Intradermal testing for autoimmune progesterone dermatitis: should we be basing the diagnosis on it?

Autoimmune progesterone dermatitis (APD) is a rare skin disorder with varying presentations, resulting from hypersensitivity to endogenous progesterone during the luteal phase of the menstrual cycle. The diagnosis has been traditionally confirmed with intradermal progesterone testing (IPT) or intramuscular challenge with progesterone or its derivatives. We present a case of a 31-year-old woman with suspected APD who underwent IPT to progesterone. The patient's cyclical symptoms, positive skin reaction and symptoms following IPT were sufficient to make a diagnosis of APD. However, we also tested 10 healthy female controls without symptoms of APD, and found that 9 of these also developed positive skin reactions to intradermal progesterone at 15 min, 24 and 48 h, albeit to a lesser extent. Therefore, these results raise doubts about the validity of using IPT to make a diagnosis of APD. Further research on appropriate testing is needed.

Melanoma in a cohort of organ transplant recipients: Experience from a dedicated transplant dermatology clinic in Victoria, Australia

BACKGROUND

There is limited information on the profile of melanomas diagnosed in a specialist transplant dermatology clinic.

OBJECTIVE

To describe the incidence and characteristics of incident primary melanomas in a cohort of organ transplant recipients (OTRs) attending a specialized transplant dermatology clinic and determine the number of pigmented lesions needed to excise for every melanoma diagnosed.

METHODS

A retrospective study of 327 OTRs monitored by an Australian clinic during a 10-year period.

RESULTS

There were 11 incident melanomas diagnosed during a total follow-up of 1280 patient-years. The mean interval between the first transplant and diagnosis was 5.5 years. Only 2 melanomas were >1 mm in Breslow thickness. Seven melanomas (64%) arose de novo. A contiguous nevus was present in 4 cases. Metastatic disease did not develop in the melanoma patients during the follow-up period, and all remain alive. The needed to excise for every melanoma diagnosed ratio was 16:1.

LIMITATIONS

The crude incidence rates were age standardized, unlike the comparison rates of melanoma in the general population, and the cohort was small.

CONCLUSION

Most melanomas diagnosed in OTR patients attending a specialized transplant dermatology service were detected early. Our data suggest early detection may reduce the proportion of OTRs presenting with thick melanomas, thus improving prognosis and patient outcomes. A needed to excise for every melanoma diagnosed ratio of 16:1 is not unreasonable for this cohort of high-risk patients. To our knowledge, this is the first time this ratio has been calculated for a cohort of OTRs.

Does clinical testing support the current guidance definition of prolonged contact for nickel allergy?

Background

The European Chemical Agency (ECHA) definition of prolonged contact was introduced in 2014 and has not been evaluated clinically.

Objectives

To assess whether nickel‐sensitized individuals react on patch testing with high nickel‐releasing metal discs for short and repetitive periods.

Materials and methods

We patch tested 45 nickel‐sensitized individuals double‐blind with 2 different types of high nickel‐releasing discs for 10, 30 and 60 minutes on 3 occasions over a period of 2 weeks, and for 1 longer period. Discs were tested for nickel release.

Results

Nickel release from both discs significantly exceeded the 0.5 μg Ni/cm²/week limit of the EU REACH nickel restriction. However, only 1 individual tested had a largely dose‐dependent allergic reaction.

Conclusions

The majority of nickel‐allergic subjects did not react to nickel discs after 2 hours or after repetitive exposures of up to 30 minutes on 3 occasions over a period of 2 weeks. The length of time needed to cause nickel allergic contact dermatitis in most nickel‐allergic individuals is longer than the ECHA guidance definition. Longer test times are needed to define the time required to cause dermatitis in most nickel‐allergic individuals. As a limitation, the test conditions did not adequately assess real‐life factors such as friction, which is relevant for some uses of nickel.

Lichenoid keratosis is frequently misdiagnosed as basal cell carcinoma

Lichenoid keratosis (LK), also known as benign lichenoid keratosis or lichen planus-like keratosis, is a solitary, pink to red-brown scaly plaque representing a host immunological response to a variety of precursor lesions. LK is often misdiagnosed as a dermatological malignancy owing to its clinical resemblance to basal cell carcinoma (BCC) or Bowen disease. We performed a retrospective analysis of the pathology records of a series of LK lesions with reference to the demographic features and accuracy of clinical diagnosis. The pathology records from 2008 to 2009 of 263 consecutive patients with a histological diagnosis of LK from a specialized skin laboratory were retrieved. Data relating to clinical diagnosis, age, sex, anatomical location, time of year of presentation and any coexistent pathological lesions adjacent to the LK were recorded. Mean age at presentation was 64 years (range 34-96), and 58% of patients were female. The most common anatomical site was the chest/anterior torso, followed by the back and legs. The most common coexisting lesion was solar keratosis at 14%, followed by seborrhoeic keratosis (SK) at 7.8%. The correct clinical diagnosis of LK was made in 29.5% of cases. The most common clinical diagnosis was BCC (47%), while SK was the preferred diagnosis in 18%. A clinical diagnosis was not given in 5.5% of cases. In conclusion, it appears that LK is frequently misdiagnosed, with misdiagnosis occurring in > 70% of cases in this study.

Rosacea

BACKGROUND

Rosacea is a chronic and common cutaneous condition characterised by symptoms of facial flushing and a broad spectrum of clinical signs. The clinical presentation for rosacea is varied, and there are four primary subtypes, which may overlap - erythrotelangiectatic, inflammatory, phymatous and ocular. It is important to recognise the different subtypes because of the differences in therapy.

OBJECTIVE

The objective of this article is to provide evidence-based clinical updates to clinicians, specifically general practitioners (GPs), to assist with their everyday practice, and effective assessment and treatment of rosacea.

DISCUSSION

Therapeutic modalities are chosen on the basis of the subtypes and clinical features identified; often a combination of these therapies is required.

A comparison of a less invasive piriformis-sparing approach versus the standard posterior approach to the hip

We undertook a randomised controlled trial to compare the piriformis-sparing approach with the standard posterior approach used for total hip replacement (THR). We recruited 100 patients awaiting THR and randomly allocated them to either the piriformis-sparing approach or the standard posterior approach. Pre- and post-operative care programmes and rehabilitation regimes were identical for both groups. Observers were blinded to the allocation throughout; patients were blinded until the two-week assessment. Follow-up was at six weeks, three months, one year and two years. In all 11 patients died or were lost to follow-up.

There was no significant difference between groups for any of the functional outcomes. However, for patients in the piriformis-sparing group there was a trend towards a better six-minute walk test at two weeks and greater patient satisfaction at six weeks. The acetabular components were less anteverted (p = 0.005) and had a lower mean inclination angle (p = 0.02) in the piriformis-sparing group. However, in both groups the mean component positions were within Lewinnek’s safe zone. Surgeons perceived the piriformis-sparing approach to be significantly more difficult than the standard approach (p = 0.03), particularly in obese patients.

In conclusion, performing THR through a shorter incision involving sparing piriformis is more difficult and only provides short-term benefits compared with the standard posterior approach.

Central and peripheral components of morphine mydriasis in mice

Mice treated with morphine (intracerebroventricularly, retrobulbarly or intraperitoneally) demonstrated dose related bilateral mydriasis. Intracerebroventricular (ICV) injection was much more potent than either retrobulbar (RB) or intraperitoneal (IP) injections. Morphine applied topically onto one eye resulted in bilateral mydriasis which was more marked in the treated eye. The mydriatic effect was antagonized by naloxone administered either IP or ICV or given on one eye. Here again, ICV naloxone was most effective. Naloxone eye drops diminished the mydriasis produced by systemic morphine bilaterally but more in the treated eye. These results suggest that in mice the mydriasis produced by morphine is mainly of central origin, but a local ocular effect also occurs.

Lack of effect of cannabinoids on carbonic anhydrase

Cannabinoids have significant anticonvulsant effects, the mechanism of which is obscure. In addition, these agents reduce intraocular pressure. Inhibitors of carbonic anhydrase also share these two pharmacological actions. In order to investigate whether these actions of cannabinoids are mediated through inhibition of carbonic anhydrase (CA), commercial solutions of the enzyme were exposed to delta 9-tetrahydrocannabinol and cannabidiol. No inhibition was observed at concentrations of 10(-7)--10(-5) M.

Alteration of human serum ribonuclease activity in malignancy

A review of the literature and current biochemical studies is presented which provides significant evidence of alteration in the level of the enzyme ribonuclease activity in cancer. Current studies reveal that 80% of all cancer patients have alteration in ribonuclease activity and that individuals known to be at high risk for the development of cancer also demonstrate significant alteration of ribonuclease activity. It is noted that while elevation of serum ribonuclease exists within the cancer state and appears to be independent of clinical status (relapse, remission, or cured), diminished activity is found within the tumor itself. Animal models are reviewed which demonstrate that ribonuclease activity becomes elevated in the murine species subsequent to the transplantation of tumor and following the infection of the host with oncogenic virus. The occurrence of elevated ribonuclease activity in high tumor incidence strain mice long before the development of overt tumor is alos discussed. To date it is not possible to assign a specific function to the changes in the level of ribonuclease in connection with the cancer state. However, evidence indicating that tumor chemotherapy is generally associated with early elevation of ribonuclease activity within the tumor cell suggests that increased ribonuclease activity may play a role in the process by which the host restricts neoplastic transformation. The potential of this enzyme as a biochemical marker in cancer is discussed.

Carcinoma of the lung and cigarette smoking. Effect on serum ribonuclease activity

Serum ribonuclease levels were determined in 54 patients with lung carcinoma, 74 long-term cigarette smokers, and 172 nonsmokers. The mean serum ribonuclease level was significantly higher in patients with lung carcinoma and long-term smokers compared with healthy nonsmokers (P less than .001). The serum ribonuclease activity level was not related to chronological age, sex, or race of the smoker or nonsmoker population. Forty (75%) of 53 patients with lung cancer and 49 (66%) of 74 smokers had elevated serum ribonuclease levels compared with 13 (7%) of 179 nonsmoker healthy controls (P less than .001). The highest incidence of elevation was noted in patients with epidermoid carcinoma (95%).

A long-term effect of adult thymectomy on cortisone sensitivity and alkaline RNAse activity of murine lymphoid cells

The alkaline RNAse content of lymphoid cells was measured in two year old mice that had been thymectomized at six to seven weeks of age and found to be three times higher in spleen and four times in lymph nodes than in sham thymectomized age-matched controls. There was, however, no difference in the content of alkaline RNAse in the liver between the two groups of mice. Following administration of cortisone, the RNAse level in the lymphoid organs was increased to a much greater extent in the control than in the thymectomized mice.

Participation of hormone in the early stages of the immune response

Immunization of weanling rats with sheep erythrocytes leads within 24 hours to an increase in DNA synthesis in the spleen but not in the lymph nodes. Growth hormone, insulin and oestradiol, given together with the antigen, increase the response of the spleen to antigenic stimulation, and initiate a pronounced increase in DNA synthesis of the lymph nodes in response to antigen. On the other hand, thyrotrophin reduces the rate of DNA synthesis in spleen and in lymph nodes following antigenic stimulation. When administered singularly, only growth hormone and insulin increase DNA synthesis in spleen, but not in lymph nodes.

It is suggested that growth hormone, oestradiol, or insulin are involved in the proliferative response of lymphoid organs following an antigenic stimulation.

The hormonal control of ribonuclease activity in the lymphatic tissue of mice

Ribonuclease activity in thymus and lymph nodes is stimulated by cortisone; insulin increases ribonuclease activity only in the thymus. Growth hormone and theophylline do not cause changes in thymus and lymph nodes ribonuclease levels. Injections of cortisone combined with growth hormone or with theophylline increase the activity more than cortisone alone. Insulin does not enhance the action of cortisone on ribonuclease activity. A synergistic loss in weight of thymus and spleen was found after administration of cortisone in combination with either growth hormone or with theophylline.