Recommendations for the use of etanercept in psoriasis: a European dermatology expert group consensus

BACKGROUND

Psoriasis is a chronic, inflammatory skin disorder that has a significant impact on quality of life and, particularly in moderate to severe cases, adversely affects the patient's overall health and well-being. Biological treatments, such as etanercept, are being widely adopted across Europe for treatment of moderate to severe psoriasis due to favourable safety and efficacy profiles. The increase in usage, combined with a growing body of clinical evidence, has identified a need to clarify the best use of etanercept within its current treatment label.

OBJECTIVE

To prepare a series of recommendations agreed by an expert group of dermatologists, relating to the most effective use of etanercept for psoriasis in Europe, within the product license.

METHODS

An expert panel of dermatologists from across Europe completed a Delphi survey to address the current use of etanercept in psoriasis in Europe. In June 2005 the results were presented to the expert panel at their nominal group meeting, and a consensus was agreed.

RESULTS

It was recommended that, where possible, patients are initiated on the 50 mg twice-weekly (BIW) dose. Etanercept should be given until remission is achieved (maximum 24 weeks) and retreatment should be initiated according to the physician's judgement. Before commencing treatment, contraindications, such as infection or previous malignancy (within 5 years), should be ruled out.

CONCLUSIONS

The consensus presented herein provides valuable clarification of use of etanercept according to the label, which may have wider implications relating to the use of all biological therapies in psoriasis.

Subjective and Objective Evaluation of Noncultured Epidermal Cellular Grafting for Repigmenting Vitiligo

BACKGROUND

Noncultured epidermal cell transplantation in vitiligo permits the coverage of relatively large areas without culturing cells.

OBJECTIVE

To investigate the effectiveness of noncultured epidermal cell transplantation in treating stabilized vitiligo using objective and subjective evaluation methods.

METHODS

Noncultured autologous melanocytes and keratinocytes were grafted in a hyaluronic-acid-enriched suspension on superficially laser-abraded vitiligo lesions in 40 patients with refractory stable vitiligo (30 with generalized and 10 with localized vitiligo). The repigmentation was evaluated 3-12 months after grafting using a digital image analysis system. Furthermore the treatment was evaluated from the patients' point of view with the DLQI (Dermatology Life Quality Index) and a 'global assessment'.

RESULTS

The mean percentage of repigmentation, evaluated at the last follow-up visit, was 72% (median 84%), and a repigmentation of >or=70% was observed in 62% of patients. The best results were achieved in the neck and the presternal region. A subjective evaluation was performed in half of the subjects. The mean DLQI score at inclusion (6.95, SD = 6.68, n = 20) was significantly decreased after treatment (p = 0.013, mean 3.85, SD = 4.13, n = 20). The patients were satisfied with the achieved result, found it worthwhile to undergo the treatment and would choose it again.

CONCLUSION

According to both subjective and objective evaluation methods, noncultured epidermal cell transplantation is promising in patients with stable vitiligo.

Consistent cutaneous imaging with commercial digital cameras

OBJECTIVE

To demonstrate how to improve the reproducibility and accuracy of digital images of the skin taken with commercially available digital cameras by transforming them to a standard color space, sRGB.

METHODS

Our computer algorithm transforms digital images to the standard sRGB color space. It is based on a card with a number of color squares with known colorimetric properties that is included in the image, thereby removing any ambiguity about the color information in the image. Reproducibility and accuracy of the method were assessed by comparing images of color squares with known colorimetric properties taken with different digital cameras at different exposures and zoom settings.

RESULTS

Although calibrated images exhibit markedly improved precision and accuracy compared with noncalibrated images, all variability of the imaging process cannot be eliminated.

CONCLUSION

With a little care and effort, a calibrated color chart, and computer software, it is possible to greatly improve the quality of clinical imaging in dermatology and possibly other fields of medicine.

Different approaches for assaying melanosome transfer

Many approaches have been tried to establish assays for melanosome transfer to keratinocytes. In this report, we describe and summarize various novel attempts to label melanosomes in search of a reliable, specific, reproducible and quantitative assay system. We tried to fluorescently label melanosomes by transfection of GFP-labeled melanosomal proteins and by incubation of melanocytes with fluorescent melanin intermediates or homologues. In most cases a weak cytoplasmic fluorescence was perceived, which was probably because of incorrect sorting or deficient incorporation of the fluorescent protein and different localization. We were able to label melanosomes via incorporation of 14C-thiouracil into melanin. Consequently, we tried to develop an assay to separate keratinocytes with transferred radioactivity from melanocytes after co-culture. Differential trypsinization and different magnetic bead separation techniques were tested with unsatisfactory results. An attempt was also made to incorporate fluorescent thiouracil, since this would allow cells to be separated by FACS. In conclusion, different methods to measure pigment transfer between donor melanocytes and acceptor keratinocytes were thoroughly examined. This information could give other researchers a head start in the search for a melanosome transfer assay with said qualities to better understand pigment transfer.

Quality of life and stigmatization profile in a cohort of vitiligo patients and effect of the use of camouflage

BACKGROUND

Few studies have paid attention to the effects of treatment interventions on the psychosocial consequences of vitiligo.

OBJECTIVES

To quantify and analyse the psychosocial benefit of the use of camouflage in vitiligo patients.

PATIENTS AND METHODS

78 vitiligo patients completed the Dermatology Life Quality Index (DLQI) and an adapted stigmatization questionnaire, and 62 of them completed the DLQI after at least a 1-month use of camouflage.

RESULTS

The initial mean overall DLQI score (n = 78) is 6.9 (SD 5.6). The mean global stigmatization score is 38%. Disease extent and disease severity are strong predictors of the DLQI (p < 0.0001). Vitiligo on the face/head/neck substantially affects the DLQI, independently of degree of involvement. The mean DLQI score before and after use of camouflage (n = 62) is 7.3 (SD 5.6) and 5.9 (SD 5.2; p = 0.006). Mainly the high-scoring items 'feelings of embarrassment and self consciousness' and 'choice of clothing' improve. Predictors of improvement are higher DLQI scores (p = 0.0005) and higher total severity scores (p = 0.03).

CONCLUSIONS

Camouflage can be recommended, particularly in patients with higher DLQI scores or self-assessed disease severity. Patients with minor involvement of the face benefit from camouflage.

Clinical and molecular abnormalities in lipoid proteinosis

Lipoid proteinosis (hyalinosis cutis et mucosae) is a rare, autosomal recessive disease. The main clinicopathological features comprise skin and mucous membrane infiltration and scarring with deposition of hyaline material. In this report, we describe a 6-year-old boy in whom a diagnosis of lipoid proteinosis was first suspected when he presented with blisters and erosions at 4 years, a history of life-long dysphonia and a previous epileptic convulsion. The diagnosis was confirmed by histology and identification of a homozygous frameshift mutation, 501insC, in exon 6 of the gene encoding extracellular matrix protein 1, ECM1. Lipoid proteinosis may show protean clinical features and be difficult to diagnose on clinical grounds alone. This case report illustrates that lipoid proteinosis may show protean clinical features and yet remain undiagnosed for many years. Although the gold standard for definite diagnosis remains histology, molecular characterisation of the gene mutation will add to our understanding of genotype-phenotype correlation and perhaps to the development of a rationale for future therapeutics.

Effect of vitiligo on self-reported health-related quality of life

BACKGROUND

Vitiligo is a pigmentary disorder affecting at least 1% of the total population. Although the disease does not produce direct physical impairment, it may considerably influence the psychological well-being of the patients. It has been suggested that patients suffer from low self-esteem, poor body image and a poor quality of life. The majority of the studies on the psychosocial impact of vitiligo were conducted in the U.S.A. and England.

OBJECTIVES

This study aims to quantify the burden of vitiligo by estimating health-related quality of life in the Dutch-speaking Belgian population (Flanders). This is compared with the level of disability caused by psoriasis in a similarly recruited population. It is also our purpose to detect those at risk of experiencing a poor quality of life and to identify variables that might predict this impairment.

PATIENTS AND METHODS

Patients with vitiligo (n = 119) and 162 patients with psoriasis were included in a postal survey. In order to obtain a patient-based measurement of quality of life we used the Dermatology Life Quality Index (DLQI), a widely validated questionnaire that is easy to use and allows comparison between several skin disorders. Other survey questions were related to demographic data and disease-related characteristics.

RESULTS

We obtained excellent response rates in both patient groups. The overall mean DLQI score for vitiligo (4.95) was lower than that for psoriasis (6.26) (P = 0.01). Patients with vitiligo experienced significantly less impairment of life quality from the symptoms and treatment of the disease (P < 0.001). The highest individual mean scores in vitiligo were found for Q2 (feelings), Q4 (clothing), Q5 (social and leisure activities) and Q3 (daily routine). The interaction of disease and sex on the DLQI score was highly significant (P = 0.001). While men with vitiligo scored significantly lower than men with psoriasis (P < 0.001), we found a comparable overall DLQI score for women in these disease groups. The number of consultations (P = 0.005) and severity of the disease (P < 0.001) were independently related to the DLQI.

CONCLUSIONS

Our study quantifies the burden on the quality of life caused by vitiligo and indicates specific areas of patients' lives which are most affected by the disease. Sex, number of consultations and subjective disease severity independently predict the quality of life. The quality of life impairment in women affected with vitiligo equals the impairment caused by psoriasis in our study population. These results should awake the interest of physicians in this 'cosmetic' disease, since appropriate treatment is likely to improve the quality of life of vitiligo patients.

Rab27b is Up-Regulated in Human Griscelli Syndrome Type II Melanocytes and Linked to the Actin Cytoskeleton via Exon F-Myosin Va Transcripts

Patients with the autosomal recessive Griscelli-Pruniéras syndrome type II are immunologically impaired and have an unusual silvery-grey hypopigmented colour of scalp hair, eyelashes and eyebrows but no noteworthy pigmentary abnormalities of the skin. In most Griscelli patients, the RAB27A gene, which encodes a small GTPase that is associated with the melanosome membrane in melanocytes, is mutated. Here we discuss a genomic RAB27A deletion found in a 21-month-old Moroccan Griscelli patient. Additionally, we provide evidence that the loss of functional Rab27a in melanocytes of this Griscelli patient is partially compensated by the up-regulation of Rab27b, a homologue of Rab27a. By real-time quantitative PCR and western blot analysis, we found that Rab27b mRNA and protein, expressed at low levels in normal human melanocytes, is significantly up-regulated in melanocytes derived from this patient. Our immunofluorescence and yeast two-hybrid screening studies reveal that Rab27b can form a tripartite complex on the melanosome membrane with Melanophilin, a Rab27a effector, and protein products of Myosin Va transcripts that contain exon F. Our data suggest that up-regulated Rab27b in melanocytes of the Griscelli patient can partially take over the function of Rab27a, which could explain the fact that this patient had an evenly pigmented skin and was able to tan.

Double-blind Placebo-Controlled Study of Autologous Transplanted Epidermal Cell Suspensions for Repigmenting Vitiligo

OBJECTIVES

To investigate the efficacy of epidermal noncultured cellular grafting in patients with vitiligo and the role of postinflammatory, spontaneous, or UV-induced pigmentation in obtaining repigmentation.

DESIGN

A prospective, randomized, double-blind, placebo-controlled study.

SETTING

Ambulatory patients in an institutional practice. Patients were followed up for 3 to 12 months.

PATIENTS

A total of 33 paired, symmetrically distributed leukodermic lesions, all resistant to therapy, were observed in 28 patients. Nineteen patients appeared to have a stable vitiligo (group 1), whereas there was doubt about the stability of the disease in 9 patients (group 2).

INTERVENTION

After laser ablation, a hyaluronic acid-enriched cellular graft was applied to 1 lesion while the paired lesion received placebo. Three weeks later all lesions were exposed to UV irradiation twice per week for approximately 2 months.

MAIN OUTCOME MEASURES

Primarily, the percentage of repigmentation was assessed after 3, 6, and 12 months using a digital image analysis system. The repigmentation pattern was also evaluated after 1 and 3 months.

RESULTS

A strongly significant difference between cellular grafts and placebo was observed after 3, 6, and 12 months (P<.001, P = .002, and P = .002, respectively). In group 1, repigmentation of at least 70% of the treated area was achieved in 55%, 57%, and 77% of the actively treated lesions 3, 6, and 12 months after treatment, whereas in group 2 repigmentation of at least 70% of the treated area was not observed at any time point. The repigmentation pattern was diffuse in 94% of the responding patients.

CONCLUSIONS

After a strict preoperative selection for disease stability, transplantation resulted in repigmentation of at least 70% of the treated area in most actively treated vitiligo lesions. Repigmentation was primarily caused by the transplanted melanocytes.

Ciclosporin in psoriasis clinical practice: an international consensus statement

The main recommendations for the use of ciclosporin in the management of psoriasis are: (i) intermittent short courses (average of 12 weeks duration) of ciclosporin are preferable; (ii) ciclosporin should be given in the dose range 2.5-5.0 mg kg(-1) day(-1) (doses greater than 5.0 mg kg(-1) day(-1) should only be given in exceptional circumstances); (iii) treatment regimens should be tailored to the needs of each patient; (iv) selection of patients should take into account psychosocial disability, as well as clinical extent of disease and failure of previous treatment; (v) each patient's renal function (as measured by serum creatinine) should be thoroughly assessed before and during treatment; (vi) each patient's blood pressure should be carefully monitored before and during treatment; (vii) adherence to treatment guidelines substantially reduces the risk of adverse events; (viii) long-term continuous ciclosporin therapy may be appropriate in a subgroup of patients; however, duration of treatment should be kept below 2 years whenever possible; and (ix) when long-term continuous ciclosporin therapy is necessary, annual evaluation of glomerular filtration rate may be useful to accurately monitor renal function.

Topical class I corticosteroids in 10 patients with bullous pemphigoid: correlation of the outcome with the severity degree of the disease and review of the literature

BACKGROUND

Treatment of bullous pemphigoid (BP) with systemic immunosuppressive agents, in particular with systemic corticosteroids, has many long-term side-effects. A dozen reports were published regarding the efficacy of topical corticosteroids in the treatment of bullous pemphigoid.

OBJECTIVE

To evaluate the efficacy of potent class I topical corticosteroids in relation to the affected body surface area (BSA) in patients with bullous pemphigoid and to review the literature.

METHODS

An open prospective trial with 10 patients with BP with measurement of the affected BSA. Treatment protocol consisted of three steps: potent class I topical corticosteroid treatment, systemic tetracyclines and systemic corticosteroids. Follow-up period was between 24 and 72 months.

RESULTS

Our study suggests a correlation between the success rate of topical corticosteroid treatment and the body surface area initially affected: all patients with an affected BSA of less than 20% healed with topical treatment only. The patients with more than 40% affected BSA needed systemic treatment with steroids.

CONCLUSION

Topical class I corticosteroids seem to be effective in healing lesions of BP, especially if less than 20% of the BSA is affected. This study comprises only 10 patients, making further studies necessary to draw definite conclusions.

Autologous transplantation techniques for vitiligo: how to evaluate treatment outcome

Effective methods for measuring treatment outcome in vitiligo are essential to accurately assess possible therapeutic modalities. This systematic review article aims to bring the problems concerning evaluation of treatment outcome in vitiligo studies using transplantation techniques to the attention of clinical investigators. Furthermore we highlight the interpretation of the achieved result from both physicians' and patients' view point using a questionnaire put to 558 dermatologists and 152 vitiligo patients in Belgium. There is no consensus about the choice of an evaluation method in surgical vitiligo studies. The interpretation of a 'successful' treatment result seemed to differ among dermatologists and vitiligo patients. We conclude that further research is needed to develop a universally accepted, objective, reliable and useful measurement method to evaluate the efficacy of surgical vitiligo treatments. A combination of both a clinical and a psychological measurement is likely to be the most appropriate choice.

Early treatment of hemangiomas with lasers. A review

Hemangiomas can present a difficult problem in management. Much controversy exists over whether it is better to watch and wait for natural involution or to be more aggressive and attempt to prevent some of the potential negative sequelae. Different modalities have been employed in the treatment of hemangiomas, including systemic therapy - antiangiogenic drugs, i.e. systemic corticosteroids and alpha-interferon - and local therapy - surgical procedures, arterial embolization and cryotherapy. Overall, a very conservative approach to therapy has been recommended because of treatment risks, treatment inadequacy and lack of evidence showing superiority over natural involution. Recently laser treatment has been used in the therapeutic approach of hemangiomas. This review discusses the pros and contras of early laser treatment of hemangiomas. For superficial hemangiomas, the flashlamp pumped pulsed dye laser in particular has proven itself in numerous studies. In the treatment of hemangiomas with subcutaneous components, the Nd:YAG laser is the treatment of choice.

Adverse skin reactions to anti-TNF-alpha monoclonal antibody therapy

Various adverse cutaneous reactions to anti-TNF-alpha monoclonal antibody have been reported. In clinical studies with infliximab (Remicade) adverse drug reactions were most frequently reported in the respiratory system and in the skin and appendages. We describe here 6 patients receiving anti- TNF-alpha therapy (infliximab) for Crohn's disease or rheumatoid arthritis who consulted our out-patient department for adverse cutaneous reactions between November 1999 and February 2002. The following diagnoses were made: leukocytoclastic vasculitis, lichenoid drug reaction, perniosis-like eruption (2 patients), superficial granuloma annulare and acute folliculitis.

Interactions of human Myosin Va isoforms, endogenously expressed in human melanocytes, are tightly regulated by the tail domain

Primary human epidermal melanocytes express six endogenous isoforms of the human actin-associated myosin Va motor protein, involved in organelle transport. As isoforms containing exon F are most abundant in melanocytes, we hypothesized that these isoforms probably have a melanocyte-specific function. To uncover the biologic role of the six isoforms we introduced enhanced green fluorescent protein (eGFP)-myosin Va tail constructs in human melanocytes. We found that the medial tail, undergoing alternative splicing, has to be expressed in combination with the globular tail in order to obtain clear colocalization with organelles. Our data show that isoforms lacking exon F but containing exon D are associated with vesicles near the Golgi area. Myosin Va isoforms containing exon F are able to colocalize with and influence melanosome distribution by indirect interaction with rab27a and direct interaction with melanophilin. These results indicate that the myosin Va medial tail domain provides the globular tail domain with organelle-interacting specificity.

Diffuse plane normolipaemic xanthomatosis in a patient with chronic lymphatic leukaemia and monoclonal gammopathy

Diffuse plane normolipaemic xanthomatosis is a well-defined uncommon condition characterized by yellow-orange plaques involving the eyelids, neck, upper trunk, buttocks and flexural folds. Over half of the reported cases are associated with lymphoproliferative disorders. The condition may arise as a result of perivascular deposition of lipoprotein-immunoglobulin complexes. We present a female patient with clear clinical features of diffuse plane xanthomatosis associated with chronic lymphatic leukaemia and monoclonal gammopathy. In this patient, we found evidence of complement consumption supporting the hypothesis that complexes of lipoprotein and paraprotein are formed. Lipid electrophoresis of fasting serum revealed the presence of a faint precipitate at the application slot, also indicative of the presence of protein-lipid complexes.

Efficacy and safety of a topically applied Avène spring water spray in the healing of facial skin after laser resurfacing

BACKGROUND

Although laser resurfacing is a well-accepted treatment, tolerance problems may preclude patient's acceptance of the procedure. Post-laser protracted erythema is a prime problem, associated with the symptoms of pain, itching, stinging and tightening.

OBJECTIVE

The present study was conducted to evaluate a low-salt medical spring water (Avène, Avène-les-Bains, France), in conjunction with the standard use of an emollient, to improve tolerance by hydrating the postlaser skin.

METHODS

A controlled, randomized, open-labeled, multicentric and two parallel group study was completed after 84 days in 74 patients, 34 applying a petrolatum ointment alone (control group), and 40 applying petrolatum ointment in association with the Avène spring water spray ad libitum (water group).

RESULTS

The water spray showed a pronounced effect on reducing erythema, from the second week of postlaser onwards, with a statistically significant difference in favor of the water group compared with the control group (p < or = 0.04 from day 14 to day 84, except a non-significant trend on day 28). In addition, the water spray was found to significantly reduce itching on day 28 (p < 0.05), and stinging and tightening on day 14 and day 21 (p < 0.05). Pain was not modified by the water.

CONCLUSION

Topical water appears to be a helpful adjunctive treatment to petrolatum ointment for counteracting erythema, itching, stinging and tightening during the postlaser treatment period.

[Motor proteins and pigmentation]

One essential part of the process of skin pigmentation comprises the production of melanosomes, the melanin-containing organelles, and correct transport towards their target cells, the keratinocytes. In this overview the molecular mechanisms of these processes are discussed in view of a number of pigmentation syndromes.

CD-34 and Ki-67 staining patterns of basaloid follicular hamartoma are different from those in fibroepithelioma of Pinkus and other variants of basal cell carcinoma

BACKGROUND AND AIMS

Basaloid follicular hamartoma is a rare disorder regarded as a developmental malformation. It may be solitary or generalized, linear or regionalized, and is sometimes associated with myasthenia gravis or alopecia. We compared immunohistochemical staining patterns of selected markers in order to differentiate this hamartoma from fibroepithelioma of Pinkus, a basal cell carcinoma variant it can be confused with.

METHODS

The expression of three immunohistochemical markers--CD-34, Ki-67, bcl-2--was studied in a basaloid follicular hamartoma and in a fibroepithelioma of Pinkus. Two basal cell carcinomas, a nodular and a fibrosing type, and a trichoepithelioma were included as controls.

RESULTS

Basaloid follicular hamartoma shows a low proliferation index and an at least focally circumferential expression of CD-34 around the epithelial strands. This compares to the findings in trichoepithelioma. In contrast, fibroepithelial tumor of Pinkus and two other basal cell carcinoma subtypes display a high proliferative index and an absence of CD-34 expression around the epithelium. These findings support the non-neoplastic nature of basaloid follicular hamartoma.

Microcystic adnexal carcinoma: an uncommon tumor with debatable origin

BACKGROUND

Microcystic adnexal carcinoma is an uncommon skin appendage neoplasm exhibiting both pilar and sweat duct differentiation. This tumor remains a subject of controversy as to its differentiation profile, histogenesis, and classification which is reflected in the nomenclature used to designate the neoplasm in question. Beyond this controversy the tumor remains a diagnostic challenge because of its rarity, the histologic mimicry it may display, and its banal cytologic appearance; it also poses a therapeutic challenge, as it is characterized by slow but aggressive and destructive local growth extending beyond clinical margins together with a high tendency for perineural invasion and recurrence.

OBJECTIVE

We report two cases of this unusual tumor illustrating some of its characteristics. Our review emphasizes the divergent opinions concerning its differentiation profile and its origin. An organoid nevus as the origin of microcystic adnexal carcinoma in one of our patients is discussed in this context.

Modified technique of autologous noncultured epidermal cell transplantation for repigmenting vitiligo: a pilot study

BACKGROUND

Several reports have demonstrated that grafting of autologous melanocytes from normally pigmented donor skin can be used for repigmentation of achromic macules in vitiligo.

OBJECTIVE

To investigate a modified approach in which noncultured autologous melanocytes and keratinocytes are grafted on superficially laser dermabraded vitiligo lesions in a suspension enriched with hyaluronic acid.

METHODS

Four patients with stable vitiligo were treated using a noncultured melanocyte-keratinocyte suspension. The cellular suspension was grafted on vitiliginous lesions previously dermabraded with a CO2 laser. To improve the viscosity and fixation of the cellular suspension hyaluronic acid was added. Three weeks after grafting, psoralen plus ultraviolet A (PUVA) or ultraviolet B (UVB) therapy was started. Residual leukodermic areas were subsequently retreated.

RESULTS

Repigmentation was observed within 2-4 weeks and continued to increase for 3 months after treatment. In all patients, 85-100% repigmentation was achieved. A temporary slight color mismatch was visible in all patients. The most homogeneous repigmentation was obtained 5 months after treatment.

CONCLUSION

This modified procedure seems to be a simple and promising treatment for larger vitiliginous areas.

The dilute locus and Griscelli syndrome: gateways towards a better understanding of melanosome transport

In this review an overview of recent advances in the understanding of melanosome movement within epidermal melanocytes is given. Exploration of the molecular events involved in and determining the process of melanosome transport, as an essential part of human pigmentation, could lead to the identification of agents that augment, or down-regulate the transfer of melanosomes to surrounding keratinocytes. This would present a major breakthrough in the possibilities to influence pigmentation and related disorders, of great concern to some patients. Moreover, melanosome transport offers a good model to study mammalian organelle trafficking and its key players in general.

Bilateral corneal melting in a patient with paraneoplastic pemphigus

An 80-year-old man, with a solid abdominal tumor and multiple skin lesions, was admitted to the hospital because of a perforated right cornea and an impending perforation of the left. The clinical, histological, immunohistological and immunoprecipitation findings of the skin lesions were consistent with Anhalt's criteria for paraneoplastic pemphigus (PNP). The underlying malignancy proved to be an incurable peripheral neuronal shaft tumor. Both conjunctivae appeared normal. The right eye revealed a flat anterior chamber, due to a spontaneous, central corneal perforation. The central part of the left cornea had severely thinned, resulting in a descemetocele, which eventually perforated. Multiple surgical interventions were needed to restore the anterior chamber in both eyes. Although a causative association between PNP and corneal perforation could not be demonstrated, we think that corneal melting should be added to the list of ocular complications in patients with PNP.

Surgical techniques for vitiligo: a review

Although the treatment of vitiligo has improved during the last decade, therapy is still not satisfying for many patients. This is probably due to the fact that the aetiopathogenesis is unknown. Several treatment modalities, such as PUVA, UVB and local corticosteroids are currently used in the treatment of active vitiligo. However, these treatments usually induce incomplete repigmentation. Surgical methods intended to repigment leucoderma are an interesting therapeutic option if patients have stable disease. Two types of surgical techniques are available: tissue grafts and cellular grafts, with in between autologous cultured epithelial grafts. Tissue grafts are full-thickness punch grafts, split-thickness grafts and suction blister grafts. With tissue grafts, only a limited surface area can be treated but with good results in the majority of cases. Cellular grafts include non-cultured keratinocytes/melanocytes and cultured melanocytes. The exact success rate of repigmentation with cellular grafts is still unknown, since only a small number of studies have been published. Starting from autologous cellular suspensions, epithelial grafts of various compositions can be cultured in vitro. They can be used for larger areas. The purpose of this review is to describe the applications of different surgical techniques used to treat recalcitrant vitiligo.

Autologous cellular suspensions and sheets in the treatment of achromic disorders: the need for future controlled studies

Transplantation techniques using cultured and noncultured keratinocyte and/or melanocyte suspensions or sheets have been reported as successful in inducing repigmentation in achromic epidermal diseases such as vitiligo and piebaldism. However, the role of a lot of variable factors in the transplantation procedure remains unclear. Occasionally control sites are included in the reported patient series. We point out the need for future controlled studies when performing transplantations of cellular suspensions and sheets. This approach will help to understand how these techniques induce repigmentation and may eventually indicate the essential requirements for successful results.

Gabapentin for pain control in cancer patients' wound dressing care

A patient with mycosis fungoides illustrates the problem of pain management during wound care and suggests the utility of a novel treatment, gabapentin. Skin lesions, be they induced through necrosis of tumor, therapy (e.g., radiotherapy), or by pressure ulceration, are often the cause of continuous pain or acute wound dressing pain. Optimizing the analgesic treatment in those patients is thus of major importance. Anti-inflammatory drugs and opioids are the cornerstones in the treatment of cancer pain but are rarely sufficient to control wound pain. Different adjuvant techniques can be used, including topical analgesics, psychological distraction techniques, anxiolytics, and co-analgesics. There is growing evidence that anticonvulsants, and sodium channel blockers in particular, are effective not only in neuropathic but also in inflammatory pain. Gabapentin, a voltage sensitive sodium and calcium channel blocker, was used as a co-analgesic to supplement morphine in this case of cancer wound dressing pain.

Diagnostic ability of general practitioners and dermatologists in discriminating pigmented skin lesions

BACKGROUND

Early recognition of melanoma is the key in preventing metastatic disease.

OBJECTIVE

The aim of this study was to evaluate diagnostic ability of general practitioners (GPs) and dermatologists concerning pigmented skin lesions in general and melanoma in particular. We also investigated whether the diagnostic ability of GPs changed after a lecture on melanoma.

METHODS

A test set of 13 pigmented skin lesions on 35-mm color slides was presented to 160 GPs and 60 dermatologists during educational courses.

RESULTS

GPs correctly evaluated biologic behavior of the pigmented skin lesions in 72% of the evaluations. In 71% of these evaluations they correctly identified the lesions. The proportion of lesions correctly identified was positively correlated with the frequency of pigmented skin lesions in everyday practice. Dermatologists made a correct identification of the lesions in 88% of all evaluations, and they correctly evaluated biologic behavior in 94% of these. Recognition of melanoma was proportional to melanoma exposure in everyday practice. Thick melanomas were better recognized than thin melanomas in both physician groups. After a lecture on melanoma, sensitivity of GPs to recognize malignant disease increased from 72% to 84%, without a significant decrease in specificity. The proportion of lesions correctly identified also rose significantly (66% vs 52%).

Time delays and related factors in the diagnosis of cutaneous melanoma

Delay in melanoma diagnosis was investigated in a population-based sample of 130 patients. The median time elapsing from the first notice of the lesion to excision was 110.5 days. There was no linear correlation between total delay time and Breslow-thickness of the diagnosed melanomas (P=0.19). Patient delay, defined as the time from first notice of a (change in a) lesion to the first observation by a physician, exceeded 2 months in half of all patients. Only 41% of the patients consulted a doctor because they were worried about the lesion. Colour change and itch were associated with a longer patient delay. There was no correlation with age, gender, socio-economic factors, localisation of the lesion and the person who first noticed the lesion. In one quarter of all patients, the time from first observation by a physician to excision of the lesion exceeded 2.5 months. This physician delay seemed to be attributed to misdiagnosis and to a delay occurring during referral.

Polyarteritis nodosa mimicking polymyalgia rheumatica

We report a case of polyarteritis nodosa with a clinical presentation mimicking polymyalgia rheumatica, as well as pathological findings of non-giant-cell arteritis on temporal artery biopsy with symptoms of jaw claudication. Although certain clinical syndromes have been attributed to specific types of systemic vasculitis, considerable overlap occurs. Obtaining tissue biopsy in cases of vasculitis is mandatory for diagnosis and classification.

Value of standard laboratory tests for the early recognition of group A beta-hemolytic streptococcal necrotizing fasciitis

The laboratory data for 17 patients with group A beta-hemolytic streptococcal necrotizing fasciitis (GAS NF) were compared with data for 145 patients hospitalized for cellulitis during the same period. Admission values of C-reactive protein and creatine kinase were higher for patients in the group with GAS NF than for patients in the group with cellulitis (P<.001), suggesting that standard laboratory tests may be useful for the early differential diagnosis of GAS NF and cellulitis.

Colocalization of dynactin subunits P150Glued and P50 with melanosomes in normal human melanocytes

Melanocytic dendrites consist of a central core of microtubules (MT) and a subcortical actin network. In previous reports we showed the presence of MT-associated motor proteins kinesin and cytoplasmic dynein on the melanosomal surface, forming a link with MT (Vancoillie et al. J Invest Dermatol 2000;114:421-429; Vancoillie et al. Br J Dermatol 2000;143:258-306). We could also demonstrate the association of kinectin, the kinesin receptor, with melanosomes. The interaction of cytoplasmic dynein with its cargoes is thought to be indirectly mediated by dynactin, a complex that binds to the dynein intermediate chain. Therefore, in this study, we investigated the in vitro expression of dynactin subunits P150Glued and P50 in normal human epidermal melanocytes, keratinocytes, and dermal fibroblasts by reverse transcription-polymerase chain reaction and northern blot analysis. In an attempt to gain an insight into the subcellular localization of dynactin, immunofluorescence and immunoelectron microscopy (IEM) studies were performed. The two isoforms of P150Glued and P50 are expressed in all studied skin cells. Immunofluorescence staining shows punctate distributions for P150Glued and P50 in melanocytes. P150Glued shows a clear centrosomal staining and accentuation in the dendrite tips. P50 is also accentuated in the perinuclear area and dendrite tips. Immunofluorescence double-labeling with a melanosome marker showed apparent colocalization of both P150Glued and P50 with melanosomes. By IEM, P50 is detected on the surface of the majority of melanosomes in melanocytes. The colocalization of different subunits of the dynactin complex with melanosomes is consistent with the earlier finding of cytoplasmic dynein association with melanosomes and supports the hypothesis that this complex could form a link between cytoplasmic dynein and the melanosomal membrane.

The Schöpf-Schulz-Passarge syndrome

The Schöpf-Schulz-Passarge syndrome is a rare genodermatosis with autosomal recessive transmission. It is characterized by palmoplantar keratoderma, eyelid apocrine hydrocystomas, hypodontia, hypotrichosis and hypoplastic nails. Several epithelial tumors have been described in this syndrome. This report describes a case with actinic keratoses, two tumors of the follicular infundibulum and one poroma with follicular differentiation. This is the first report of an association between the Schöpf-Schulz-Passarge syndrome and a poroma with follicular differentiation.

Occurrence of scleroderma in monozygotic twins

Familial occurrence of scleroderma is rare and concordance for the disease in twins has been reported exceptionally. We describe 2 female identical twin pairs concordant for scleroderma. The first twin pair was diagnosed with the systemic form of scleroderma, the second pair with the localized form.

Cyclosporin in atopic dermatitis: review of the literature and outline of a Belgian consensus

This paper reflects the consensus reached among Belgian professors of dermatology on the place of cyclosporin (CsA) in the treatment of atopic dermatitis (AD). Existing therapeutic modalities and ways to evaluate efficacy of treatment are reviewed briefly. Based on data from the literature and personal experience, guidelines for the use of CsA in AD are proposed. CsA can be prescribed in recalcitrant cases of AD on a short-term basis, both in adults and children. Long-term treatment, up to 1 year, should be considered only in exceptional cases that cannot be controlled by short-time therapy. Contraindications, drug interactions and necessary controls during treatment are also discussed.

Osteoma cutis in pseudohypoparathyroidism

Pseudohypoparathyroidism (PHP) is a hereditary disorder characterized by an end-organ resistance for parathormone. PHP can be classified into different types by biochemical and phenotypic characteristics and the level of the defect in the hormone-receptor complex. PHP is described as Albright's hereditary osteodystrophy (AHO) when a specific phenotype is present. We report a case of osteoma cutis in a 30-year-old woman with AHO. Successful treatment was obtained by debriding the lesion followed by split-thickness skin grafting.

Cytoplasmic dynein colocalizes with melanosomes in normal human melanocytes

BACKGROUND

Melanocytic dendrites consist of a central core of microtubules and a subcortical actin network. Several studies provide arguments supporting the hypothesis that actin-based and microtubule-based motor proteins co-operate in melanosome transport towards the dendrite tips. Melanosomes can move bidirectionally along microtubules in vitro, and in murine melanocytes, they move towards the cell periphery and back again. Microtubules have a fast-growing plus end and a slow-growing minus end. Microtubule-associated motor proteins move unidirectionally either towards the plus or towards the minus end. However, it is not known which motor protein is responsible for minus end-directed movement of melanosomes.

OBJECTIVES

We aimed to investigate the in vitro expression of the minus end-directed motor protein cytoplasmic dynein in normal human epidermal melanocytes, keratinocytes and dermal fibroblasts.

METHODS

Reverse transcription-polymerase chain reaction and Northern blot analysis were used. In addition, an attempt to obtain insight into the subcellular localization of cytoplasmic dynein, immunofluorescence studies and immunogold electron microscopic studies were performed.

RESULTS

The three different forms of cytoplasmic dynein heavy chain were expressed in all studied skin cells. Immunofluorescence staining showed similar punctate distributions for dynein heavy chain 1 and dynein heavy chain 2 in melanocytes, with accentuation in the perinuclear area and dendrite tips. Double labelling with a melanosome marker showed apparent co-localization of both dynein heavy chains 1 and 2 with melanosomes in the perinuclear area and dendrite tips. For the dynein intermediate chain of 74 kDa, again a punctate staining pattern was seen with intense centrosomal staining. A close association of dynein intermediate chain 74 and alpha-tubulin with the melanosome surface was detected using immunogold electron microscopy.

CONCLUSIONS

The colocalization of different subunits of the cytoplasmic dynein complex with melanosomes is consistent with the hypothesis that this motor protein supports minus end-directed melanosome movement along microtubules.

Serological markers for melanoma

We present a review of current literature concerning the significance of serological markers in melanoma patients. Results for cytokines, cytokine receptors, cell adhesion molecules, S100 protein, melanoma inhibitory activity, tissue-specific reverse transcription-polymerase chain reaction, neurone-specific enolase, lipid-bound sialic acid and melanin metabolites such as 5-S-cysteinyldopa and 6-hydroxy-5-methoxyindole-2-carboxylic acid are discussed. For most of these substances, serum levels are more pronounced in the more advanced stages of disease. Therefore, these markers seem to have no place in the early detection of melanoma. On the other hand, sensitivity in the advanced stages of disease seems to be < 100%, compromising their use as a new staging procedure. Some markers show promising results as a possible prognostic factor in the early detection of disease progression or in the prediction of therapy outcome. If confirmed by further studies, this could direct future therapeutic strategies and could help to select patients who would benefit most from more aggressive (adjuvant) therapies. In addition, the study of some of these substances could add to the knowledge of tumour biology and immunology.

Current guidelines in melanoma treatment. Melanoma Working Group of Gent and Bordet

This article focuses on the actual management of cutaneous melanoma, dealing both with established, internationally well-accepted standard procedures and interventions which are still being investigated. It wants to offer a global picture to the dermatologist of what is currently available in the therapeutic arsenal against melanoma.

An imaging system with calibrated color image acquisition for use in dermatology

We propose a novel imaging system useful in dermatology, more precisely, for the follow-up of patients with an increased risk of skin cancer. The system consists of a Pentium PC equipped with an RGB frame grabber, a three-chip charge coupled devices (CCD) camera controlled by the serial port and equipped with a zoom lens and a halogen annular light source. Calibration of the imaging system provides a way to transform the acquired images, which are defined in an unknown color space, to a standard, well-defined color space called sRGB. sRGB has a known relation to the CIE1 XYZ and CIE L*a*b* colorimetric spaces. These CIE color spaces are based on the human vision, and they allow the computation of a color difference metric called CIE deltaE*ab, which is proportional to the color difference, as seen by a human observer. Several types of polynomial RGB to sRGB transforms will be tried, including some optimized in perceptually uniform color spaces. The use of a standard and well-defined color space also allows meaningful exchange of images, e.g., in teledermatology. The calibration procedure is based on 24 patches with known color properties, and it takes about 5 minutes to perform. It results in a number of settings called a profile that remains valid for tens of hours of operation. Such a profile is checked before acquiring images using just one color patch, and is adjusted on the fly to compensate for short-term drift in the response of the imaging system. Precision or reproducibility of subsequent color measurements is very good with (deltaE*ab) = 0.3 and deltaE*ab < 1.2. Accuracy compared with spectrophotometric measurements is fair with (deltaE*ab) = 6.2 and deltaE*ab < 13.3.

arg-cys substitution at codon 1246 of the human myosin Va gene is not associated with Griscelli syndrome

Myosin Va is an actin-associated motor protein involved in organelle transport such as melanosomes and neuron synaptic vesicles and has always been proposed as the candidate gene for the autosomal recessive Griscelli-Pruniéras syndrome, one of the silvery hair syndromes, which is a lethal disease combining immunodeficiency and neurologic and pigmentary abnormalities. Thus far, two mutations in the myosin Va gene have been described to be associated with this syndrome. One of these mutations was a homozygous mis-sense mutation causing an arginine to cysteine alteration at codon 1246. Because we also found this particular substitution after mutation analysis of a Griscelli patient, we checked its relevance in a control group of 124 unrelated healthy individuals and found it to be present, even in homozygous state, in normal unaffected individuals. It is clear that this arg1246cys substitution is a polymorphism occurring in the human population and not occurring in association with Griscelli syndrome. Distinguishing a polymorphism from a bona fide mutation is of utmost importance and has major ethical implications with regard to prenatal genetic counseling in affected families.

Absence of telomerase activity and telemorase catalytic subunit mRNA in melanocyte cultures

The classic model of activation of telomerase, for which activity has been found in most cancers including cutaneous malignant melanoma (CMM), dictates that enzyme activity is generated by pathological reactivation of telomerase in telomerase-negative somatic cells. However, recent data demonstrated physiological up-regulation in some normal cell types when established as proliferating cultures, indicating that, in some cancer types, telomerase is expressed by the process of up-regulation in telomerase-competent precursor cells. In this study, cultures of epidermal melanocytes, progenitor cells of CMM, were established and harvested in the logarithmic phase of growth. Telomerase activity was looked for using a non-isotopic variant of the telomeric repeat amplification protocol, and transcript expression of the hTERT gene, the rate-limiting catalytic telomerase subunit, was investigated by the reverse transcription polymerase chain reaction. Neither telomerase activity nor hTERT mRNA could be detected in proliferating melanocyte cultures. Our in vitro data argue against the model of telomerase as a common biomarker of cell proliferation. The results further suggest that telomerase is tightly controlled in normal melanocytes, and that telomerase is reactivated rather than up-regulated in melanocytic precursors during melanoma initiation or progression.

Mutation analysis of P73 and TP53 in Merkel cell carcinoma

The p73 gene has been mapped to 1p36.33, a region which is frequently deleted in a wide variety of neoplasms including tumours of neuroectodermal origin. The p73 protein shows structural and functional homology to p53. For these reasons, p73 was considered as a positional and functional candidate tumour suppressor gene. Thus far, mutation analysis has provided no evidence for involvement of p73 in oligodendrogliomas, lung carcinoma, oesophageal carcinoma, prostatic carcinoma and hepatocellular carcinoma. In neuroblastoma, two mutations have been observed in a series of 140 tumours. In view of the occurrence of 1p deletions in Merkel cell carcinoma (MCC) and the location of p73 we decided to search for mutations in the p73 gene in five MCC cell lines and ten MCC tumours to test potential tumour suppressor function for this gene in MCC. In view of the possible complementary functions of p73 and TP53 we also examined the status of the TP53 gene. Sequence analysis of the entire coding region of the p73 gene revealed previously reported polymorphisms in four MCCs. In one MCC tumour, a mis-sense mutation located in the NH2-terminal transactivation region of the p73 gene was found. These results show that p73, analogous to neuroblastoma, is infrequently mutated in MCC. This is also the first report in which the role of TP53 in MCC has been investigated by sequencing the entire coding region of TP53. TP53 mis-sense mutations and one non-sense mutation were detected in three of 15 examined MCCs, suggesting that TP53 mutations may play a role in the pathogenesis or progression of a subset of MCCs. Moreover, typical UVB induced C to T mutations were found in one MCC cell line thus providing further evidence for sun-exposure in the aetiology of this rare skin cancer.

Immune-mediated pathology following hepatitis B vaccination. Two cases of polyarteritis nodosa and one case of pityriasis rosea-like drug eruption

The association of hepatitis B virus infection and vasculitis or other immune-mediated manifestations is well documented. Reports on such manifestations in relation to hepatitis B vaccination are scarce, however. We report 2 patients who developed polyarteritis nodosa following vaccination against hepatitis B. In one patient this resulted in an ischemic and necrotic digital ulcus, necessitating surgical amputation. The other patient presented with typical cutaneous polyarteritis nodosa which responded well to corticosteroid treatment. A third patient developed a severe pityrias rosea-like eruption. He was treated with topical steroids with healing of the lesions, leaving only post-inflammatory hyperpigmentation. The literature on these associations is reviewed.

Understanding the trends in melanoma incidence and mortality: where do we stand?

In previous decades melanoma incidence rates have risen spectacularly in white populations worldwide and a parallel - although more moderate - increase has been observed for melanoma mortality. More recently several reports have been made of a stabilization or decrease of mortality rates in the younger birth cohorts, resulting in a stabilization in the overall mortality in the 1980s for some populations. This article reviews past and current trends in melanoma epidemiology. It further handles the possible explanations for these trends and the currently available indications for or against these trends being brought about by real or artefactual influences. Time will undoubtedly reveal more about the truth.