Occupational allergic contact dermatitis to Piperamido Nitrotoluene in pharmaceutical workers: a case series

BACKGROUND

Imatinib mesylate is a first generation tyrosine kinase inhibitor. Piperamido Nitrotoluene, also known as F5, is an intermediate used in the manufacturing of Imatinib. We present a case series of allergic contact dermatitis to F5 in pharmaceutical workers.

METHODS

Four male pharmaceutical workers were referred between 2007 and 2021 with new dermatitis predominantly affecting the periorbital region. All were involved in the production of Imatinib and particularly exposed to F5. Following medical history and examination, they underwent patch testing to standard series and F5 diluted in white soft paraffin (WSP) RESULTS: All patients tested positive confirming a diagnosis of contact allergy to F5. The first case tested positive to F5 diluted to 1% in WSP, the second to F5 diluted to 10% in WSP, the third and fourth to F5 diluted to 1% and 10% in WSP. In all four cases, dermatitis resolved when they were removed from exposure to F5.

CONCLUSIONS

To our knowledge, these are the first cases of allergic contact dermatitis to F5 confirmed by patch testing in the literature. In February 2016 a generic formulation of Imatinib entered the market. Globalised production of Imatinib may result in further cases presenting to dermatology departments worldwide.

Irritant contact dermatitis in healthcare workers as a result of the COVID-19 pandemic: a cross-sectional study

COVID‐19 healthcare workers (HCWs) require frequent handwashing and use of personal protective equipment (PPE) to prevent infection. However, evidence is emerging that these practices are causing adverse effects on their skin integrity. A single‐centre, cross‐sectional study of HCWs from an Irish hospital was undertaken to evaluate the degree of COVID‐19‐related irritant contact dermatitis (ICD) between April and May 2020. Of 270 participants surveyed, 223 (82.6%) reported symptoms of ICD. The hands were the most commonly affected site (76.47%) and the most frequently reported symptom was dry skin (75.37%). Nearly all (268; 99.26%) HCWs had increased hand‐washing frequency, but 122 (45.35%) did not use emollients. In the ICD group, 24.7% cited a history of dermatitis compared with 4.3% of unaffected staff (P < 0.001). The ICD group recorded PPE usage for an average of 3.15 h compared with the non‐ICD group at 1.97 h (P = 0.21). Promoting awareness of COVID‐19‐related ICD is vital to highlight prevention and treatment for frontline staff.

What is in? What is out? Updating the British Society for Cutaneous Allergy facial series

BACKGROUND

Allergic contact dermatitis (ACD) to cosmetics is widely reported. To ensure we are accurately diagnosing ACD, patch test series should be continually reviewed to identify relevant and emerging allergens and highlight those that are outdated. The current British Society for Cutaneous Allergy (BSCA) facial series recommends 26 allergens and was last modified in 2012.

OBJECTIVES

To review and update the BSCA facial series.

METHODS

We retrospectively reviewed the results from 12 UK and Ireland patch test centres' facial series from January 2016 to December 2017. We recorded the number of allergens tested in each centre and the detection rate for each allergen. Using a 0·3% positive rate as the inclusion threshold, we established which allergens in the BSCA facial series had positive patch test rates < 0·3% and > 0·3%. Allergens not in the BSCA facial series that had a positive patch test rate > 0·3% were identified.

RESULTS

Overall, 4224 patients were patch tested to the facial series. The number of allergens included in individual centres' facial series ranged from 24 to 66, with a total of 103 allergens tested across all centres. Twelve of the 26 allergens in the BSCA facial series had a positive patch test rate < 0·3% and 14 had a rate > 0·3%. Twenty-five allergens not recommended in the BSCA facial series had a positive patch test rate > 0·3%.

CONCLUSIONS

This audit has highlighted the significant variation in practice that exists among patch test centres, despite a recommended facial series. The BSCA facial series has been updated and now contains 24 allergens. Fifteen allergens remain, 11 allergens have been dropped and nine new allergens have been added.

Skin Cancer Excision Is More Efficient and Cost Effectivein a Specialist Secondary Care Service

Aim To compare the relative efficiencies of skin excisions in primary and secondary care. Methods We compared the benign: malignant ratio for specimens referred by General Practice, General Surgery and the Skin Cancer Service to the regional pathology laboratory over one month. We used cost minimization analysis to compare the relative efficiencies of the services. Results 620 excisions were received: 139 from General Practice, 118 from General Surgery and 363 from the Skin Cancer Service. The number (%) of malignant lesions was 13 (9.4%) from General Practice, 18 (15.2%) from General Surgery and 137 (37.7%) from the Skin Cancer Service. Excision was cheaper in General Practice at €84.58 as compared to €97.49 in the hospital day surgical unit. However, the cost per malignant lesion excised was €1779.80 in general practice versus €381.78 in the Skin Cancer Service. Conclusion Our results indicate that moving skin cancer treatment to General Practice may result in an excess of benign excisions and therefore be both less efficient and less cost effective.

Distance as a Barrier to Melanoma Care

Aim Our aim was to review cases of melanoma diagnosed histologically in UHK in 2016 and to compare them to cases of melanoma nationally and in Kerry. Methods For each patient we recorded age, Breslow depth, and shortest distance to travel by car and travelling time (without traffic) to the South Infirmary Victoria University Hospital (SIVUH) from their primary residence (calculated using Google maps™ (2018)). Results 20 cases of invasive melanoma were diagnosed in UHK in 2016. Of the 20 cases, 9 (45%) presented at a very advanced stage with a Breslow depth of greater than 4mm. A further 7 (35%) cases had a depth of 1.5-4mm. These patients with invasive melanoma had a mean age of 72.5 (±15). The mean shortest distance to travel from the patient’s primary residence to the SIVUH was 114.8km (±15.5) taking an average of 102 minutes (±14.6) by car. Conclusion Cases of melanoma diagnosed locally in UHK presented at an advanced stage compared to the national average. We suspect that the long distances to travel to the SIVUH pigmented lesion clinic is a barrier for these patients.

Recommendation to test limonene hydroperoxides 0·3% and linalool hydroperoxides 1·0% in the British baseline patch test series

BACKGROUND

There is a significant rate of sensitization worldwide to the oxidized fragrance terpenes limonene and linalool. Patch testing to oxidized terpenes is not routinely carried out; the ideal patch test concentration is unknown.

OBJECTIVES

To determine the best test concentrations for limonene and linalool hydroperoxides, added to the British baseline patch test series, to optimize detection of true allergy and to minimize irritant reactions.

METHODS

During 2013-2014, 4563 consecutive patients in 12 U.K. centres were tested to hydroperoxides of limonene in petrolatum (pet.) 0·3%, 0·2% and 0·1%, and hydroperoxides of linalool 1·0%, 0·5% and 0·25% pet. Irritant reactions were recorded separately from doubtful reactions. Concomitant reactions to other fragrance markers and clinical relevance were documented.

RESULTS

Limonene hydroperoxide 0·3% gave positive reactions in 241 (5·3%) patients, irritant reactions in 93 (2·0%) and doubtful reactions in 110 (2·4%). Linalool hydroperoxide 1·0% gave positive reactions in 352 (7·7%), irritant reactions in 178 (3·9%) and doubtful reactions in 132 (2·9%). A total of 119 patients with crescendo reactions to 0·3% limonene would have been missed if only tested with 0·1% and 131 patients with crescendo reactions to 1·0% linalool would have been missed if only tested with 0·25%. In almost two-thirds of patients with positive patch tests to limonene and linalool the reaction was clinically relevant. The majority of patients did not react to any fragrance marker in the baseline series.

CONCLUSIONS

We recommend that limonene hydroperoxides be tested at 0·3% and linalool hydroperoxides at 1·0% in the British baseline patch test series.

Gentamicin-induced anaphylaxis

BACKGROUND

Gentamicin is a common cause of allergic contact dermatitis but immediate (type 1) hypersensitivity is unusual.

AIMS AND METHODS

We report a case of anaphylaxis to gentamicin in a 69-year-old man who developed urticaria, hypotension and loss of consciousness within minutes of receiving intravenous gentamicin.

RESULTS

The patient was successfully resuscitated and made a full recovery. Prick testing and patch testing to gentamicin was positive.

CONCLUSIONS

Although allergic reactions to gentamicin are well recognised, there are few reported cases of anaphylaxis to gentamicin.

An exploratory prospective observational study of environmental factors exacerbating atopic eczema in children

BACKGROUND

Possible exacerbating factors are a major concern of parents of children with atopic eczema (AE). However, there is minimal evidence for their direct role in leading to disease flares.

OBJECTIVES

To assess the association between 'trigger factors' and disease flares in AE.

METHODS

Twenty-five children with AE were recruited. Participants completed diaries, recording severity and exposure to potential exacerbating factors (18 variables) over 28 days. Severity was assessed at baseline and study completion. The relationship between severity and exposures was assessed.

RESULTS

At episode level, on the day of exposure (lag 0), hot weather correlated to increased scratch scores (P=0.043). At a lag of 2 days after exposure, damp weather was associated with raised scratch scores (P=0.027). At lag 3 days, elevated scratch scores were associated with sweating and stress (P=0.029 and 0.019, respectively). Outside damp was associated with elevated scores (P=0.001) at lag 4. Multivariate analysis of all significant variables showed that only damp at lag 4 was significantly associated with flares (P=0.039).

CONCLUSIONS

This study suggests association between stress, damp and heat and disease flares. These findings need to be studied over a longer period, using objective exposure measures.

The importance of a dedicated patch test clinic

BACKGROUND

A specialist patch test clinic was set up in April 1997 at the Department of Dermatology, South Infirmary-Victoria Hospital, Cork, Ireland. The number of batteries available was expanded from six to 21 and the routine testing of patients to their own products was introduced, as was prick testing for latex hypersensitivity.

OBJECTIVES

To assess the impact of introducing this clinic on the detection of allergic contact dermatitis.

METHODS

Patch test results for the first full year of operation of the clinic (1998) were compared with those in the year prior to setting it up (1996).

RESULTS

Although the number of patients tested rose after the introduction of the new clinic, the difference was not significant as the number of new dermatology general referrals had also risen. Thirty-one of the 91 patients tested in 1996 had positive patch tests compared with 84 of 158 tested in 1998 (P = 0.0036). Eighteen allergens were detected in 1996 and 53 in 1998. Two patients were positive to their own products in 1996, compared with 12 in 1998 (P = 0.04). The commercial batteries were negative in four of these cases. Three cases of latex hypersensitivity were detected in 1998.

CONCLUSIONS

The introduction of a specialist patch test clinic resulted in an increase in detected cases of allergic contact dermatitis. The larger range of batteries available and the more widespread testing of patients' own products were the principal factors involved.

Cryotherapy of viral warts: a sustained 10-s freeze is more effective than the traditional method

BACKGROUND

Cryotherapy is a standard treatment for viral warts. Although textbooks recommend treating until there is a halo of ice around the wart (traditional freeze), many authors advocate more aggressive cryotherapy. There are no previously published studies assessing the efficacy of longer freezing times.

OBJECTIVES

To compare the efficacy of the traditional freeze and a sustained 10-s freeze in the treatment of common viral warts with liquid nitrogen.

METHODS

Patients attending a dedicated wart clinic were randomized to receive either a traditional freeze or a 10-s sustained freeze with liquid nitrogen delivered by a spray gun. Two hundred patients were recruited, 100 in each group.

RESULTS

After five treatments, 49 patients in the 10-s freeze group were clear of warts (64% of non-defaulters) as compared with 31 (39%) of those in the traditional freeze group (chi2 = 6.7; P = 0.009). Seventy-four patients in the 10-s freeze group as compared with 59 in the traditional freeze group had either improved or cleared after five treatments (chi2 = 5.0; P = 0.02). Morbidity was significantly greater in the 10-s freeze group. Sixty-four patients suffered pain or blistering as compared with 44 in the traditional freeze group (chi2 = 10.8; P = 0.0045). Five patients were withdrawn from the 10-s freeze group because of pain as compared with one patient in the traditional freeze group.

CONCLUSIONS

A 10-s sustained freeze is more effective in the cryotherapy of viral warts but carries a significantly greater morbidity in terms of pain and blistering.

Report of occupational asthma due to phytase and beta-glucanase

OBJECTIVES

Occupational asthma is the principal cause of respiratory disease in the workplace. The enzymes phytase and beta-glucanase are used in the agricultural industry to optimise the nutritional value of animal feeds. A relation between these enzymes and occupational asthma in a 43 year old man was suspected.

METHODS

Inhalation challenge tests were performed with the enzymes phytase, beta-glucanase, and amylase. Skin prick tests were performed with the enzymes diluted to a concentration of 1 mg/ml and 5 mg/ml. Specific IgE to phytase and beta-glucanase were measured with a radioallergosorbent test.

RESULTS

Baseline spirometry values were normal. A histamine challenge test showed bronchial hyperreactivity. Exposure to phytase and beta-glucanase led to significant reductions in forced vital capacity and forced expired volume in 1 second. No significant differences were noted after exposure to amylase. Skin tests showed a positive reaction to beta-glucanase (5 mm) at a concentration of 1 mg/ml and positive reactions to beta-glucanase (7 mm) and phytase (5 mm) at a concentration of 5 mg/ml. Similarly specific IgE was present against both phytase and beta-glucanase, at 2.5% and 9.3% binding respectively (2% binding is considered positive).

CONCLUSIONS

This is the first description of occupational asthma due to the enzymes phytase and beta-glucanase. Their addition to the ever increasing list of substances associated with occupational asthma will have notable implications for those exposed to these enzymes.

False negative clinical diagnoses of malignant melanoma

The false negative rate for the clinical diagnosis (FNR) for malignant melanoma is reported to be of the order of 20-50%. The aim of this study was to investigate possible predictor variables for FNR, with particular reference to the features and score of the seven-point check-list within the total population (778) of histologically proved malignant melanomas presenting in Leicestershire between 1982 and 1996. The FNR was 18.5%. The check-list would have failed as a referral indication in only 0.8-1. 1% of the lesions. The major check-list features occurred more commonly than the minor features, excepting size >/= 7 mm, confirming the diagnostic importance of the major criteria. The FNR was unaffected by age or sex. More rarely involved sites had higher rates (31-42%), and the face was a particularly difficult diagnostic site. Clinical features of lesions associated with a higher FNR were lack of irregular pigmentation and shape, altered sensation, the presence of inflammation and size < 7 mm. The FNR was inversely related to the total score and major feature score, but directly related to the minor score. The minor features, in addition to the major features, are potentially valuable in avoiding false negative diagnoses and we suggest their retention as part of the check-list. There was only one patient, in whom the diagnosis of melanoma was initially missed and who was not biopsied on presentation to hospital, who re-presented after 1 year. However, the study illustrates the importance of avoiding a false negative diagnosis as there was marked delay in the excision of such lesions.

The reproducibility of patch tests

There is conflicting evidence regarding the reproducibility of patch testing. Discordant results have been reported in up to 44% of cases. The clinical relevance of these discordant patch tests has not been previously assessed. We studied 383 consecutive patients receiving simultaneous duplicate patch testing on opposite sides of the upper back with 10 allergens from the European standard series. Completely discordant patch tests-a negative test on one side with a positive test on the opposite side-were recorded in 30 (8%) patients. Two patients had discordant tests to two of the allergens; 28 had discordant reactions to one allergen. Completely discordant tests were recorded for nickel in 10 (3%) patients, balsam of Peru in two (0.5%), thiomersal in one (0.3%), cobalt in four (1%), paraphenylenediamine in three (0.8%), fragrance mix in two (0.5%), formaldehyde in four (1%), potassium dichromate in two (0.5%), lanolin in three (0.8%) and Kathon CG in one (0.3%). Of those patients with completely discordant patch tests, the allergen was deemed to be a true positive in 11 (3% of total) cases and of possible relevance in a further three. The allergen was felt to be relevant to the presenting complaint in seven (2% of total) patients.

Long-term outcome of severe chronic plaque psoriasis following treatment with high-dose topical calcipotriol

We have previously reported the effectiveness of high-dose calcipotriol in extensive psoriasis. We now report the long-term outcome in patients following this treatment. Twenty-eight patients with severe psoriasis were treated as in-patients with high-dose topical calcipotriol for 2 weeks. There was a mean reduction in the psoriasis area and severity index of 65%. Sixty-nine per cent were controlled for 3 months and 42% for 6 months. The relapse rate was comparable with that following Ingram's regimen, the in-patient stay was shorter and the treatment more acceptable. Careful monitoring of calcium homeostasis is mandatory.

The effect of the introduction of a pigmented lesion clinic on the interval between referral by family practitioner and attendance at hospital

The value of pigmented lesion clinics (PLCs) for the early detection and treatment of malignant melanoma has been questioned. We have examined the effect of the introduction of a PLC on the referral interval between patients with melanoma presenting to their general practitioner (GP) and their attendance at hospital. The case notes of all patients presenting with melanoma in Leicestershire between 1984 and 1994 were reviewed. There was a significant initial reduction in the mean referral interval following the introduction of the PLC from 27.9 days (SEM = 6.6) in 1984 to 11.3 (2.3) days in 1987 (P < 0.01). However, the referral interval gradually rose over the following 7 years to a mean of 20.4 (4.4) days in 1994, which was not significantly better than the 1985/86 level. The increase in the referral interval was due to a greater percentage of melanomas being referred to clinics other than the PLC. Only 48% of melanomas were referred to the PLC in 1994 compared with 70% in 1987. We also reviewed the referral letters for those patients presenting in 1991 and 1994, and decided, on the basis of the content of the letter, whether the GP had suspected the diagnosis of melanoma. More than 50% of the melanomas were correctly diagnosed by the GP, but only half of these were then appropriately referred to the PLC. We believe that PLCs are of value in the early diagnosis and treatment of melanoma, but only if they are appropriately utilized by GPs.

The effects of topical calcipotriol on systemic calcium homeostasis in patients with chronic plaque psoriasis

BACKGROUND

Calcipotriol is an effective treatment of chronic plaque psoriasis. We have previously demonstrated that it has a small effect on systemic calcium homeostasis even at recommended doses.

OBJECTIVE

We attempted to determine the mechanism of the effect of calcipotriol on systemic calcium homeostasis so we could assess the possible consequences of long-term use.

METHODS

Sixteen patients with extensive chronic plaque psoriasis were hospitalized and treated with high-dose topical calcipotriol. Up to 360 gm of calcipotriol (50 micrograms/gm) ointment was applied per week for 2 weeks under controlled conditions.

RESULTS

There was a dose-dependent rise in intestinal absorption of calcium. No effect on bone turnover was demonstrated over this short period. Five patients became hypercalcemic, and there was a dose-dependent rise in serum total adjusted calcium, serum ionized calcium, serum phosphate, urine calcium, and urine phosphate. There was a dose-dependent fall in serum parathyroid hormone and serum 1,25 dihydroxyvitamin D3.

CONCLUSION

Calcipotriol exerts its effects on systemic calcium homeostasis by increasing intestinal absorption of calcium and probably phosphate. This results in suppression of parathyroid hormone and 1,25 dihydroxyvitamin D3.

The effects of UVB plus calcipotriol on systemic calcium homeostasis in patients with chronic plaque psoriasis

We studied the effects of combining topical calcipotriol, used at the maximal licensed dose, and narrow-band short wave ultraviolet light (TL01) on systemic calcium homeostasis in the treatment of chronic plaque psoriasis. Patients were randomized in an open fashion to receive either UVB alone, UVB plus 100 g of calcipotriol (50 micrograms/g) ointment per week or calcipotriol ointment alone (100 g/week). With the exception of a slight increase in serum phosphate in the group receiving combination therapy (from 0.92 to 1.22 mmol/l; P = 0.046), no differences were observed between or within the groups. Psoriasis area and severity scores (PASI) improved to a greater extent in those patients receiving both UVB and calcipotriol (P = 0.045). The combination of UVB and calcipotriol is a safe, effective treatment for chronic plaque psoriasis.

Allergy to phosphorus sesquisulfide: 0.5% pet. is a more appropriate concentration for patch testing

Patch testing was performed with phosphorus sesquisulfide P4S3 in 2 groups containing equal numbers of patients using different concentrations (0.5% P4S3 in pet. and 1% P4S3 in pet., the usual suggested test concentration as recommended by the International Contact Dermatitis Research Group). We found that there was a statistically significant increase in the number of clinically irrelevant irritant reactions in the group tested with the concentration (chi 2 = 16, p < 0.0004). We recommend that patch testing with phosphorous sesquisulfide should be at a reduced concentration of 0.5% pet.

Sweet's syndrome and malignancy in the U.K

Acute febrile neutrophilic dermatosis (Sweet's syndrome) is reported to be a marker for underlying malignancy. Much of the evidence for this is based on case reports, small series of cases and reviews of the literature. In order to clarify the association with malignancy and determine the common clinical features of Sweet's syndrome, we reviewed the case notes of patients presenting to six dermatology units in the U.K. Eighty-seven cases of histologically proven Sweet's syndrome were reviewed. Fourteen patients (16%) developed associated malignancy, predominantly haematological, two patients (2%) had a history of previous malignancy and four patients (5%) had premalignant conditions (monoclonal gammopathy, two: myelodysplasia, two). Malignancy developed up to a year after presentation with Sweet's syndrome. Patients with associated malignancy were more likely to be anaemic (P < 0.01) at presentation, had a lower mean platelet count (207 x 10(9)/L vs. 332 x 10(9)/L; P < 0.003) and were, on average, older (59 years vs. 49 years; P = 0.002). Contrary to previous reports, a greater percentage of females developed malignancy than males.

A randomized double-blind comparison of the effects on systemic calcium homeostasis of topical calcitriol (3 micrograms/g) and calcipotriol (50 micrograms/g) in the treatment of chronic plaque psoriasis vulgaris

Calcitriol and calcipotriol are effective treatments for psoriasis, although the two have never been directly compared. We compared the efficacy and toxicity of each agent in 24 patients with moderately extensive chronic plaque psoriasis, who were randomized in double-blind fashion to apply 90 g per week of either calcitriol (3 micrograms/g) ointment or calcipotriol (50 micrograms/g) ointment over an 8-week period. Mean PASI in patients applying calcitriol fell from 13 to 8.8 (p < 0.05) and in patients applying calcipotriol from 14.9 to 4.7 (p < 0.005). The reduction was significantly greater in the calcipotriol-treated group (p < 0.05). There was a small increase in serum ionized calcium in the calcipotriol-treated group (from 1.21 mmol/L to 1.25 mmol/L, p < 0.05) but no effect on calcium homeostasis in the calcitriol group.

Etretinate may work where acitretin fails

Acitretin (Ro 10-1670, Neotigason), a second-generation monoaromatic retinoid, is the main acid derivative and active metabolite of etretinate (Ro 10-9359, Tigason). Three patients who were unresponsive to treatment with acitretin but who responded to etretinate are reported. Twenty-nine patients in the U.K. are currently receiving etretinate on a named-patient basis. Possible explanations for the functional discrepancy between the two drugs are discussed.

Vitamin D analogues in psoriasis: effects on systemic calcium homeostasis

Vitamin D and its analogues are effective in the treatment of psoriasis. The principal concern about the use of these agents is the possibility of adverse effects on systemic calcium homeostasis. We review the effects of vitamin D and its analogues on systemic calcium homeostasis and discuss the implications for patients with psoriasis.

A new microemulsion formulation of cyclosporin (Neoral) is effective in the treatment of cyclosporin-resistant dermatoses

Cyclosporin is a highly effective treatment for severe psoriasis and atopic dermatitis. However, both inter- and intrapatient gastrointestinal absorption of the conventional formulation of cyclosporin (Sandimmun) are very variable, ranging from 20 to 50%. Variations in bioavailability may explain isolated resistance to therapy. Neoral is a novel microemulsion formulation of cyclosporin which has been developed to enhance and standardize its absorption. We report the first experience with Neoral in patients with psoriasis and atopic dermatitis refractory to Sandimmun.

An immunohistochemical study of the dermal infiltrate and epidermal staining for interleukin 1 in 12 cases of Sweet's syndrome

Interleukin 1 (IL-1) has been proposed as a possible mediator in Sweet's syndrome. We examined all cases of Sweet's syndrome (n = 12) presenting to the department over a 10-year period, from 1982 to 1992, for the presence of IL-1 and also assessed the nature of the dermal inflammatory infiltrate in those cases. Staining for IL-1 alpha and IL-1 beta was stronger in control tissues than in Sweet's syndrome. This may possibly be explained by the release of IL-1 alpha and IL-1 beta into the dermis in Sweet's syndrome. Contrary to recent reports, we found that neutrophils predominated in all cases examined, although histiocytes were present in increased numbers indicating their possible role in the pathophysiology of Sweet's syndrome.

Fatal systemic amyloidosis (AA type) in two sisters with dystrophic epidermolysis bullosa

Systemic amyloidosis is a rare but recognized complication of dystrophic epidermolysis bullosa. We report the cases of two siblings with recessive dystrophic epidermolysis bullosa who died of complications associated with systemic amyloidosis (AA type). This is the first report of systemic amyloidosis in siblings with dystrophic epidermolysis bullosa.

Protection of children against sunburn: a survey of parental practice in Leicester

The incidence of melanoma in the U.K. is increasing more rapidly than that of most other malignant tumours. Sunburn in childhood increases the risk of malignant melanoma in later life and it is therefore essential that protection of children is improved if primary prevention of melanoma is to be effective. We asked 238 parents in Leicester how they protected their children against sunburn, how often their children suffered sunburn, and whether they had heard of malignant melanoma. Although most (80%) had heard of melanoma, 47% did not regularly ensure that their children used a sunblock lotion, and only 34% regularly protected them from the midday sun. Forty-eight per cent of parents stated that their children burned at least once a year. New approaches to public education about melanoma may be needed to improve the protection of children against sunburn.

Cryotherapy of common viral warts at intervals of 1, 2 and 3 weeks

We studied the efficacy, and time to clearance, of more frequent cryotherapy of viral warts, by randomizing 225 patients to receive treatment at 1-, 2- or 3-weekly intervals. The mean times to clearance of warts in each group were 5.5, 9.5 and 15 weeks in the weekly, 2-weekly and 3-weekly groups, respectively (P < 0.01). Cure rates after 3 months correlated with frequency of treatment (P < 0.05). After 3 months, 43% (66% of non-defaulters) had cleared in the group treated weekly, 37% (47%) of the group treated every 2 weeks, and 26% (30%) of those treated every 3 weeks. The mean numbers of treatments needed to achieve clearance were similar in each group (5.5, 4.75 and 5 treatments). After 12 treatments, cure rates were similar for all three groups: 43% for the weekly-treated group (3 months), 48% for the 2-weekly group (6 months), and 44% for the 3-weekly group (9 months). Percentage cure is related to the number of treatments received, and independent of the interval between treatments. A more rapid cure may, therefore, be achieved by more frequent treatment.

Melanoma awareness and sun exposure in Leicester

The city of Leicester, in conjunction with other centres throughout the U.K., was targeted for publicity about melanoma over a 3-year period from 1987 to 1989. We report the results of a survey to assess the level of awareness of melanoma, and to document current sunbathing practices subsequent to that period. The general level of awareness of melanoma in the community was good (74%). People who knew about melanoma were more likely to use a sunscreen at home and abroad (odds ratios 1.63, 95% CI 1.19-2.24 and 1.39, 95% CI 1.03-1.86), but paradoxically more likely to sunbathe than those who had never heard of melanoma (odds ratio 1.33, 95% CI 1.03-1.72). Females were more knowledgeable than males (odds ratio 1.74, 95% CI 1.26-2.22), but continued to sunbathe. Teenagers and young adults tended to be relatively ignorant of melanoma, and were less likely to protect themselves against sunburn while sunbathing than other age groups. Teenagers, young adults, and males need to be targeted more effectively in future publicity campaigns. Furthermore, many people who know about melanoma continue to put themselves at risk by sunbathing. New strategies need to be developed to influence behaviour as well as increasing awareness.

Bullous pemphigoid following radiotherapy

We report the case of a 57-year-old woman who developed bullous pemphigoid 3 weeks after electron beam radiotherapy. The bullae were confined to the area of the radiation field and responded to topical clobetasol propionate 0.05% cream (Dermovate). This is the second case of bullous pemphigoid confined to an area of previous radiotherapy. Radiotherapy may be a rare trigger for the development of bullous pemphigoid.

Pemphigoid nodularis: a report of two cases

Pemphigoid nodularis is a rare variant of bullous pemphigoid characterized by the development of pruritic hyperkeratotic nodules. These nodules may be the presenting feature of the disease, and may precede the development of bullae by several years. The condition appears to be more common in females than males, and is often resistant to treatment. We report two definite cases and one possible case of pemphigoid nodularis, and review the literature relating to this disorder.

High dose topical calcipotriol consistently reduces serum parathyroid hormone levels

OBJECTIVE

Calcipotriol is a vitamin D analogue which is an effective topical treatment for chronic plaque psoriasis. It has been reported to have no effect on systemic calcium homeostasis provided the manufacturer's guidelines are adhered to (maximum 100 g of calcipotriol ointment (50 micrograms/g) per week). However, there have been reports of hypercalcaemia in patients using topical calcipotriol even at recommended doses. The purpose of this study was to investigate the effects of topical calcipotriol in vivo using the recently developed 'intact' PTH assay as a more sensitive index of systemic calcium homeostasis.

DESIGN AND PATIENTS

Seven patients with extensive psoriasis were recruited for the study. Each patient was admitted to hospital and applied 200 g of calcipotriol (50 micrograms/g) ointment over the first week followed by 300 g over the second week. In the third week of treatment, patients were treated with 2% crude coal tar which served as a biochemical washout phase.

MEASUREMENTS

Serum total adjusted calcium was measured at baseline and three times a week during the study. Twenty-four-hour urinary calcium excretion was measured at baseline and twice a week throughout the study. Peak (0400 h) and trough (0900 h) PTH levels were measured at baseline and at the ends of weeks 2 and 3.

RESULTS

Serum PTH levels were reduced in every patient after 2 weeks' treatment with calcipotriol and rose after withdrawal. Mean 0400 h PTH fell by 2.58 pmol/l (95% confidence interval 1.45-3.70) from 5.11 to 2.53 pmol/l (P < 0.01) and mean 0900 h PTH fell by 2.08 pmol/l (0.84-3.36) from 4.04 to 1.96 pmol/l (P < 0.01). Mean serum and urine calcium rose during treatment with calcipotriol and fell after withdrawal. Mean adjusted total calcium rose by 0.14 mmol/l (95% confidence interval 0.10-0.16) from 2.25 to 2.39 mmol/l (P < 0.01). Mean 24 hour urine calcium excretion rose by 2.09 mmol/24 h (0.51-3.26) from 3.40 to 5.49 mmol/24 h (P < 0.05). No patient developed hypercalcaemia at any stage of the study although hypercalcaemia was recorded transiently in three patients.

CONCLUSION

Topical calcipotriol is likely to have a dose dependent effect on systemic calcium homeostasis.

An evaluation of the revised seven-point checklist for the early diagnosis of cutaneous malignant melanoma

The seven-point checklist has been widely advocated as a sensitive screening test for malignant melanoma. A number of groups have questioned the sensitivity of this system, especially in the detection of early lesions. We have assessed the sensitivity and specificity of the revised seven-point checklist when applied to lesions seen in our department over a 26-month period and compared it with the American ABCDE evaluation system. All melanomas (n = 65) were detected using the revised seven-point checklist and all were found to have at least one of the three major criteria defined by that system. Five (7.7%) melanomas were not picked up by the ABCDE checklist. Of 100 randomly selected patients who attended the clinic during the same period, with clinically diagnosed benign pigmented lesions, 63 had at least one major feature of the revised seven-point checklist. Forty (62%) of the melanomas, compared with only (4%) of the benign lesions, had more than one major feature. This study confirms the sensitivity of the revised seven-point checklist in the diagnosis of cutaneous malignant melanoma.

Urine calcium excretion during treatment of psoriasis with topical calcipotriol

Urine calcium excretion is a very sensitive method of detecting vitamin D intoxication, and may rise in the absence of any apparent change in the serum level. Little attention has been paid to urine calcium levels during the large trials performed to assess the efficacy and safety of calcipotriol in psoriasis vulgaris. There are some urine calcium data from short-term studies of average dose rates of calcipotriol. However, there are no published data on long-term usage, nor on the use of dose rates at the upper end of the licensed range (100 g/week). In a group of 20 patients, who were using typical quantities of calcipotriol ointment (50 micrograms/g) to treat psoriasis vulgaris, urine calcium excretion was measured prior to treatment, and then monthly for 12 months. There was no significant change in urine calcium over the year. In a separate group of 10 patients, who were using calcipotriol in the same concentration, at the maximum recommended rate of 100 g/week, urine calcium was measured at baseline, and after 2 and 4 weeks. There was a statistically significant rise in calcium excretion. This is the first trial to demonstrate that topical calcipotriol affects calcium homeostasis when used within the recommended dose range. Further studies are necessary to determine more precisely the magnitude and variability of this effect in a large group of individuals. For the present, caution is required when prescribing calcipotriol for any patient with known hypercalciuria or a history of renal stone formation. Consideration should be given to monitoring urine calcium excretion during prolonged use at dose rates approaching the recommended maximum.

Occlusion enhances the efficacy of topical calcipotriol in the treatment of psoriasis vulgaris

Forty-eight patients with symmetrical chronic plaque psoriasis affecting the limbs were recruited for a single-blind right/left within patient study to assess the effect of combining occlusion with topical calcipotriol. Subjects were randomized into two groups. Sites of similar severity on opposing limbs were selected as target areas. The first (group A) treated one side with calcipotriol alone and the opposite side with calcipotriol plus occlusion. The second (group B) treated one side with placebo plus occlusion and the opposite side with calcipotriol plus occlusion. In group A the mean improvements were 40% (P < 0.001) for calcipotriol alone and 61% (P < 0.001) for calcipotriol plus occlusion. In group B, occlusion plus calcipotriol resulted in a mean 62% improvement (P < 0.001) while occlusion plus placebo produced no significant change. The combination of calcipotriol plus occlusion was significantly better than calcipotriol alone (P < 0.005). The results indicate that occlusion improves the response to calcipotriol by enhancing its penetration. Indices of calcium metabolism remained unchanged throughout the study.

Urine calcium excretion during treatment of psoriasis with topical calcipotriol

Urine calcium excretion is a very sensitive method of detecting vitamin D intoxication, and may rise in the absence of any apparent change in the serum level. Little attention has been paid to urine calcium levels during the large trials performed to assess the efficacy and safety of calcipotriol in psoriasis vulgaris. There are some urine calcium data from short-term studies of average dose rates of calcipotriol. However, there are no published data on long-term usage, nor on the use of dose rates at the upper end of the licensed range (100 g/week). In a group of 20 patients, who were using typical quantities of calcipotriol ointment (50 micrograms/g) to treat psoriasis vulgaris, urine calcium excretion was measured prior to treatment, and then monthly for 12 months. There was no significant change in urine calcium over the year. In a separate group of 10 patients, who were using calcipotriol in the same concentration, at the maximum recommended rate of 100 g/week, urine calcium was measured at baseline, and after 2 and 4 weeks. There was a statistically significant rise in calcium excretion. This is the first trial to demonstrate that topical calcipotriol affects calcium homeostasis when used within the recommended dose range. Further studies are necessary to determine more precisely the magnitude and variability of this effect in a large group of individuals. For the present, caution is required when prescribing calcipotriol for any patient with known hypercalciuria or a history of renal stone formation. Consideration should be given to monitoring urine calcium excretion during prolonged use at dose rates approaching the recommended maximum.

High-dose topical calcipotriol in the treatment of extensive psoriasis vulgaris

Ten patients with extensive plaque psoriasis were treated with calcipotriol ointment (50 micrograms/g) for 2 weeks (200 g for 1 week, followed by 300 g during the second week). Mean improvement in psoriasis area and severity index (PASI) was 71%. Mean 24 h urine calcium rose from 4.79 mmol/24 h to 7.27 mmol/24 h (P < 0.0001). Urine calcium returned towards baseline after stopping calcipotriol. Mean serum calcium also rose slightly, but significantly, from 2.26 mmol/l to 2.32 mmol/l (P < 0.005), and fell again in the washout phase. Individual serum calcium values remained within the normal range throughout the study. Topical calcipotriol is an effective, rapidly acting and safe in-patient treatment for extensive plaque psoriasis.