A growing family of outcome measurement proposals for hidradenitis suppurativa

Linked Article: Goldfarb et al. Br J Dermatol 2021; 184:905–912.

A survey among dermatologists: diagnostics of superficial fungal infections - what is used and what is needed to initiate therapy and assess efficacy?

BACKGROUND

Superficial fungal infections are common. It is important to confirm the clinical diagnosis by mycological laboratory methods before initiating systemic antifungal treatment, especially as antifungal sensitivity and in vitro susceptibility may differ between different genera and species. For many years, the gold standard for diagnosis of superficial fungal infections has been direct fungal detection in the clinical specimen (microscopy) supplemented by culturing. Lately, newer molecular based methods for fungal identification have been developed.

OBJECTIVE

This study was initiated to focus on the current usage of mycological diagnostics for superficial fungal infections by dermatologists. It was designed to investigate whether it was necessary to differentiate between initial diagnostic tests and those used at treatment follow-up in specific superficial fungal infections.

METHODS

An online questionnaire was distributed among members of the EADV mycology Task Force and other dermatologists with a special interest in mycology and nail disease.

RESULTS

The survey was distributed to 62 dermatologists of whom 38 (61%) completed the whole survey, 7 (11%) partially completed and 17 (27%) did not respond. Nearly, all respondents (82-100%) said that ideally they would use the result of direct microscopy (or histology) combined with a genus/species directed treatment of onychomycosis, dermatophytosis, Candida- and Malassezia-related infections. The majority of the dermatologists used a combination of clinical assessment and direct microscopy for treatment assessment and the viability of the fungus was considered more important at this visit than when initiating the treatment. Molecular based methods were not available for all responders.

CONCLUSION

The available diagnostic methods are heterogeneous and their usage differs between different practices as well as between countries. The survey confirmed that dermatologists find it important to make a mycological diagnosis, particularly prior to starting oral antifungal treatment in order to confirm the diagnose and target the therapy according to genus and species.

Towards global consensus on core outcomes for hidradenitis suppurativa research: an update from the HISTORIC consensus meetings I and II

BACKGROUND

A core outcomes set (COS) is an agreed minimum set of outcomes that should be measured and reported in all clinical trials for a specific condition. Hidradenitis suppurativa (HS) has no agreed-upon COS. A central aspect in the COS development process is to identify a set of candidate outcome domains from a long list of items. Our long list had been developed from patient interviews, a systematic review of the literature and a healthcare professional survey, and initial votes had been cast in two e-Delphi surveys. In this manuscript, we describe two in-person consensus meetings of Delphi participants designed to ensure an inclusive approach to generation of domains from related items.

OBJECTIVES

To consider which items from a long list of candidate items to exclude and which to cluster into outcome domains.

METHODS

The study used an international and multistakeholder approach, involving patients, dermatologists, surgeons, the pharmaceutical industry and medical regulators. The study format was a combination of formal presentations, small group work based on nominal group theory and a subsequent online confirmation survey.

RESULTS

Forty-one individuals from 13 countries and four continents participated. Nine items were excluded and there was consensus to propose seven domains: disease course, physical signs, HS-specific quality of life, satisfaction, symptoms, pain and global assessments.

CONCLUSIONS

The HISTORIC consensus meetings I and II will be followed by further e-Delphi rounds to finalize the core domain set, building on the work of the in-person consensus meetings.

European S1 guideline for the treatment of hidradenitis suppurativa/acne inversa

Hidradenitis suppurativa/acne inversa (HS) is a chronic, inflammatory, recurrent, debilitating skin disease of the hair follicle that usually presents after puberty with painful, deep-seated, inflamed lesions in the apocrine gland-bearing areas of the body, most commonly the axillae, inguinal and anogenital regions. A mean disease incidence of 6.0 per 100,000 person-years and an average prevalence of 1% has been reported in Europe. HS has the highest impact on patients' quality of life among all assessed dermatological diseases. HS is associated with a variety of concomitant and secondary diseases, such as obesity, metabolic syndrome, inflammatory bowel disease, e.g. Crohn's disease, spondyloarthropathy, follicular occlusion syndrome and other hyperergic diseases. The central pathogenic event in HS is believed to be the occlusion of the upper part of the hair follicle leading to a perifollicular lympho-histiocytic inflammation. A highly significant association between the prevalence of HS and current smoking (Odds ratio 12.55) and overweight (Odds ratio 1.1 for each body mass index unit) has been documented. The European S1 HS guideline suggests that the disease should be treated based on its individual subjective impact and objective severity. Locally recurring lesions can be treated by classical surgery or LASER techniques, whereas medical treatment either as monotherapy or in combination with radical surgery is more appropriate for widely spread lesions. Medical therapy may include antibiotics (clindamycin plus rifampicine, tetracyclines), acitretin and biologics (adalimumab, infliximab). A Hurley severity grade-relevant treatment of HS is recommended by the expert group following a treatment algorithm. Adjuvant measurements, such as pain management, treatment of superinfections, weight loss and tobacco abstinence have to be considered.

Millimeter wave silicon micromachined waveguide probe as an aid for skin diagnosis--results of measurements on phantom material with varied water content

BACKGROUND

More than 2 million cases of skin cancer are diagnosed annually in the United States, which makes it the most common form of cancer in that country. Early detection of cancer usually results in less extensive treatment and better outcome for the patient. Millimeter wave silicon micromachined waveguide probe is foreseen as an aid for skin diagnosis, which is currently based on visual inspection followed by biopsy, in cases where the macroscopical picture raises suspicion of malignancy.

AIMS

Demonstration of the discrimination potential of tissues of different water content using a novel micromachined silicon waveguide probe. Secondarily, the silicon probe miniaturization till an inspection area of 600 × 200 μm2, representing a drastic reduction by 96.3% of the probing area, in comparison with a conventional WR-10 waveguide. The high planar resolution is required for histology and early-state skin-cancer detection.

MATERIAL AND METHODS

To evaluate the probe three phantoms with different water contents, i.e. 50%, 75% and 95%, mimicking dielectric properties of human skin were characterized in the frequency range of 95-105 GHz. The complex permittivity values of the skin are obtained from the variation in frequency and amplitude of the reflection coefficient (S11), measured with a Vector Network Analyzer (VNA), by comparison with finite elements simulations of the measurement set-up, using the commercially available software, HFSS. The expected frequency variation is calculated with HFSS and is based on extrapolated complex permittivities, using one relaxation Debye model from permittivity measurements obtained using the Agilent probe.

RESULTS

Millimeter wave reflection measurements were performed using the probe in the frequency range of 95-105 GHz with three phantoms materials and air. Intermediate measurement results are in good agreement with HFSS simulations, based on the extrapolated complex permittivity. The resonance frequency lowers, from the idle situation when it is probing air, respectively by 0.7, 1.2 and 4.26 GHz when a phantom material of 50%, 75% and 95% water content is measured.

DISCUSSION

The results of the measurements in our laboratory set-up with three different phantoms indicate that the probe may be able to discriminate between normal and pathological skin tissue, improving the spatial resolution in histology and on skin measurements, due to the highly reduced area of probing.

CONCLUSION

The probe has the potential to discriminate between normal and pathological skin tissue. Further, improved information, compared to the optical histological inspection can be obtained, i.e. the complex permittivity characterization is obtained with a high resolution, due to the highly reduced measurement area of the probe tip.

Objective scoring of hidradenitis suppurativa reflecting the role of tobacco smoking and obesity

BACKGROUND

Hidradenitis suppurativa (HS) is a long-standing disease with abscess and often fistula formation, predominantly in the axillae and groins. The disease is difficult to treat and has a severe impact on quality of life. A clinically relevant system for scoring disease severity is lacking in HS.

OBJECTIVES

To evaluate the modified Hidradenitis Suppurativa Score (HSS) and to study the impact of body mass index (BMI) and smoking habits on disease severity.

METHODS

Two hundred and fifty-one consecutive patients with HS referred to a clinic with special interest in the disease were included, of whom 115 were scored. Points were given for regions involved, types of lesion (nodules, fistulas), total area involved and whether lesions were separated by normal skin. Background characteristics included BMI and smoking habits. Two hundred and forty-six patients completed the Dermatology Life Quality Index (DLQI).

RESULTS

The median (interquartile range, IQR) HSS for all patients was 38 (18-66): women 38 (18-71) and men 37 (19-51). Median (IQR) HSS for smokers was 41 (22-75.5), former smokers 27 (16-53) and nonsmokers 22 (10-57). Median (IQR) HSS for patients with BMI < 25 kg m(-2) was 32 (12-54), BMI 25-30 kg m(-2) 44 (22-56) and BMI > or = 30 kg m(-2) 50 (18-86). Mean +/- SD DLQI for the whole group of patients was 10.3 +/- 7.5, median 9, and showed no significant differences between the groups studied. There was a significant positive correlation of fair degree between HSS and DLQI. There were significant differences in HSS between nonsmokers and smokers as well as between women of normal weight compared with obese women.

CONCLUSIONS

The modified HSS is simple and practical and it extracts important clinical information. A connection between disease severity and BMI as well as smoking habits in patients with HS is presented. The results suggest that the HSS may be a relevant outcome measure in future therapeutic trials in HS.

What causes hidradenitis suppurativa?

Hidradenitis suppurativa (HS)--a rather common, very chronic and debilitating inflammatory skin appendage disorder with a notoriously underestimated burden of disease--has long been a playground for the high priests of nomenclature: Ask a bunch of eminent dermatologists and skin pathologists to publicly share their thoughts on what causes HS, and they will soon get entrenched in a heated debate on whether this historical term is a despicable misnomer. Fortunately, the recently founded Hidradenitis Suppurativa Foundation (HSF; http://www.hs-foundation.org), to which EXP DERMATOL serves as home journal, has broken with this unproductive tradition and has encouraged publication of the current CONTROVERSIES feature. This is exclusively devoted to discussing the pathobiology of this chronic neutrophilic folliculitis of unknown origin. Although traces of terminological bickering remain visible, it does the HS experts in our virtual debate room credit that they engage in a constructive and comprehensive dissection of potential pathogenesis pathways that may culminate in the clinical picture we know under the competing terms HS or acne inversa. These experts sketch more often complementary than mutually exclusive pathogenesis scenarios, and the outlines of a conceivable consensus on the many open pathobiology questions begin to emerge in these CONTROVERSIES. Hopefully, this heralds a welcome new tradition: to get to the molecular heart of HS pathogenesis, which can only be achieved by a renaissance of solid basic HS research, as the key to developing more effective HS therapy.

Evaluation of the effects of topical clobetasol propionate by visual score, electrical impedance and laser Doppler flowmetry

BACKGROUND/PURPOSE

The intensity of steroid-induced skin blanching is usually evaluated subjectively by a trained observer using a visual score although a few methods have been described for doing this objectively. In this study we wished to establish whether the effects of topical steroids can be detected by measuring the electrical impedance of the skin.

METHODS

Ten healthy volunteers were treated with three concentrations of clobetasol propionate (0.005, 0.05, and 0.5 mg/mL) on the forearm covered by a dressing overnight. On the following morning, we assessed dermal blanching using a visual score, laser Doppler flowmetry and electrical impedance.

RESULTS

Using the visual score, we found dose-response blanching at all concentrations of clobetasol propionate. The laser Doppler flow values declined significantly after the application of clobetasol propionate (0.005 mg/mL (P<0.01) and 0.5 mg/mL (P<0.05)), as compared with the test site treated with the vehicle alone. Electrical impedance showed a significant increase in phase index after the application of 0.05 mg (P<0.01) and 0.5 mg (P<0.01) of clobetasol propionate, and a significant reduction in real part index after of 0.05 mg/mL (P<0.05) and 0.5 mg/mL (P<0.05) compared with the test site treated with the vehicle alone. The magnitude index and imaginary part index were not affected by this steroid.

CONCLUSION

Our findings indicate that the dermal blanching induced by topical corticosteroids can be evaluated with a skin impedance spectrometer.

Biophysical assessment of atopic dermatitis skin and effects of a moisturizer

BACKGROUND

The mechanisms of the skin barrier impairment in patients with atopic dermatitis (AD) are still unknown and need further studying.

OBJECTIVE

We evaluated the skin of healthy subjects and of patients having atopic dermatitis with an instrument measuring electrical impedance and other noninvasive methods (transepidermal water loss, capacitance) and studied the effects of a new emollient [Proderm (Pro-Q in the USA)].

METHODS

After a 2-week washout period, we treated clinically noneczematous skin on the forearm of 24 patients with AD and assessed the effects with the noninvasive methods. 22 healthy subjects were used as controls.

RESULTS

The findings indicate that barrier function and hydration, and certain patterns of electrical impedance of AD skin are abnormal compared with normal skin. Moreover, there was an increase in hydration in patients' skin after treatment and a reversal of certain impedance indices towards normal.

CONCLUSIONS

Our findings demonstrate that the moisturizer we used changes some biophysical parameters when applied to atopic skin. In addition, a technique based on electrical impedance seems to give valuable information in atopic skin studies, especially the effects of moisturizers.

Effect of perorally administered pivmecillinam on the normal oropharyngeal, intestinal and skin microflora

To study the ecological effects of pivmecillinam on the human oropharyngeal, intestinal and skin microflora, 15 healthy volunteers were given pivmecillinam tablets 400 mg twice daily for 7 days. Saliva, stool and skin specimens were taken before (days -3 and 0) and on the 2nd, 4th and 7th days during the administration period and 14 and 21 days after the start of administration. Mecillinam caused no major changes in the aerobic or anaerobic oropharyngeal microflora. In the aerobic intestinal microflora there was a decrease in the numbers of Escherichia coli while no changes occurred in the anaerobic microflora. In the skin microflora there was a transient decrease in the numbers of Propionibacterium spp. underneath the wing of the nose. The major effect of pivmecillinam was seen on E. coli and to some extent on Propionibacterium spp. No further ecological disturbances were noticed in the oropharyngeal, intestinal or skin microflora.

Incidence of cancer among patients with hidradenitis suppurativa

BACKGROUND

On the basis of some case reports, a relationship has been suggested between hidradenitis suppurativa (HS) and the development of nonmelanoma skin cancer.

OBJECTIVES

To confirm this relationship and to explore the risk of other cancers among patients with HS.

PATIENTS

Patients with a discharge diagnosis of HS were obtained from the computerized database of hospital discharge diagnoses from January 1, 1965, through December 31, 1997. A total of 2119 patients with HS were identified.

SETTING

All hospitals in Sweden.

DESIGN

With record linkage to the Swedish National Cancer Registry, standardized incidence ratios (SIR [the ratio of the observed to expected incidence]) were calculated to estimate relative risk.

RESULTS

The risk of developing any cancer in the cohort with HS increased 50% (95% confidence interval of SIR, 1.1-1.8, based on 73 observed cases). Statistically significant risk elevations were observed for nonmelanoma skin cancer (5 cases; SIR, 4.6; 95% confidence interval, 1.5-10.7), buccal cancer (5 cases; SIR, 5.5; 95% confidence interval, 1.8-12.9), and primary liver cancer (3 cases; SIR, 10.0; 95% confidence interval, 2.1-29.2).

CONCLUSIONS

This study confirms an increased risk of nonmelanoma skin cancer among patients with HS. The risk for buccal cancer and primary liver cancer was also elevated among this cohort, but these associations should be interpreted cautiously because the combination of multiple significance testing and the few observed cases may have generated chance findings.

Neutrophil-related host response in hidradenitis suppurativa: a pilot study in patients with inactive disease

Host-defence defects in hidradenitis suppurativa patients have been suspected, but not proven. Activated neutrophils can destroy the surrounding tissues by a release of reactive oxygen species and active proteases. Peripheral neutrophils from 15 female patients (mean age 46, range 27-57 years) in an inactive state of their hidradenitis suppurativa, were studied and compared with 15 age-matched healthy female controls. There were no significant differences between patients and controls in the assessments of intracellular elastase activity, total content of antigenic elastase or release of elastase. Furthermore, no differences were found in total content and membrane expression of the receptors measured. The generation of free oxygen radicals, after stimulation with the protein kinase C activator phorbol myristate acetate, was significantly higher in the patients than in the controls, while there was no difference after Fc-receptor-mediated stimulation. Dysfunctional neutrophils might be involved in the pathogenesis of hidradenitis suppurativa, but the findings should be interpreted with caution because of the small number of observed cases.

Instrumental measurement of the Mantoux test: differential effects of tuberculin and sodium lauryl sulphate on impedance response patterns in human skin

BACKGROUND AND OBJECTIVE

The tuberculin (PPD) test is a model reaction for the cell-mediated immune system of the skin. The aim of this study is to compare the non-invasive technique based on electrical impedance for investigation of the tuberculin test with an irritant contact reaction induced by sodium lauryl sulphate, which has already been carefully evaluated using this method.

METHODS

0.1 ml of PPD (2 TU) was injected intracutaneously into the volar forearms of 20 adult healthy subjects, all known to be tuberculin sensitized. Assessments were performed 3 and 7 days after the injections, using visual scoring, a new electrical impedance technique and transepidermal water loss (TEWL).

RESULTS

In the 16 cases that completed the study, compared to relevant controls and reactions induced by sodium lauryl sulphate statistically significant changes in 3 of the 4 impedance indices were found: both the means of index MIX and index IMIX increased (p< or = 0.01) and the mean of index PIX decreased (p< or = 0.05). Furthermore, similar impedance response patterns occurred in another cell- mediated immune reaction that we have studied previously - namely, the allergic contact reaction induced by nickel sulphate. Unlike the irritant reactions, no significant increase in TEWL values in tuberculin reactions were found. This can be explained by the fact that the epidermis is little affected, since the inflammatory process in the tuberculin reaction is located more deeply in the dermis than with the irritant reaction.

CONCLUSION

The current study strongly indicates that electrical impedance in the described version, besides contact dermatitis, also seems suitable for studies of the tuberculin reaction. This will add a new indication for the technique, and studies of further clinical applications are in progress.

Do urea and sodium chloride together increase the efficacy of moisturisers for atopic dermatitis Skin? A comparative, double-blind and randomised study

Urea has long been used to treat dry skin. In the present report, we compared two creams, identical with the exception that one contained both urea and sodium chloride and the other urea alone, in 22 patients with atopic dermatitis. Following a 2-week wash-out period, their clinically non-eczematous, rough or normal-appearing skin on the forearms was treated twice daily in a double-blind and randomised manner. We examined the treated areas by measuring transepidermal water loss, capacitance and electrical impedance. Our findings suggest that a moisturiser containing both urea and sodium chloride seems somewhat more effective than the same moisturiser without sodium chloride, at least concerning the ability to reverse impedance indices of atopic skin towards normal, an effect ascribed mainly to changes in hydration of the stratum corneum. However, the clinical significance of our impedance measurements is somewhat premature to decide.

No human leukocyte antigen-A, -B or -DR association in Swedish patients with hidradenitis suppurativa

Hidradenitis suppurativa (HS) is a cicatrizing, inflammatory and recurrent disease restricted to inverse skin, such as that of the axilla and groin of younger adults. In a previous study, using serological tissue-typing techniques, no significant increases in the human leukocyte antigen (HLA)-A and -B specificities were found in patients with HS. The aim of this study was to determine the frequencies of HLA-A, -B and, for the first time, HLA-DR alleles, using genomic tissue-typing methods in patients with HS. Forty-two unrelated Swedish patients with HS were included and compared with 250 controls. According to clinical staging adopted from Hurley all of the patients had stage II HS, i.e. recurrent abscesses with tract formation and cicatrization and single or multiple widely separated lesions. No association with HLA-A, -B or -DRB1 alleles was found in patients with HS. Genetic factors associated with the HLA class I or II regions do not appear to contribute significantly to the possible genetic susceptibility of HS.

Electrical impedance of nodular basal cell carcinoma: a pilot study

BACKGROUND

Previously, we have explored the use of measurements of electrical impedance and devised 4 physically distinct indices named magnitude index (MIX), phase index, real part index and imaginary part index (IMIX) from the impedance data. Our results indicated that these indices could characterize contact reactions.

OBJECTIVE

The goal of the present study was to use the electrical impedance method for the preoperative assessment of nodular basal cell carcinoma (BCC).

METHODS

We included 11 patients with a total of 12 nodular BCC, diagnosed clinically and histologically. The noninvasive measurements were performed by transepidermal water loss (TEWL) and electrical impedance. For reference, normal looking contralateral or ipsilateral skin was used.

RESULTS

Compared to controls, the mean TEWL of BCC was increased, but this finding was not statistically significant. The electrical impedance measurements of BCC tissue revealed statistically significant changes of the impedance indices MIX and IMIX (p </=0.001).

CONCLUSION

The results suggest that the measurement of electrical impedance might become useful for investigations of BCC.

PUVA and cancer risk: the Swedish follow-up study

There is concern about the long-term carcinogenic effects of psoralen and ultraviolet A radiation (PUVA) for treatment of skin disorders. Many authors have found an increased risk for cutaneous squamous cell carcinoma (SCC). Except in anecdotal reports, malignant melanoma had not been observed in patients treated with PUVA until recently. In the U.S.A., a 16-centre prospective study of 1380 patients showed for the first time that there might also be an increased risk for malignant melanoma in patients treated with high cumulative dosages of PUVA. We have therefore followed up the Swedish PUVA cohort until 1994. This cohort had previously been followed up until 1985. Information from 4799 Swedish patients (2343 men, 2456 women) who had received PUVA between 1974 and 1985 was linked to the compulsory Swedish Cancer Registry in order to identify individuals with cancer. The average follow-up period was 15.9 years for men and 16.2 for women. We did not find any increased risk for malignant melanoma in our total cohort of 4799 patients treated with PUVA or in a subcohort comprising 1867 patients followed for 15-21 years. For cutaneous SCC there was an increase in the risk: the relative risk was 5.6 (95% confidence interval, CI 4. 4-7.1) for men and 3.6 (95% CI 2.1-5.8) for women. Significant (P < 0.05) increases were also found in the incidence of respiratory cancer in men and women and of kidney cancer in women. In conclusion, we did not find any increased risk for malignant melanoma in our patients treated with high doses of PUVA and followed up for a long time. We confirm previous reports of an increase in the incidence of cutaneous SCC in patients treated with PUVA, and recommend that patients should be carefully selected for PUVA and rigorously followed up.

Heme oxygenase inhibitors transiently increase serum ferritin concentrations without altering other acute-phase reactants in man

Sn protoporphyrin (SnPP) and Sn mesoporphyrin (SnMP), potent inhibitors of heme oxygenase (HO), significantly suppress bilirubin production, lower serum and biliary bilirubin levels and increase biliary heme output in animals and man. In this study, 20 healthy volunteers, 7 patients with primary biliary cirrhosis and 4 patients with idiopathic hemochromatosis were treated with SnPP and 4 healthy volunteers with SnMP. In all cases, serum ferritin levels increased substantially but transiently after administration of these HO inhibitors. Values returned to baseline within a few days. Infusion of hematin in 4 healthy volunteers did not significantly affect ferritin levels. No increases occurred in 7 other acute-phase reactants. The observation that these HO inhibitors transiently increase serum ferritin levels implies a link between ferritin, iron metabolism and HO activity which may be usefully explored in disorders of iron metabolism.

On assessment of skin reactivity using electrical impedance

Pathophysiological events in biological tissue are characterized by a shift in electrical impedance spectra of the tissue under study. In this paper, techniques based on electrical impedance are reviewed with emphasis on their possible role in evaluating the skin reactivity of an individual, including results from impedance measurement studies on patients with allergic contact reactions, wheals, tuberculin tests, and irritant contact reactions and on an appropriate number of controls. The results show that, compared to relevant controls, at different types of experimental cutaneous reactions, both of allergic and irritant type, statistically significant changes of the impedance parameters have been detected. Each reaction type had a specific impedance index pattern. Data up to now indicate that the improved impedance technique offers not only a noninvasive alternative for characterization and perhaps differentiation between the skin responses induced by either an allergen or an irritant, but also a capability to distinguish responses induced by chemically different irritants.

Coagulase-negative staphylococci are the most common bacteria found in cultures from the deep portions of hidradenitis suppurativa lesions, as obtained by carbon dioxide laser surgery

The significance of bacterial findings in hidradenitis suppurativa (HS) is controversial. Interpretation of the results of bacteriological examinations from the surface of HS lesions is obscured by the possible contamination of resident skin bacteria. Bacteriological analysis of aspirates from deeper parts of HS is liable to show low sensitivity. We used a carbon dioxide (CO2) laser method to evaporate the diseased tissue level by level from the surface downwards, allowing concurrent sampling of bacteriological cultures from each level and thereby minimizing contamination with bacteria from the level above. In this study, 22 women and three men with a mean age of 35.3 years and a mean HS duration of 10.6 years were treated with this CO2 laser surgical method. Aerobic and anaerobic cultures from superficial and deep levels were taken during surgery. The regions treated were axillary in eight and perineal in 17 cases. Bacterial cultures were positive for one or more specimens from at least one level in all cases and from deep levels in all but three cases. Sixteen different species or sub-species were found. Staphylococcus aureus and coagulase-negative staphylococci (CNS) were the species most frequently found. Peptostreptococcus species and Propionibacterium acnes were not uncommon. S. aureus was detected in a total of 14 cases, six of which were from the deep levels. S. aureus was the sole bacterium isolated in two deep cultures. CNS were found in 21 patients and 16 of these isolates were from the deep levels. In nine of the 16 deep samples CNS were the only bacteria detected. These findings motivate a re-evaluation of the significance of bacteria in the progress of HS and in particular they suggest that CNS are true pathogens. It is known that foreign bodies aggravate the virulence of the CNS in surgical implants, and an environment which resembles that produced by a foreign body, as found in chronic HS tissue, serves to intensify the pathogenic properties of CNS in HS.

[Despite better knowledge of pathogenesis and treatment: atopic eczema--a disease with increasing incidence in Sweden]

The past twenty years have witnessed an increasing incidence of atopic dermatitis in Western Europe. The article consists in a discussion of the pathogenesis, clinical signs and treatment of this common skin disease. Both an IgE-mediated reaction on epidermal Langerhans cells, and a physiological/biochemical defect of the skin barrier structure may be crucial factors of the multifactorial pathogenesis. Local treatment with corticosteroids and moisturisers remains the basic approach, though the development of new more specific treatments is under way. Although much remains to be learned about atopic dermatitis, today all patients can be offered effective treatment resulting in improved quality of life.

Electrical impedance for quantification and classification of experimental skin reactions

BACKGROUND

Pathophysiologic events in biological tissue are characterized by a shift of the electrical impedance spectra of the tissue under study.

OBJECTIVE

To discuss studies on experimental skin reactions with an improved impedance spectrometer. The instrumentation is related to noninvasive techniques based on other physical principles.

METHODS

The results from studies on patients with allergic contact reactions (n = 8), prick tests (n = 10), and irritant contact reactions (benzalkonium chloride [n = 14], sodium lauryl sulfate [n = 12], and nonanoic acid [n = 14]), and an appropriate number of controls are reviewed.

RESULTS

Results show statistically significant changes of the impedance parameters when compared with relevant controls, at different types of experimental cutaneous reactions, both allergic and irritant type. Each reaction type had a specific impedance index pattern.

CONCLUSIONS

Current data indicate that the improved impedance technique offers a possible noninvasive alternative for characterization and perhaps differentiation, not only between the skin responses induced by either an allergen or an irritant, but also a capability to distinguish responses induced by chemically different irritants. The assumption that the impedance method is capable to distinguish allergic from irritant contact reactions has not been proven yet in direct comparative studies.

Information in full and reduced data sets of electrical impedance spectra from various skin conditions, compared using a holographic neural network

Information relating to patho-physiological events in living tissues, including skin, should be found in the beta-dispersion frequency range of the electrical impedance. For intact skin, the alpha-dispersion is strongly influenced by the condition of the stratum corneum, particularly its hydration. For intact skin, these dispersions are not well separated: in a Nyquist plot, most of the relatively small beta-dispersion will be hidden behind the upper-frequency end of the alpha-dispersion arc. In the study, information obtained with a set of four indices, claimed to extract most of the information in the pertinent frequency interval, is compared with the full information measured at 31 frequencies, between 1 kHz and 1 MHz, for irritant and allergic contact reactions and nodular basal cell carcinomas, using a holographic neural network that appears to be useful for model-independent evaluation of the consequences of data-reduction procedures. Cole parameters should be avoided in the beta-range for intact skin. The indices are well supported, as long as differences from a reference site are used, and it seems that they can serve as the basis for differential diagnostics even as absolute values, although more information may be extracted from the complete spectrum.

Direct and sequential switching from mu to epsilon in patients with Schistosoma mansoni infection and atopic dermatitis

Immunoglobulin isotype switching to IgE in patients infected with Schistosoma mansoni and patients with atopic dermatitis was studied. Patients with parasitic infections or allergic diseases have a higher production of IgE. We found a four-fold increased production of I epsilon RNA in both patient groups as compared to control donors. The increased expression of germ-line transcripts correlates with higher serum IgE levels. Nested primer polymerase chain reaction was used to generate S mu/S epsilon fragments from DNA of patient peripheral blood mononuclear cells. Twenty-nine out of fourty sequenced switch fragments had undergone direct joining from S mu to S epsilon whereas seven fragments showed mono sequential switching from S mu via either S mu, S gamma2, S gamma4 or S epsilon to S epsilon and four fragments demonstrated double sequential switch: S mu/S mu/S gamma1/S epsilon, S mu/S gamma2/S epsilon/S epsilon or S mu/S gamma1/ S gamma2/S epsilon. The sequential switching had occurred either via deletions or inversions. Mapping of the breakpoints showed hot spots for recombination within S mu, S gamma1 and S epsilon. To our knowledge, this is the first in vivo study in humans demonstrating that switching to IgE can occur from sequential rearrangements via gamma1, gamma2 or gamma4.

An electrical impedance technique for assessment of wheals

In previous studies of the electrical impedance of the skin, we introduced a set of physical indices which could be used to distinguish between the cutaneous effects produced by different irritants and allergic contact reactions. In this study, wheals were induced in 10 allergic patients by performing prick tests on the forearm with the relevant allergen and histamine, respectively. Normal skin was used for control. The wheals were evaluated by visual scoring, laser Doppler, and electrical impedance. As expected, there was a close agreement between the visual and laser Doppler readings. Compared to the controls, there were significant changes in the electrical impedance of the wheals, especially in the index related to the phase angle. The changes in the indices were found to follow a particular pattern, which diverged from those obtained in contact skin reactions of both allergic and irritant type. Our results indicate that, by the application of the impedance technique, it will be possible to characterize objectively and quantify the wheal reaction. The results also suggest that cutaneous reactions of completely different causes, such as allergic skin reactions of the late and immediate type, and irritant contact reactions, may be distinguished on the basis of their effects on the electrical impedance of the skin.

Successful treatment for acrodermatitis continua of Hallopeau using topical calcipotriol

We report a 71-year-old woman who had severe inflammatory acrodermatitis continua of Hallopeau. The administration of local remedies, soft X-rays and a number of systemic treatments resulted only in transient and incomplete resolution of the lesions. The pustules, increased skin fragility, tender oedema and erythema were successfully controlled by the local administration of calcipotriol.

On T-cell recognition of nickel as a hapten

T-cells recognize antigens as peptides associated with self-molecules encoded by genes of the HLA region. In patients with contact allergy to nickel, T-cells that are specific for non-peptide haptens have been described. Previously, we have isolated HLA class II-restricted nickel-specific T-cell clones from patients with nickel sensitivity. In this paper, data on the fine specificity of a nickel-specific HLA-DR4-restricted clone have been reevaluated. Genomic tissue typing employing polymerase chain reaction and sequence-specific primers were used. Nickel was presented to the T-cell clone by all three subtypes of HLA-DR4 included in our panel. Two different DRB4*0404-positive cells presented nickel, whereas only 3 of the 7 DRB1*0401-positive and one of the 3 DRB1*0408-positive cells restimulated the T-cell clone. These findings are compatible with the notion that nickel interacts with endogenous peptides in the antigen-presenting groove of the HLA molecule, thereby changing these peptides' antigenicity rather than their ability to bind to the HLA molecule. Variations of the endogenous peptide in the antigen-presenting groove as well as differences of the HLA molecules give the DR4 specificity of the nickel-specific clone MCE2.

Multiple basal cell carcinomas: no association with HLA-DRB, HLA-DQA1 or HLA-DQB1 in Swedish patients

Many diseases with autoimmune features are associated with alleles of the human leucocyte antigen (HLA). However, few if any malignant disorders have reproducibly been shown to be HLA-associated. In three independent studies, using serological tissue typing techniques, an increase of the HLA class II specificity DR1 has been found in patients with multiple basal cell carcinomas. These observations prompted us to determine the frequencies of DRB1, DQA1, and DQB1 alleles by high-resolution genomic tissue-typing methods, including subdivision of the serological DR1 specificity in the four sequence-defined alleles, DRB1*0101 to DRB1*0104, in 50 unrelated Swedish patients with a history of four or more basal cell carcinomas and 250 healthy controls. The frequency of DR1 was the same in patients and controls (18%). All DR1-positive patients and controls carried the DQA1*0101 and DQB1*0501 alleles. Six of the nine DR1-positive patients and controls carried the DQA1*0101 and DQB1*0501 allels. Six of the nine DR1-positive patients were DRB1*0101-positive, one DRB1*0102 and two carried the DRB1*0103 allele. This distribution of DRB1*01 alleles did not differ from the one found in the controls. We conclude that genetic factors associated with the HLA class II region do not contribute significantly to the aetiology of multiple basal cell carcinomas.

Correlation of impedance response patterns to histological findings in irritant skin reactions induced by various surfactants

We have explored the use of measurements of electrical impedance to discriminate between the effects of different irritant substances upon the skin, and have studied the relationships between impedance and histopathological change. Three compounds with different chemical profiles were tested on volunteers: sodium lauryl sulphate, benzalkonium chloride and nonanoic acid. The concentrations selected were such that each irritant produced responses of a similar order, as judged by visual scores. The magnitude and phase of electrical impedance were measured and, for comparison, also the transepidermal water loss. Four physically distinct aspects (indices) were devised from the impedance data, and the values obtained were statistically analysed. The three irritants produced different effects, giving distinctive impedance patterns. These were also found to be reflected by three different types of histopathological skin response. Our results suggest that the indices can be used to classify irritant contact reactions, which it is difficult or impossible to achieve by other non-invasive techniques.

Mucocutaneous manifestations in 22 consecutive cases of primary HIV-1 infection

Twenty-two consecutive patients presenting with symptomatic human immunodeficiency virus 1 (HIV-1) seroconversion were studied. Most of the patients had a glandular fever-like illness. All patients had fever and pharyngitis, and eight of them also suffered from ulcers of the oral, genital or anal mucosa. Uniform skin eruptions were observed in 17 of the 22 patients. The exanthem consisted of varying numbers of macular or maculopapular lesions that were oval or rounded in shape, ranging from a few millimetres to 1 cm in diameter. The lesions were distributed on the upper thorax in all cases, and were particularly profuse in the collar region. The face, forehead and scalp were involved in most cases, but the eruption was sparse or absent at the periphery of the extremities. In the majority of patients, the exanthem appeared after 2 or 3 days of fever. The exanthem developed during the first day, persisted for 5-8 days, and then cleared concurrently with the general recovery of the patients. Histopathological studies of skin punch biopsy specimens from four patients showed a sparse lymphocytic cell infiltrate distributed around vessels of the dermal superficial plexus. The infiltrates predominantly consisted of equally represented T-helper/inducer and T-suppressor/cytotoxic cells. A vacuolar aberration of basal layer cells was found in two of the four cases studied histologically. The microscopic findings correspond to the histopathological patterns seen in toxicodermia and in the interface dermatitis of morbilliform viral exanthems. The exanthem is a frequent and characteristic sign of primary HIV infection, which is further indicated if mucosal ulcers are present.

Electrical impedance measured to five skin depths in mild irritant dermatitis induced by sodium lauryl sulphate

The non-invasive electrical impedance technique used in this study reflects structural changes in a tissue, and provides an estimate of the level of oedema by a simple impedance index. Sodium lauryl sulphate (SLS), dissolved in water at concentrations of 0.1, 0.5 and 2.0%, was applied for 24 h in 12 mm Finn chambers on both volar forearms of 12 healthy volunteers. An unoccluded area was used as a reference site. Readings from all sites were taken before the application of the irritant, and 24 h after its removal. After the last reading, a 3-mm punch biopsy was taken from each test site for histological examination. The results obtained from electrical impedance measurements at five different skin depths were correlated with those obtained from histological examination, visual scoring and transepidermal water loss (TEWL). For all of the methods used the responses were proportional to the concentration of the irritant. Statistically significant changes of electrical impedance were found for all depths and concentrations, except for 0.1% SLS at the most superficial depth. The histological changes were focused in the epidermis, and mainly consisted of oedema. Alterations in the thickness of the epidermis due to oedema were used as a quantitative parameter for correlation with the assessment of irritation using the electrical impedance technique. For the detection of irritant reactions, TEWL and electrical impedance are more sensitive than visual scoring, and selection of the optimum depth penetration further increases the sensitivity of the electrical impedance measurement.

Photochemotherapy of oral lichen planus. A controlled study

Photochemotherapy with 8-methoxypsoralen and long-wave ultraviolet light (PUVA) has become a useful alternative in dermatologic therapy. PUVA therapy has been successfully used in the treatment of severe psoriasis and cutaneous lichen planus. The aim of this investigation was to use PUVA in the treatment of oral lichen planus (OLP). Eighteen patients with long-standing, bilateral, and severe OLP of the buccal mucosa participated in the investigation. A dose of 0.6 mg/kg 8-methoxypsoralen was administered orally 2 hours before long-wave ultraviolet light irradiation was done. The patients were randomly assigned to treatment of the left or right side of the buccal mucosa. The irradiation therapy was given 12 times at intervals of 2 to 3 days, and the patients received a total average dosage of 16.5 J/cm2. The results showed that 13 treated sites compared with six control sites responded significantly favorable to PUVA therapy. Two patients dropped out because of side effects that were similar to those seen after whole-body irradiation PUVA treatment. The follow up times was 12 months. The conclusion of this study is that PUVA seems to be effective in the treatment of OLP and should be considered in severe cases of OLP.

Surgical treatment of chronic hidradenitis suppurativa: CO2 laser stripping-secondary intention technique

The objective of our study was to evaluate a surgical method of management of patients with hidradenitis suppurativa (HS), using a CO2 laser technique for stepwise horizontal vaporization and peroperative monitoring of the removal of diseased tissue. Twenty-four patients were selected for treatment, 21 women and three men, who had suffered from HS for a mean of 13 years (range 1-28 years) and experienced more than three recurrences of suppurating lesions during the year prior to entering the study. The mean follow-up time after CO2 laser surgery was 27 months (range 15-47 months), with clinical follow-up once or twice a week during the wound-healing period, and then at intervals of 1-3 months to evaluate recurrences and assess the end result. The patients' healing time was approximately 4 weeks (range 3-5 weeks). During the follow-up period two patients had recurrences in the treated areas. Twenty-two patients had no recurrences in the treated areas, but in four cases de novo suppurating lesions appeared 5-10 cm beyond the initial sites of surgery. Ten patients had exacerbations of HS lesion(s) in a region other than the treated site. Eight patients did not have any recurrences. Post-surgery results were satisfactory both cosmetically and with regard to quality of life. The CO2 laser stripping-secondary intention technique is a rapid, efficient, and economical method for the treatment of HS. It allows simple treatment of early lesions which would otherwise have been treated using less effective local conservative remedies.

Electrical impedance compared with other non-invasive bioengineering techniques and visual scoring for detection of irritation in human skin

A new, non-invasive device, which enables local measurements of electrical impedance to a controlled depth, has been used to evaluate the degree of irritation in human skin. The results have been compared with those obtained using other non-invasive techniques, i.e. with transepidermal water loss (TEWL), electrical capacitance moist measurement (ECM), laser-Doppler flowmetry (LDF), and visual scoring. Sodium lauryl sulphate solutions (0.1-5.0%), and a blank, were applied in Finn Chambers for 24 h on the volar forearm of 10 healthy volunteers. Values were recorded before application of the test chambers, and at 1 h, 24 h, 1 week and 2 weeks after removal. Thus, both the degree of initial damage and the healing process were monitored. There was close agreement among values obtained using electrical impedance, TEWL and visual readings. Results obtained using ECM and LDF were not consistent with the other three methods. In evaluating irritation of the skin, the practical situation may influence the choice of bioengineering tools. In most circumstances, a combination of methods would be preferable.

Angiokeratomas in Fabry's disease and Fordyce's disease: successful treatment with copper vapour laser

Two patients with multiple angiokeratomas on genitalia and thighs, one with Fabry's disease and one with Fordyce's disease, were treated with copper vapour laser light of 578 nm wavelength. The result was desirable, with destruction and disappearance of the lesions and minimal scarring and posttreatment hyper- or hypopigmentation.

Roxithromycin compared to doxycycline in the treatment of genital chlamydial infection and non-specific urethritis

A single-blind randomized follow-up study was conducted to evaluate the efficacy and tolerance of roxithromycin 300 mg once a day compared to doxycycline 200 mg day 1 and 100 mg day 2-10 in the treatment of genital chlamydial infection in men and women and non-specific urethritis (NSU) in men. A total of 211 patients (200 men and 11 women) between 18 and 46 years were enrolled. The women were excluded from the efficacy analysis because of the low number, but were included in the tolerance analysis. The clinical (clearance of polymorphonuclear leucocytes in urethral smears) and bacteriological response was evaluated one and 11 days after the treatment. Of 113 included men with chlamydial infection, 105 (93%) and 96 (85%) were evaluable on respective follow-up visits and of 87 included men with NSU, 74 (85%) and 64 (74%) were evaluable one and 11 days after treatment, respectively. The bacteriological eradication rate immediately after the treatment in chlamydia positive patients was 92.7% and 100% for roxithromycin and doxycycline, respectively, and 91.8% and 100% at follow-up. The clinical cure rate of all evaluable patients was 83.1% and 80.7% for roxithromycin and doxycycline, respectively, one day after the treatment and 80.5% and 85.3% for the two drugs, respectively, 11 days after treatment. None of these observed differences was statistically significant. The diagnosis did not influence the clinical response rate with either drug. Probable and possible drug-related side-effects were more common after doxycycline than after roxithromycin, 35% and 19% respectively (P = 0.0032).(ABSTRACT TRUNCATED AT 250 WORDS)