Livedoid vasculopathy: thrombotic or inflammatory disease?

The pathogenesis of livedoid vasculopathy (LV) is still unclear. However, with increasing knowledge of disorders of coagulation over the past few years, the cause of some cases of LV has been elucidated. LV has now been described in association with hyperhomocysteinaemia, activated protein C resistance, and prothombin gene mutations in the absence of significant underlying inflammatory disease. When LV is seen in association with systemic lupus erythematosus or polyarteritis nodosa, it is probably due to the pro‐coagulable state induced by these diseases rather than being true vasculitis. We review recent insights into LV provided by published clinical cases and discuss its pathogenesis.     

Hidradenitis suppurativa and inflammatory bowel disease: are they associated? Results of a pilot study

Background  The co-occurrence of hidradenitis suppurativa (HS) and Crohn disease (CD) published in a few case reports resulted in the wide acceptance of an association between these two diseases. However, the combined prevalence of these diseases is currently unknown; furthermore, it is unknown whether this co-occurrence also applies for ulcerative colitis (UC).
Objectives  To estimate the prevalence of HS in patients with inflammatory bowel disease (IBD) living in the Southwest of the Netherlands.
Methods  During an IBD patient information meeting, randomly, 158 patients with IBD were interviewed about recurrent painful boils in the axillae and/or groin and were shown illustrative clinical pictures of the appearance of HS.
Results  Of the 158 patients interviewed, 102 (65%) had CD and 56 (35%) had UC. Twenty-five people (16%) responded that they had had or still experienced painful boils in the axillae and/or groin, of whom 17 were patients with CD (17%) and eight had UC (14%).
Conclusions  This pilot study shows for the first time that HS occurs in patients with CD or UC. More prospective studies are warranted to establish the association between HS and IBD and its underlying pathogenesis.     

How well is pelvic inflammatory disease managed in general practice? A postal questionnaire survey

OBJECTIVE: Many patients with pelvic inflammatory disease (PID) present to their general practitioners. Chlamydia trachomatis is the organism most commonly implicated in this condition. This study aims to examine how well PID is managed in the primary care setting and highlight areas for improvement. METHODS: The study was performed by sending postal questionnaires to 180 randomly selected general practitioners in Birmingham. Given the example of a woman presenting clinically with PID, the doctors were asked questions on diagnosis and treatment. To assess factors that may influence the answers, they were also asked about their sex, year of qualification, and postgraduate training. RESULTS: 139 questionnaires (77%) were returned. 91.4% of the respondents feel confident in managing patients with PID, and only 9.3% would usually refer these patients on. However, 54.7% do not perform an endocervical swab for C trachomatis, 37.4% do not include anti-chlamydial antibiotics in their treatment regimen, and 24.5% do not advise sexual partners to be screened. Female doctors, those with higher degrees, or obstetrics and gynaecology experience were more likely to give anti-chlamydial therapy, but no factors of the respondents significantly influenced contact tracing behaviour. CONCLUSIONS: The management of a patient presenting with PID should include investigation for C trachomatis and treatment with an appropriate antibiotic. As PID is often a sexually transmitted disease, contact tracing of sexual partners should be undertaken. The study suggests that a significant proportion of general practitioners would not have offered optimal management to patients with PID.     

Corticosteroids for herpes zoster: what do they accomplish?

For some patients, herpes zoster infections not only result in acute pain but serious consequences, including postherpetic neuralgia and damage to ocular tissues. Some authors have recommended corticosteroids for the treatment of these acute symptoms and complications. The literature concerning the use of corticosteroids for herpes zoster, however, either provides conflicting results or includes recommendations based on clinical experience rather than clinical trials. The author performed a search of the literature to address the question of whether corticosteroids are well tolerated and effective for the treatment/prevention of the acute pain of herpes zoster, postherpetic neuralgia, and/or the ocular complications resulting from herpes zoster. While smaller trials found oral corticosteroids beneficial for preventing postherpetic neuralgia, larger, better designed trials have not found oral corticosteroids to be more efficacious than placebo in preventing postherpetic neuralgia. Trials investigating the effect of oral corticosteroids for the acute pain of herpes zoster have found that corticosteroids provide a statistically significant improvement. Whether these improvements are clinically significant is uncertain. Thus, oral corticosteroids may confer a slight benefit for initial symptoms as long as the patient is not at risk for complications resulting from corticosteroid therapy. Most trials of topical and injectable corticosteroids are limited by several shortcomings. Therefore, topical and most forms of parenteral corticosteroids have yet to be proven effective for the treatment of acute pain or prevention of complications. Two controlled, blinded trials investigating the use of intrathecal corticosteroid administration for intractable postherpetic neuralgia suggest that corticosteroid administration results in a significant improvement in pain. Despite this, several authors have voiced concern over possible serious adverse events with the intrathecal administration of corticosteroids. Intrathecal corticosteroids may provide a benefit for intractable postherpetic neuralgia, but because of risks of serious complications, this is a last-line option and should only be administered by experienced personnel.     

Multiple primary melanomas: do they look the same?

Background  A series of studies has investigated epidemiological, clinical and genetic characteristics of patients with multiple primary melanoma (MPM). However, comparison of the clinical and dermoscopic features of MPM within a given individual has been described only in case reports. Objectives  To describe the dermoscopic features of MPM for each given patient, and to evaluate the characteristics eventually associated with similar or dissimilar appearance. Methods  From the databases of three skin‐lesion clinics in the U.S.A., Italy and Spain we collected the dermoscopic images of melanomas in patients diagnosed with MPM. Results  Among 58 patients with MPM, we found that 53% of patients had dermoscopically similar melanomas and 47% of patients had dermoscopically different melanomas. In older patients 59% of melanomas were dermoscopically similar vs. 47% in younger patients (P = 0·377). Similar thickness was associated with the occurrence of dermoscopically similar melanomas (19/30 cases, 63%; P = 0·039). Most (65%) of the synchronous lesions were similar, compared with 36% of nonsynchronous lesions (P = 0·029), and most (69%) of the melanomas on sun‐damaged skin were similar, vs. 37% of melanomas on nonsun‐damaged skin (P = 0·015; odds ratio 3·88, 95% confidence interval 1·11–13·98). The percentage of dermoscopically different melanomas was higher in patients with a family history of melanoma (67% vs. 48%). Conclusions  MPMs in a given patient have almost the same chance of looking dermoscopically similar or different. However, a subset of elderly patients with sun‐damaged skin may present multiple, similar, thin melanomas characterized by pigment‐network and regression structures.     

Chemotherapy and biologic therapies for melanoma: do they work?

The incidence of melanoma is increasing, and the therapeutic options for unresectable disease are limited, resulting in an increase in the death rate. Melanoma is usually resistant to standard chemotherapy, and the response rate for any single agent or combination of agents is 15% to 25%. High-dose interleukin-2 results in prolonged responses in a minority of patients, and biochemotherapy (combinations of chemotherapy, interferon, and interleukin-2) is associated with an improved response rate, but no clear effect on overall survival. A number of promising new agents have entered clinical trials in recent years, including monoclonal antibodies and small molecule inhibitors that target either the malignant melanocytes or negative regulators of the immune system. These drugs appear to benefit subsets of patients, and identification of predictors of response is the subject of intense research. This contribution summarizes the risks and benefits of older regimens and discusses the newer, targeted therapies.     

Occupational dermatitis in hairdressers: do they claim workers' compensation?

Background. Hairdressers are one of the largest occupational groups attending our Occupational Dermatology Clinic. However, few seek workers' compensation for their occupational dermatitis. Objectives. To retrospectively analyse and compare workers' compensation claims data and diagnosed disease data for occupational contact dermatitis in hairdressers from 1993 to 2009, for the state of Victoria, Australia. Patients/materials/methods. Data from the Occupational Dermatology Clinic database, the Compensation Research Database and the Australian Bureau of Statistics were used in this study. Results. The clinic database identified 157 hairdressers and apprentices with a confirmed diagnosis of occupational contact dermatitis assessed between 1993 and 2009. Forty‐six unique claims for occupational contact dermatitis from 46 individuals were identified from the Compensation Research Database over the same time period. Hairdressers in the 15–24‐year age group were significantly over‐represented in the claims data relative to the diagnosed disease data (p < 0.01). The median cost per claim was AU$1421, and the median time off work per claim was 20 days. Conclusion. Increased efforts are needed to reduce the incidence of occupational contact dermatitis in hairdressers in Australia, and to ensure that hairdressers with occupational contact dermatitis are aware of their compensation entitlements. Reliance on workers' compensation data for disease surveillance may lead occupational health and safety regulators to underestimate the magnitude of the problem of occupational contact dermatitis in the hairdressing profession.     

999 abuse: do mothers know what they are using?

Many parents purchase topical applications without knowing what they contain, and apply them liberally to their children with dermatological disorders. In one such case, an infant developed fever, diarrhea and a small ulcer near the right labia majora which was treated with a topical cream called '999' containing dexamethasone acetate. The infant subsequently developed extensive necrotizing fasciitis. She required prolonged intravenous antibiotic use and underwent multiple surgical procedures for debridement and reconstruction. Another mother was concerned about therapeutic corticosteroids prescribed to her 11-year old daughter with eczema. She acquired the 999 cream from the Chinese mainland and applied it liberally as an emollient to her daughter's back. When assessed at the clinic, her daughter appeared cushingoid with accelerated growth velocity in BMI and weight but decelerated growth in height. Furthermore, one mother applied a large quantity of 999 on her daughter with mild eczema and another mother applied it on her son with impetigo. None of these mothers knew that they were using potent topical corticosteroids. This report serves to alert the public to avoid applying unknown topical medication on children with skin diseases. The physician caring for patients with skin disease should be aware that even steroidophobic parents might indeed be unknowingly using potent corticosteroids.     

Connections between nerve endings and epidermal cells: are they synapses?

Abstract: Based on electron microscopy and confocal scanning microscopy, contacts between sensory axons and the cells of the epidermis have been described: with keratinocytes, Langerhans cells, melanocytes and Merkel cells. We would like to initiate a debate on this question: “Are neuro‐epidermal connections synapses?”. Anatomically, neuro‐epidermal junctions can be considered as synapses in our opinion. If neuro‐epidermal junctions are synapses, they probably belong to the family of en passant synapses, with nerve endings passing along epidermal cells and occasionally connecting to them. In conclusion, we suggest that neuro‐epidermal junctions could be considered as true synapses, but this does not exclude non synaptic interactions.