Reactivity to autologous serum skin test and relationship with complement levels in chronic idiopathic urticaria and angio-oedema

BACKGROUND

A role for complement in autoantibody-mediated histamine release in urticaria has been suggested but not proven in vivo. Aim. To study serum complement levels in patients with chronic idiopathic urticaria (CIU) and to determine whether there was a relationship with autologous serum skin test (ASST) reactivity.

METHODS

We recruited 35 patients with CIU. Complement (C3, C4) levels and ASST were measured in all patients; additional investigations were undertaken dependent on history and examination.

RESULTS

Complement concentrations were outside the population reference intervals in 19/35 patients, with low C3 noted in 3/35 and low C4 in 18/35. Of 12 patients with a positive ASST, 7 had low complement levels, and 12/23 with a negative ASST had low complement levels. Patients with a positive ASST had a median C3 of 1.24 g/L (range 0.35-1.51) compared with a median of 1.25 g/L in those with a negative ASST (P = 0.36), and a median C4 of 0.20 g/L (range 0.185-0.452) in those with a positive ASST compared with 0.18 g/L in those with a negative ASST (P = 0.88).

CONCLUSIONS

We conclude that both a reduction in C4 and positive ASST are common in CIU and although these immunological abnormalities often coexist, there is no clear relationship between them. Other components of the complement system may be worth exploring.

Laboratory measurements of the volatilization of PCBs from amended dredged material

Since 1997, over 6 million cubic meters of material dredged from the navigation channels of NY/NJ Harbor has been amended with Portland cement and then used as fill and capping material at landfill and brownfield sites in New Jersey, New York, and Pennsylvania. Previous studies have determined that polychlorinated biphenyls (PCBs) will volatilize from this material as it dries. In the present study, time constants for the decay of the volatilization rate were determined taking into account the degree of stabilization. The experiments were conducted in a laminar flow flux chamber in which air was drawn past the dredged material and then through a polyurethane foam (PUF), sample matrix. The concentration of PCBs on the PUF found at various time increments at the downstream end of the chamber was compared to that found for the same time increments in a PUF installed in an air sampler at the upstream end of the chamber in order to calculate the flux. The time constant determined for raw dredged material was about 4 times greater than material stabilized with 8% Portland cement. The average time constants for the decay of flux rates from raw dredged material were 56, 67, and 60h for the di-, tri-, and tetra-chlorinated homologues, respectively. These times decreased with increasing proportion of Portland cement in the mixture. When stabilized with 8% Portland cement, the average time constants were 14, 13, and 19h, respectively. The effects of temperature on PCB flux rate were also investigated. The results suggest that a 3 degrees C temperature increase will more than double the flux rate.

Management of basal cell carcinoma by surveyed dermatologists in Scotland

BACKGROUND

The British Association of Dermatologists (BAD) has produced guidelines for management of basal cell carcinoma (BCC) in the UK.

OBJECTIVES

Our primary objectives were to assess the management of BCCs in Scotland and to compare it with BAD guidelines. Our secondary objectives were to audit waiting times and referral patterns.

METHODS

In phase I of the audit, dermatologists in 14 centres across Scotland prospectively registered demographic and clinical data of all lesions suspected to be BCCs over a 6-week period between October and December 2000. In phase II, details of management of these lesions were evaluated by case note review.

RESULTS

Of the 48 consultant dermatologists contacted, 42 took part in the survey. There were 524 clinically suspected BCCs seen in 470 patients; 164 lesions in 146 patients showed pathology other than BCC and were excluded from analysis, thus leaving 360 lesions available for analysis. There was wide variation in waiting times among Scottish dermatology centres. BCCs were equally distributed between the sexes, and lesions most commonly presented in those aged 71-80 years. A diagnostic biopsy was taken in 22% of lesions, and the rest were treated definitively after a clinical diagnosis of BCC, of which 90% were confirmed on histology. Nodulocystic lesions were the most common type of tumour, comprising 48% of lesions, and most BCCs were located on the head and neck region. Correlation of the histological type of BCC and treatment received showed that nodulocystic and morpheic BCCs were managed as recommended. There were more superficial BCCs treated with surgical excision than expected (22 of 34 lesions). Four of 21 recurrent tumours and 9 of 81 tumours on high-risk areas of the face were managed with curettage and cautery or cryotherapy, rather than surgical excision. Of the 297 excised tumours, 25 (9%) were incompletely excised. All the high-risk tumours and incompletely excised tumours were offered follow-up in the dermatology clinics.

CONCLUSIONS

In general, BCCs are managed according to BAD guidelines in Scotland, but waiting times vary considerably.

Pyoderma gangrenosum associated with hidradenitis suppurativa

Pyoderma gangrenosum (PG) is associated with a number of systemic diseases. PG in association with hidradenitis suppurativa (HS) has been rarely reported. We describe six patients (three men, three women; aged 35--51 years), who developed PG on a background of HS. The onset of PG occurred only after HS had been present for at least two decades. No relationship in disease activity between the two conditions was observed. Three patients described previous severe adolescent acne vulgaris, one had concurrent systemic lupus erythematosus and another had chronic iron-deficiency anaemia. The course of PG was severe and refractory in four patients, who required treatment including high-dose oral corticosteroids, ciclosporin, intravenous immunoglobulin and intravenous cyclophosphamide.

Effect of high-dose intravenous immunoglobulin in delayed pressure urticaria

BACKGROUND

Delayed pressure urticaria (DPU) is difficult to treat. High-dose intravenous immunoglobulin (IVIG) has been found to be effective in treating patients with autoimmune chronic urticaria.

OBJECTIVES

To report the effect of IVIG on eight patients with severe unremitting DPU.

METHODS

IVIG was administered at a dose of 2 g kg-1 over 2-3 days on an in-patient basis. The response to treatment was assessed subjectively and recorded as remission, improved or unchanged. An autologous serum skin test (ASST) was performed in seven patients.

RESULTS

Three of eight patients achieved remission; two after one infusion and one after three infusions. Two patients improved. Three patients remained unchanged; of these, two declined further treatment after two infusions, and one failed to improve after six infusions at monthly intervals. Four of seven patients had positive ASST; three responded to IVIG. Two developed delayed positive ASST; both responded to IVIG. Of three patients with negative ASST, two responded.

CONCLUSIONS

IVIG induced remission or improved symptoms in five of eight patients with DPU with severe unremitting disease who had failed to respond to other therapies or were controlled only with systemic corticosteroids. Those who responded did so with three or fewer infusions. ASST is not a reliable predictor of response to IVIG.

Allergic contact dermatitis in venous leg ulcer patients

Our aim was to determine the frequency and nature of contact sensitivity in venous leg ulcer patients in Lanarkshire. We performed patch testing with the European standard series, antimicrobials and medicaments on 200 patients referred to our leg ulcer clinics. Positive patch tests were found in 136 (68%) patients. Multiple allergies occurred in 102 (51%). The most frequent allergen groups were fragrances (30.5%), antimicrobials (19.5%), topical excipients (19.5%), rubber accelerators (13.5%) and topical corticosteroids (8%). We also found a high prevalence of positive patch tests to Intrasite gel (9.5%) and Hioxyl cream (8.5%), medicaments which are commonly used to treat leg ulcers in our area. Contact sensitivity is common in venous leg ulcer patients and has important implications for patient management. The allergens involved vary depending on local nursing practice. We suggest that all venous leg ulcer patients be patch tested with a locally relevant patch test series.

A new calcipotriol/betamethasone dipropionate formulation (Daivobet) is an effective once-daily treatment for psoriasis vulgaris

BACKGROUND

Topical corticosteroids and calcipotriol have been used separately for many years to treat psoriasis. A new combination ointment has been formulated, which contains both calcipotriol and the corticosteroid betamethasone dipropionate.

OBJECTIVE

To compare the combination ointment with betamethasone dipropionate ointment, calcipotriol ointment and ointment vehicle in patients with psoriasis vulgaris.

METHODS

1,603 patients were randomised to one of the 4 double-blind treatments used once daily for 4 weeks.

RESULTS

The mean percentage change in the PASI at the end of treatment was -71.3 (combination), -57.2 (betamethasone), -46.1 (calcipotriol) and -22.7 (vehicle). The mean difference of combination minus betamethasone was -14.2 (95% CI: -17.6 to -10.8, p < 0.001), of combination minus calcipotriol -25.3 (95% CI: -28.7 to -21.9, p < 0.001) and of combination minus vehicle -48.3 (95% CI: -53.2 to -43.4, p < 0.001). 6.0% of patients (combination) reported local adverse reactions compared to 4.9% (betamethasone), 11.4% (calcipotriol) and 13.6% (vehicle).

CONCLUSION

Calcipotriol/betamethasone dipropionate combination ointment used once daily is well tolerated and more effective than either active constituent used alone.

Erosive pustular dermatosis of the leg associated with compression bandaging and fungal infection

BACKGROUND

Erosive pustular dermatosis of the leg (EPDL) has been described in association with venous insufficiency and atrophy of the skin of the lower leg. Like erosive pustular dermatosis of the scalp, this disease has also been reported to be a non-infective condition.

OBJECTIVES

To investigate the clinicopathological features and, where possible, the aetiology of clinical EPDL.

METHODS

We identified a group of patients undergoing continuous compression bandaging for venous dermatitis of the legs and/or predominantly venous leg ulceration with clinical features described in patients with EPDL. They were investigated by skin biopsy, patch testing and microbiological tests for the presence of bacteria and fungi.

RESULTS

Twenty-four of 400 (6%) patients were noted to have pustules on the leg(s). There was laboratory evidence of fungal infection in 13 of 24 patients (54%), with complete and sustained resolution of pustules after antifungal treatment. Pustulation in the other 11 patients (46%) was unresponsive to antibiotics for confirmed bacterial infection; some improvement was seen with potent topical corticosteroids but full clearance was achieved only after a switch from continuous four-layer compression bandaging to the use of intermittent long stretch compression.

CONCLUSIONS

EPDL is a fairly common clinical picture seen in patients undergoing continuous compression bandaging. It may be produced by opportunistic, particularly fungal, infection. In almost half an infective aetiology cannot be demonstrated and a pyoderma gangrenosum-like process may be implicated.

A new calcipotriol/betamethasone formulation with rapid onset of action was superior to monotherapy with betamethasone dipropionate or calcipotriol in psoriasis vulgaris

In this study, we compared a new combination ointment containing both calcipotriol and betamethasone dipropionate with betamethasone dipropionate ointment (Diprosone) and calcipotriol ointment (Daivonex) in patients with psoriasis vulgaris; 1106 patients were randomized to twice daily double-blind treatment with combination, betamethasone dipropionate or calcipotriol for 4 weeks. Patients then received twice daily calcipotriol, unblinded, for a further 4 weeks. Mean percentage change in PASI at end of the double-blind phase was -74.4 (combination group), -61.3 (betamethasone group) and -55.3 (calcipotriol group). Mean difference (95% Cl) combination-betamethasone was -13.1 (-16.9 to -9.3, p < 0.001) and for combination-calcipotriol -19.0 (-22.8 to -15.2, p <0.001). The differences in PASI were also statistically significant after 1 week. In the double-blind phase, 8.1% of patients (combination) reported lesional/ perilesional adverse reactions compared to 4.7% (betamethasone) and 12.0% (calcipotriol). In the combination group, mean PASI at the end of the double-blind phase was 2.5, and at end of the unblinded phase 3.6, compared with 3.9 and 4.1 (betamethasone) and 4.4 and 3.7 (calcipotriol). Calcipotriol/betamethasone combination is more effective and has a more rapid onset of action than either active constituent used alone, and is well tolerated. It is safe to transfer patients from combination to calcipotriol, with maintenance of clinical effect.

Pulse oximetry: a new tool to assess patients with leg ulcers

The objective of the study was to investigate pulse oximetry as a guide to assessing patients with leg ulcers before treatment. Graduated elastic compression is the treatment of choice for uncomplicated venous leg ulcers, but is contra-indicated in patients with significant arterial disease. The standard assessment of arterial insufficiency by Doppler ultrasound ankle branchial pressure index (ABPI) has shortcomings which prompted this investigation of pulse oximetry as a possible additional, or alternative, method of assessment of patients with leg ulcers, prior to treatment with compression. The study, carried out on a population of patients attending hospital leg ulcer clinics, was designed to evaluate pulse oximetry assessment in the selection and monitoring of patients with venous leg ulceration leading to a prospective controlled study of ulcer healing in groups of patients with reduced and normal ABPI, selected for compression therapy by pulse oximetry criteria. Outcome measurement required follow-up of patients selected for compression therapy by pulse oximetry to record time to healing and rate of healing of leg ulcers. Results from the study show a fair correlation between the toe-finger oximetry index (TFOI) and Doppler ABPI. There is no difference between ulcer healing in patients with reduced and normal ABPI selected for treatment on the basis of pulse oximetry maximum compression pressure (MCP). In conclusion, pulse oximetry is an aid to the selection of patients who will benefit from compression therapy, but would be excluded on the basis of Doppler ABPI.

Long-term efficacy and safety of cyclosporin in severe adult atopic dermatitis

A prospective, open, multicentre study was performed to investigate the efficacy and safety of long-term treatment with cyclosporin in adults with severe atopic dermatitis. Subjects were treated for a maximum of 48 weeks. For the first 8 weeks, cyclosporin was administered at 2.5 mg/kg per day. The dose was then adjusted according to response. Disease activity was monitored using the six-area, six-sign score and the proportion of skin involved. Pruritus and sleep disturbance were assessed using four-point scales. Response was further evaluated on a five-point scale. Adverse events, blood pressure and serum biochemistry were monitored. Tolerability was assessed on a five-point scale. One hundred subjects were enrolled and 65 completed 48 weeks of treatment. Withdrawals occurred due to remission (three), inadequate response (seven), protocol violations (11) and adverse events (14, of which seven were probably treatment related). Cyclosporin produced rapid and highly significant improvements in all indices of disease activity. Sixty-five subjects considered that they had shown a considerable improvement or complete clearance of disease. Most patients relapsed after cessation of treatment, but neither signs nor symptoms had returned to baseline severity 8 weeks later. Blood pressure and serum creatinine levels increased slightly, and in one subject renal impairment was a major factor contributing to withdrawal of the drug. Overall, 85 subjects rated the tolerability of cyclosporin as good or very good. The results indicate that cyclosporin has a place in the long-term treatment of severe atopic dermatitis provided that appropriate patients are selected and careful monitoring is performed.

Ionic imbalance as a source of toxicity in an estuarine effluent

A toxicity identification evaluation (TIE) was conducted on the effluent from a petrochemical plant which discharges into an estuary. The effluent had been consistently toxic to mysid shrimp (Mysidopsis bahia) but not toxic to sheepshead minnows (Cyprinodon variegatus). Phase I effluent toxicity characterization tests revealed that treatment of the effluent with a cation exchange resin (Amberlite(R) IR-120 Plus) was partially effective at reducing, but not removing, toxicity. Phase II characterization tests revealed that four cations varied with toxicity: Ca and Sn were positively correlated with increasing toxicity; Mg and K were negatively correlated with increasing toxicity. Toxicity tests with SnCl2 revealed that the toxicity threshold for Sn was far above the concentrations present in the raw effluent. Reduction of Ca was shown to result in a significant improvement in survival, but some toxicity still remained. Further augmentation of the treated effluent with CaCl2, MgCl2, and KBr to restore the concentrations of Ca, Mg, K, and Br to natural seawater concentrations resulted in survival of all exposed organisms. Repeated success of this treatment regime on additional samples of the effluent as well as "mock effluent" studies confirmed that ion imbalance was the sole source of toxicity in this effluent. Process source water composition and essential ion balance are discussed as important components of marine effluent TIEs.

Porokeratosis and Crohn's disease

We report the cases of three patients with Crohn's disease in whom porokeratosis developed. Disseminated superficial actinic porokeratosis developed in two patients. In one of these patients, the skin lesions arose during an exacerbation of the bowel disease. In the third patient, who had congenital linear porokeratosis, the disseminated superficial form of the disorder developed during the first severe exacerbation of Crohn's disease. A family history of porokeratosis was present in one patient, but no relatives of any of these patients were known to have Crohn's disease. In all three patients, Crohn's disease was limited to the colon.

Treatment of basal cell carcinoma by dermatologists in the United Kingdom. British Association of Dermatologists Audit Subcommittee and the British Society for Dermatological Surgery

Details of presentation and treatment were obtained prospectively by questionnaire for 1366 patients with basal cell carcinoma, first attending under the care of 166 consultant dermatologists in the U.K., during a 2-week period. One thousand five hundred and ninety-seven tumours were reported in these patients (median age 71 years). Most were situated on the head and neck, and their median size was 9 mm. Excision was the most common treatment used in 58% of tumours, curettage and cautery was used in 24%, cryotherapy in 8%, and radiotherapy in 8%. On average, one in four tumours were referred to other specialists for treatment (range 0-70%). Very few patients (2%) were referred to a combined dermatology/radiotherapy/plastic surgery clinic, calling into question its value and availability. There was considerable variation in practices between dermatologists, demonstrating a clear need for individual, local audit of the management of this common dermatological problem. The data collected in this study form a suitable measure with which local performance may be compared.

Guidelines for the management of chronic venous leg ulceration. Report of a multidisciplinary workshop. British Association of Dermatologists and the Research Unit of the Royal College of Physicians

This document is the product of a multidisciplinary workshop held in November 1991 between the audit subcommittee of the British Association of Dermatologists and the Research Unit of the Royal College of Physicians. Participants included dermatologists, vascular surgeons, general practitioners, community nurses and physicians involved in care of the elderly. The text is based on papers submitted to, and presented and discussed at, the workshop, and on comments received in response to subsequent wide dissemination of the proceedings to speciality associations. Participants in the workshop, and contributors to the guidelines are: Dr B. R. Allen (Nottingham), Sister S. Bainsborough (Exeter), Professor K. Burnand (London), Professor D. Burrows (Belfast), Mr M. J. Callam (Bedford), Dr G. W. Cherry (Oxford), Dr R. P. R. Dawber (Oxford), Dr W. S. Douglas (Airdrie), Dr A. Y. Finlay (Cardiff), Dr D. Gawkrodger (Sheffield), Dr D. J. Gould (Truro), Dr A. Hopkins (Royal College of Physicians, London), Dr D. McGibbon (London), Dr A. M. Middleton (London), Dr L. Millard (Nottingham), Dr L. Rhodes (Liverpool), Professor T. J. Ryan (Oxford), Dr N. B. Simpson (Newcastle), Dr F. D. Skerrett (Fowey), Dr J. M. Sowden (Nottingham), Miss L. A. Stone (London), Dr R. Williams (Rhyl). Papers presented to the workshop (copies available from the Royal College of Physicians of London): 1. Callam M. J. Epidemiology, natural history and rate of recurrence of leg ulcers. 2. Ryan T. J. Pathology of venous leg ulcers. 3. Gould D. J. Assessment of severity; process and outcomes of care. 4. Millard L. The role of infection. 5. Cherry G. Treatment of known effectiveness. 6. Burnand K. Indications for surgical treatment.

Contact dermatitis from the old formula E45 cream

In the past 4 years, a high incidence (118/362) of positive patch test reactions to E45 cream were noted in 2 patch testing clinics. 18/54 of those patch tested to all the ingredients demonstrated allergies to ingredients. The most frequent was triethanolamine; lanolin allergy occurring in only 1 patient. The remaining reactions may be explained as irritant reactions resulting from triethanolamine stearate (TES) formation within the cream. The irritancy of triethanolamine stearate was demonstrated in patients and controls. Conductivity studies showed that TES arises from the combination of the ingredients triethanolamine and stearic acid. The formulation of E45 cream was being changed at the time of writing, with the removal of triethanolamine from the product.

Transient leukaemia cutis in hairy-cell leukaemia

Leukaemic skin infiltration is uncommon in hairy-cell leukaemia (HCL), a neoplasm characterized by the presence of uniform mononuclear cells with cytoplasmic projections in the blood, bone marrow and spleen. A case is reported in which leukaemia cutis was a transient phenomenon, appearing soon after the onset of a continuous pyrexia associated with marked systemic upset which was subsequently shown to be due to pulmonary tuberculosis.

Abnormal limb regeneration in adult newts exposed to a pulsed electromagnetic field

This investigation examined two questions: 1) whether or not forelimb regeneration results in a faithful replacement of the distal skeletal pattern and 2) what effect exposure to a pulsed electromagnetic field (PEMF), the type reported to facilitate healing of human non-united bone fractures, would have on the process of limb regeneration. Of the native forelimbs, 98% (132 out 134) had a skeletal pattern that showed little difference with the only variation being the range of carpal bones (5-8). Following a 4-5 month postamputation period, the skeletal pattern of the normal regenerates was examined. While 72% (135 out of 188) of these forelimbs resembled the native group, 28% (53 out of 188) were abnormal. These abnormalities consisted of the loss of a digit, fused carpals, and long bone defects which occurred singly or in combination with one another. Exposure to a PEMF for the first 30 days postamputation, followed by a 3-4 month postamputation period, produced in addition to the normal (60%, 144 out of 240) and abnormal forelimbs (28%, 67 out of 240), a group of forelimbs with unique gross defects (12%, 28 out of 240). These defects, occurring singly or in combination, included the loss of two or more digits with associated loss of carpals, absence of the entire hand pattern, and abnormalities associated with the radius and ulna. We can offer no explanation for these observations.

Sunscreens and PUVA

Sunscreening creams have been tested for their capacity to protect non-lesional skin in patients receiving 8-methoxypsoralen photochemotherapy (PUVA). Cosmetically acceptable preparations such as Contralum Ultra and RoC Total are effective UVA sunscreens which may reduce the risk of carcinogenesis. A simple test of efficacy is described.