured cells (macrophages were most avid) was present in enlarged vacuoles. The specific vacuolar ATPase (V-ATPase) inhibitors, bafilomycin A1 or FR167356, prevented vacuolization and drug uptake. Vacuoles in HEK 293a cells were positive for markers of late endosomes and lysosomes (GFP-Rab7, -CD63) and for an effector of macroautophagy, GFP-LC3. The vacuoles accumulated endogenous LC3 and filled with lipids (Nile red staining) following longer amiodarone treatments (> or =24 h). The electrophoretic mobility of both GFP-LC3 and endogenous LC3 changed, showing activation in response to amiodarone. Paraffin tissue sections of the pigmented skin exhibited granular LC3 accumulation in superficial dermis macrophages.

CONCLUSION AND IMPLICATIONS

Vacuolar sequestration of amiodarone occurs at concentrations close to therapeutic levels, is mediated by V-ATPase and evolves towards persistent macroautophagy and phospholipidosis. This cytopathology is not cell type specific, but tissue macrophages appear to be particularly susceptible.

Milia complicating bullous polymorphic light eruption

Polymorphic light eruption (PLE) is the most common photosensitivity disorder. Typically, PLE manifests in the spring or summer months as a recurrent pruritic papular and/or vesicular eruption occurring on photoexposed skin areas following sun exposure. The milia are caused by proliferative tendencies of the epithelium after injury. These may occur in areas of subepidermal bullous eruption. We report an original case of bullous PLE complicated by milia. Such association has not been reported previously.

[Photoaggravated contact allergy and contact photoallergy caused by ketoprofen: 19 cases]

INTRODUCTION

Between September 1994 and September 1999, we observed 19 cases of photoaggraved contact allergy or contact photoallergy to ketoprofen (non steroidal anti-inflammatory derived from arylpropionic acid). We present a clinical and photobiological retrospective study of these 19 cases with investigation of cross-reactivity between benzophenone-containing molecules.

PATIENTS AND METHODS

On clinical level, we investigated the type of eruption, the delay of appearance, the initial area of eruption and areas of diffusion. Phototesting included patchtests and photopatchtests performed with the gel containing ketoprofen (17 patients), ketoprofen 2 p. 100 petrolatum (14 patients), fenofibrate 10 p. 100 petrolatum and 10 p. 100 water (15 patients), 3 benzophenones (19 patients): oxybenzone 10 p. 100 petrolatum, mexenone 2 p. 100 petrolatum, sulisobenzone 10 p. 100 petrolatum and the other arylpropionic derivatives (4 patients). Three identical series were applied: one was irradiated with 3/4 polychromatic minimal erythematosus dose, a second was irradiated with UVA 13 J/cm2 until January 1997, then 5 J/cm2, the third series was not irradiated (control series).

RESULTS

Patients were 9 men and 10 women with an average age of 41.2 years. The type of eruption was an eczema. The delay of appearance of the eruption was one day to 3 months. For 10 patients, the delay was between 4 and 18 days. The eruption was localized to the application area in 1 case, to the application area then to the same contralateral area in 3 cases, to the application area then to all photoexposed areas in 13 cases, to the application area then to the photoexposed areas and then to non-sun-exposed areas in 2 cases. Evolution showed prolonged photosensitivity in 3 cases after withdrawal of the contact and the contact photoallergy to ketoprofen was severe. Gel-containing ketoprofen photopatchtests showed 9 photoaggravated contact allergy, 6 contact photoallergy and 2 contact allergy. Ketoprofen photopatchtests showed 12 contact photoallergy and 2 photoaggraved contact allergy. Tiaprofenic acid photopatchtests were positive in all performed cases (4/4), but photopatchtests with the other arylpropionic derivatives, without benzophenone structure, were negative. Fenofibrate photopatchtests were always positive (15/15). Benzophenones photopatchtests only showed 4 cases of contact photoallergy to oxybenzone (4/19). In 68 p. 100 of cases, patients presented a contact allergy or photoallergy to fragrances.

CONCLUSIONS

This study shows the actual frequency of contact allergy and contact photoallergy to ketoprofen with a higher frequency of contact photoallergy. Thus, photopatchtesting is essential. In cases of contact photoallergy to ketoprofen, ketoprofen, tiaprofenic acid but not the other arylpropionic derivatives, fenofibrate and benzophenones have to be withdrawn.

Prolonged photosensitivity following contact photoallergy to ketoprofen

We report the third case of prolonged photosensitivity secondary to contact photoallergy to topical ketoprofen, a 2-arylpropionic acid derivative. The patient suffered from persistent photosensitivity for more than 1 year after the withdrawal of ketoprofen with recurrent eruptions on sun-exposed skin areas. This photosensitivity was associated with a persistent decrease in polychromatic and UVA minimal erythemal doses. Photobiological testing revealed cross-reactivity with fenofibrate and benzophenones. Photoallergy to ketoprofen is due to the benzophenone structure or to the very similar thiophene phenylketone of tiaprofenic acid, but not to the arylpropionic function. Thus, fenofibrate, tiaprofenic acid and benzophenones should be avoided by patients with a positive history of photocontact dermatitis to ketoprofen.

Fixed solar urticaria to visible light successfully treated with fexofenadine

Fixed solar urticaria (FSU) represents an uncommon form of urticaria related mostly to radiation from the ultraviolet (UVB, UVA) and visible spectrum. The exact pathomechanism has so far remained unknown. A 52-year-old woman with a 3-year history of urticated eruptions limited to certain skin areas is presented. Photobiological testing revealed positive reactions limited to the visible light range. The induced lesions appeared only in originally affected skin sites. The particular distribution of whealing supports the concept of specific alteration of mast cells in well defined areas. The clinical findings and the results of phototesting lead to the diagnosis of FSU to visible light. It is recommended to carry out phototesting in patients with FSU in the originally affected skin areas, usually covered and protected by the patient, to avoid false-negative results. Fexofenadine given in the conventional dosage can prevent recurrences and represents a successful treatment measure when dealing with this peculiar form of solar urticaria.

[Drug-induced photosensitivity]

Photodermatosis are dermatoses where there is an abnormally exaggerated sensitivity to sunlight, termed photosensitivity, that is often drug-induced. Such drug-induced photosensitivity is due to the mechanism of photosensitivization that induces two types of reaction, phototoxic and photoallergic. The phototoxic reaction is photochemical, irritative and common, and can occur in any individual without any particular predisposition. The photoallergic reaction is a photoimmunologic, cell-mediated hypersensitivity reaction. It is much more rare and occurs only in some individuals with predisposition. Clinically, the phototoxic reaction usually manifests by a cutaneous "sunburn" type eruption, and the photoallergic reaction by eczema. Photosensitizing drugs are numerous: antibiotics, nonsteroid anti-inflammatory drugs, diuretics, antimitotic drugs, psychiatric drugs, amiodarone, calcium channel blockers, fibric acid derivatives, etc. Diagnosis is based on recognition of an eruption localized in zones exposed to sunlight occurring in the context of photosensitizing drug intake, correlated with the results of photobiological laboratory investigations.

Sunscreen sensitization: a 5-year study

The purpose of this study was to evaluate the prevalence of sunscreen contact allergy and/or contact photoallergy in 370 patients with suspected photodermatitis. Patch and photopatch tests were performed using the French Society of Photodermatology (SFPD) standard series. A total of 57 cases of contact allergy and/or photocontact allergy to sunscreens were diagnosed (15.4%). Amongst these, 27 reactions were related to oxybenzone and 14 to isopropyl dibenzoylmethane. These results, obtained from January 1990 to December 1994, confirm that, given the high frequency of photosensitization cases, a large part of the battery of photopatch tests should be dedicated to sunblocks.

Influence of UVA pre-exposure on UVB-induced erythema. A chromometric study

We examined the influence of ultraviolet A (UVA) pre-exposure on UVB minimal erythemal dose in 9 Caucasian subjects. Three zones were tested. One zone received only UVB, the second zone received a low UVA dose+UVB, and the third zone received a high UVA dose+UVB. Each zone was divided into 9 circles receiving increasing doses of UVB in order to obtain 3 different UVA-exposed series of 9 circles. Visual and chromometric readings were performed 24 h later. Pre-exposure to UVA caused variations in the slope of the dose-response curve (colorimetric index as a function of the UVB dose). In relation to UVB erythema, these variations indicated a protective effect for 6/9 subjects and an aggressive effect for 3/9 subjects. No predictive criteria were found for inclusion within a group.

Comparison of the DNA damage photoinduced by fenofibrate and ketoprofen, two phototoxic drugs of parent structure

Fenofibrate and ketoprofen (KP) are two drugs of similar structure derived from that of benzophenone. Both are photoallergic and promote cross reactions in patients. However, the cutaneous photosensitizing properties of KP also include phototoxic effects and are more frequently mentioned. To account for this difference in their in vivo properties, their in vitro photosensitizing properties on DNA were compared. First, it was shown that under irradiation at 313 nm, fenofibric acid (FB), the main metabolite of fenofibrate, photosensitized DNA cleavage by a radical mechanism similar to that proposed for KP but with a 50 times lower efficiency. Furthermore, FB did not photosensitize the formation of pyrimidine dimers into DNA in contrast to KP, which did promote this type of DNA damage. Their difference in efficiency as DNA breakers was compared to their relative photochemical reactivity and the quantum yield of FB photolysis was found to be eightfold lower than that of KP. The reactivity of these drugs cannot explain alone the difference in their photosensitizing properties. Other factors such as the magnitude of the ionic character of the photodecarboxylation pathway of these benzophenone-like drugs are considered in the discussion.

[Syphilitic labial leucokeratosis]

BACKGROUND

Several diagnoses, including syphilis, can be entertained in patients with leukokeratosis of the buccal mucosa. We report a case of labial leucokeratosis which revealed latent syphilis.

CASE REPORT

A 36-year-old man with a past history of genital syphilis chancre which have been treated 12 years earlier, developed buccal leucokeratosis with no other clinical manifestation. Histology showed dermal infiltration containing plasma cells, polynuclears and lymphocytes. Blood tests were positive for syphilis. Complementary examinations were unable to detect another localization. Leucokeratosis regressed completely after one injection of Extencilline. There has been no recurrence at one year.

DISCUSSION

The clinical and histological presentations of syphilis can mimic different skin diseases. Serodiagnosis alone is significant. Isolated buccal lesions are rarely described in syphilis suggesting serodiagnosis should always be ordered. Whatever the clinical stage of the diseases, serological surveillance after treatment for syphilis is essential.

[Histopathology of exogenous and idiopathic lucites and provocation phototests]

OBJECTIVE

Provocative phototests are used regularly to explore photobiology in patients with photodermatoses. Our objective was to determine the reliability of the phototest in the diagnosis of idiopathic and exogenous light eruption in order to identify the ideal date for the histological examination by correlation between the histological aspects of light- triggered and spontaneous lesions.

PATIENTS AND METHODS

Among 66 patients, there were 48 with polymorphous light eruptions, 13 with exogenous eruptions and 5 with chronic actinodermatitis. The histological findings of the provocative phototests were correlated with the clinical aspect, the date of biopsy and the histological aspect of the spontaneous lesions.

RESULTS

In polymorphous light eruptions (48 cases) this test triggered a photoallergic reaction in 48% of the patients. There was a good correlation between the histological findings and clinical features in 96% of the cases. The histological image of the light-triggered lesion on day 6 was the closest to that of the spontaneous lesion. In exogenous eruptions and chronic actinodermatitis (18 cases), only 33% of the clinically positive phototests were also positive at histological examination. The histological image was the same for the provocative tests whether they were clinically positive or negative, with signs of epidermal phototoxicity, regeneration acanthosis and moderate perivascular lymphocyte infiltration of the superficial dermal layer.

CONCLUSIONS

Our findings confirmed that the phototest provides a good correlation between histological findings and clinical presentation in idiopathic polymorphous light eruptions, justifying simple clinical interpretation, but did not demonstrate a rate of positive results as high as reported in the literature. Day 6 is the ideal date for a phototest biopsy. In exogenous light eruptions, the phototest is less reliable since the correlation between histology and clinical presentation is weaker. It is difficult to reproduce spontaneous lesions with the phototest, but if used, the phototest biopsy should be done on day 18.

[Recurrent phototriggered summer light eruption of the axillary and inguinal area: an atypical topographic form of benign summer lucitis]

INTRODUCTION This case report of benign summer light eruption emphasizes the importance of phototests in the diagnosis of photosensitive dermatoses.

CASE REPORT

A 25-year-old man, phototype II, had experienced a pruriginous papulovesicular erythematous eruption of the axillary and inguinal regions each summer for 12 years. A high-dose UV phototest (40 J/cm2 x 3 days) directed on the right posterior axillary area and a whole body exposure test (4 J/cm2 UVA, 20 mJ/cm2 UVB x 3 days) were positive both clinically and histologically on day 4. DEM B was normal at 26 mJ/cm2. Iterative polychromatic phototest (DEM x 3 days) in the area usually involved (left posterior axillary region) was negative. The simple UVA (13 J/cm2) and iterative phototests performed on the back were negative. The results of the phototests led to the diagnosis of benign light eruption despite the unusual localization.

DISCUSSION

The diagnosis of benign light eruption is generally clinical. Phototests are unnecessary in most cases. Benign light eruption can be triggered by high-dose iterative UVA exposure of the susceptible area or whole body phototests (UVA-UVB). These specific phototests are indicated in atypical forms or localizations in order to determine the course of benign light eruption and to uncover simulations.

[Photosensitive prurigo in AIDS]

INTRODUCTION

A case of photosensitive prurigo during AIDs is reported. This is the second case in the literature. We discuss the relations between HIV infection and photodermatoses.

OBSERVATIONS

A woman, known to be HIV seropositive from 1990, developed during the spring 1990 a prurigo on light exposed areas who received the next year. A photobiological investigation was performed, showing a polymorphic light eruption induced by UVB.

DISCUSSION

Patients infected with HIV have a high prevalence of UV radiation responsive skin diseases. On the other hand, UVA radiations, UVB and UVC have been shown to induce activation and replication of HIV. PUVA therapy and UVB therapy have shown their efficacity in the treatment of many photodermatoses associated with HIV infection, without any worsening of the illness. Many questions are not yet solved in the relationship between HIV and photosensitivity and the photobiological investigation should be more frequently done.

Chronic balanitis: an unusual localisation of necrobiosis lipoidica

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[Importance and results of photo-patch tests in photobiological research]

Photo patch tests (Standard battery of the SFPD) were made on 45 patients who were suspected of exogenous photosensitization during 1996. Certain suspected topicals or drugs completed the battery. The results obtained are analysed and compared with those in the literature.

Contact allergy to 3-(4' methylbenzylidene) camphor and contact and photocontact allergy to 4-isopropyl dibenzoylmethane

We report a clinical case of a 15-year-old boy who presented a photodistributed eruption after having used a sunscreen cream for 8 days. Photobiological testing showed a contact allergy to 3-(4' methylbenzylidene) camphor (Eusolex 6300) included in his sunscreen cream associated with a contact and photocontact allergy to 4-isopropyl-dibenzoylmethane (Eusolex 8020) not included.

[Actinic erythema, false innocuousness of UV.A]

The number of skin cancers is doubled every ten years. The responsibility of excessive sun exposure is incontestable as much for what concerns spino and baso cellular epitheliomas as for malignant melanomas. Over-exposure to ultraviolet B rays was considered as the determining cause of skin cancer and the entire prevention campaign was limited to the safeguard from these rays only. In reality, ultraviolet B rays are not uniquely responsible. Recent studies show that ultraviolet A rays, previously considered innocuous, are on the contrary aggressive as well and in a very deceiving way: it appears that it is the exposure to these rays in weak but repeated doses which are the most dangerous. It appeared that the visually determined value of MED was unchanged but the minimal dose responsible for color changes detectable with chromameter was decreased in the presence of UV.A for 3 subjects out of 4. This decrease was about 50% of the value obtained with UV.B alone. The strategy of protection needs to be completely reconsidered, particularly because today's lifestyle favors the exposition to ultraviolet A rays. There is an increase in exposure to UV.A rays when protection is limited only against ultraviolet B rays, giving a false sense of security especially to those who frequent tanning salons. It is therefore necessary to limit exposure time, use sunscreens protecting against not only UV.B, but also UV.A rays, and prohibit tanning salons. Public educational measures are inexistant, but should be introduced hastily in all public services.

[Cutaneous mycobacteriosis]

Tuberculosis is reappearing, due to diminished surveillance, illegal immigration, the HIV epidemic and certainly also due to emerging resistance. The clinical expression of cutaneous tuberculosis depends on the stage of development, the clinical background and the virulence of the germ. Diagnosis is predominantly clinical, but laboratory results also play a role. Treatment involves the quadruple antibiotic treatment prescribed for any tubercular infection. Atypical mycobacteria are widespread throughout the environment and are pathogenic, but also saprophytic, comensal and opportunistic, figure a favourable setting in the immunodeficient individual. Following entry by penetrance, the early lesion is papulonodulary, nodulary, keratoid, crusted, ulcerated, sporotrichoid, generally without peripheral adenopathy. Histological examination discloses a granulomatous reaction limiting the development of the infection; such development is absent in the immunodeficient patient, thus explaining the spread. The most common mycobacterial infection in France, generally in the immunocompetent individual, is "aquarium disease" which follows a benign course; the most common in tropical areas is Mycobacterium ulcerans; whereas Mycobacterium avium intracellulare, fortuitum and chelonae cause, in the immunodeficient patient, severe and extensive infection. Treatment should start as soon as diagnosis is made and the germ identified.

Acquired localized elastolysis associated with varicose veins

Localized elastolysis refers to a group of heterogeneous conditions which includes cutis laxa. We report a form of localized and non-inflammatory elastolysis evocative of cutis laxa, localized to the anteromedial aspect of the left thigh and knee, acquired at the age of 8 years and associated with unilateral adjacent venous dilatations appearing at the age of 39 years. Our case is clinically and ultrastructurally compatible with cutis laxa. Localized forms of cutis laxa not preceded by inflammation are exceptional; localization on the leg has never been described. This clinical form of elastolysis calls into question the classification of acquired elastolysis. The adjacent varicose veins also raise the question of the risk of subcutaneous damage in this condition.

Measurement of actinic erythema in healthy subjects and in subjects with polymorphous light eruption using a tristimulus colorimeter

BACKGROUND

The assessment of actinic erythema using a tristimulus colorimeter has only been reported from healthy volunteers but never from subjects with photodermatosis.

OBJECTIVE

The aim of this study was to analyse the difference of chromometric measurements in patients with polymorphous light eruption versus healthy subjects.

METHODS

Seventy-two subjects were subdivided according to two criteria: skin colour and clinical state. Measurements were done on a non-irradiated site and at the clinical minimal erythema dose site in the L*, a* and b* modes.

RESULTS

The data submitted to two-way analysis of variance demonstrate the influence of skin colour and clinical state on the above parameters.

CONCLUSION

Chromometric measurements of L* help to differentiate skin colour, whereas those of a* enable the discrimination of healthy subjects from those with photodermatosis.

Photosensitive and phototriggered pityriasis rubra pilaris

We report a 59-year-old man with photosensitive and photodistributed pityriasis rubra pilaris. The phototriggering of the lesions was obtained by the iterative polychromatic phototest (3 times the minimal erythema dose (MED) on 3 consecutive days) and was also observed on the supra MED sites, which began the 10th day and persisted several months. Our results are comparable to those already obtained in photosensitive psoriasis, which helped us to identify the clinical similarities of photosensitivity in these two instances of dermatosis.

Fabry's disease: heterozygous form of different expression in two monozygous twin sisters

A 26-year-old woman presented widespread angiokeratomas predominantly in a swimsuit distribution pattern associated with acroparesthesia in all four limbs. The tentative diagnosis of Fabry's disease (FD) was confirmed by optical and electron-microscopic findings and by appropriate biochemical testing. The work-up showed ocular and renal manifestations of the disease. The monozygous twin sister of the patient was asymptomatic although she was shown to be heterozygous for the enzymatic defect. These 2 cases illustrate the concept of extreme lyonization which can explain observed phenotypic differences in heterozygous females with X-linked hereditary diseases. The father and mother of the patient were shown to be noncarriers of the trait, suggesting de novo mutation in the twin pregnancy. However, biochemical testing for the detection of FD heterozygous females cannot rule out the possibility of the mother being heterozygous with normal enzyme activity.

Psoralen plus ultraviolet A in the prophylactic treatment of benign summer light eruption

We report the results of a French multicentre study to evaluate the efficiency of psoralen plus ultraviolet A (PUVA) therapy in the prophylactic treatment of benign summer light eruption (BSLE) and to establish the optimal protocol of radiation. Nine photobiology centres took part in this study; 83 patients (76 of them women) were evaluated. The radiation protocols were as follows: oral psoralen (8-methoxypsoralen; 0.6 mg/kg) was taken at each session; the starting dose of UVA radiation was determined according to skin type, with increments of 0.5 J/cm2 every 2 sessions. The subjects were randomized to receive 10-20 sessions 3 times per week. PUVA therapy was very effective: 68 patients (82%) reported total protection from BSLE. Four patients (5%) showed progress. Only 13% showed no improvement. The satisfactory results were not correlated with either the number of sessions or the J/cm2 of UVA. The intensity of tanning after the PUVA sessions did not appear to predict cure. Thirty-six percent of the patients had adverse reactions to treatment, including erythema, pruritus and triggering of BSLE. However, these effects only required the treatment to be stopped in 2% of the cases (for severe pruritus). The results in the various centres were similar.

Hereditary distal onycholysis--a case report

The authors present several cases of distal onycholysis from the same family. Inheritance is autosomal dominant. The clinical features include a decreased rate of growth of the nail, scleronychia, a straight or concave proximal edge of detachment, palmoplantar hyperhidrosis and marked sensitivity of the fingers to cold. The lesions of the nails are isolated. This is, to our knowledge, only the third report of such an onychopathy.

Laser Doppler flowmeter and standardized thermal test in normals and Raynaud's phenomenon

The diagnosis of Raynaud's phenomenon alone requires clinical investigations. To determine the stage of the disease, its etiology and pathophysiology, it seems desirable to perform noninvasive tests. Conclusions regarding control o the skin or muscle components of hand blood flow rely on evidence from separate measurements of skin or muscle blood flow. We described a standardized thermal provocation test, then respiratory maneuvers and pharmacological trials, to stimulate the microcirculatory control. The total cutaneous blood flow was continuously registered using a laser Doppler flowmeter. We conducted a prospective study on 100 subjects: 21 normal, 22 primary Raynaud's phenomenon (PRP), 26 secondary (SRP), 31 various microcirculatory diseases. The basal blood flow was lower in cases of severe SRP and acrocyanosis. In comparison with normals, RP cases present a less noticeable reaction to cold. Mild SRPs are more sensitive to cold and do not recover during warming up. Severe RPs are less sensitive to cold as they have a lower basal blood flow. Acrocyanosis cases are not sensitive to thermal variations. Post ischemic reactive hyperemia leads to a constant peak flow. Pharmacological assays were performed (nitroglycerine, Nifedipine) during permanent control of skin and muscle blood flow. Laser Doppler and provocation tests have no etiologic value in a Raynaud's phenomenon investigation; this methodology tries to elucidate the pathophysiology, the prognosis and the therapy of Raynaud's phenomenon.