When fue goes wrong!

Follicular unit extraction (FUE) is an accepted method of extracting individual follicular unit grafts for hair transplant surgery. Since follicles are harvested from the back of the scalp using tiny punches resulting in minimal scarring, it has gained rapid acceptance among the patients. However, due care needs to be exercised while performing FUE. FUE should not be confused with the older plug graft extraction methods of coring out hair-bearing skin plugs. Lack of due diligence while performing such extractions can lead to subluxation of the grafts into the subdermal layer of scalp. Overtumescence of the scalp donor area, use of blunt punches and trying to "core" out the full thickness grafts can all contribute to this. The following cases illustrate some pitfalls to be avoided while performing FUE and the adverse consequences if they occur.     

Erythroderma: a comparison between HIV positive and negative patients

Background Erythroderma has protean underlying causes. There have been isolated case reports suggesting an association between erythroderma and the human immunodeficiency virus (HIV). OBJECTIVE: To describe and characterize further the prevalence, etiology, and metabolic sequelae of erythroderma in HIV positive and negative patients. In a subset of patients, clinicopathologic correlation was performed. METHOD: One hundred and thirty-eight consecutive patients were prospectively recruited over a one and a half year period at the skin clinic of King Edward VIII Hospital. Demographic, clinical, biochemical, and histologic data were recorded. RESULTS: Seventy-five per cent of the patients were black, 22.5% Indian, and 2.5% white. The men to women ratio was 1.9 : 1. The mean age was 34. 7 years (range, 1 month to 85 years). Forty-three per cent of patients were HIV positive, of whom 90% were black. The commonest causes of erythroderma in the total sample were atopic dermatitis (23.9%), psoriasis (23.9%), and drug reactions (22.5%). The commonest cause in the HIV positive group was drug reactions (40.6%), the commonest being ethambutol (30.8%). HIV positive patients had a significantly lower (P < 0.05) white cell count (7.6 vs. 10.5 x 109 /L), hemoglobin (11.1 vs. 12.6 g/dL), platelets (278.3 vs. 378.0 x 109 /L), and albumin (25.4 vs. 28.7 g/L) and significantly higher serum urates (0.6 vs. 0.4 mM/L) than HIV negative patients. HIV positive patients did not have a significant increase in the number of episodes of erythroderma. Clinicopathologic correlation was greatest with psoriasis in the HIV negative group and with psoriasis and drug reactions in the HIV positive group. CONCLUSIONS: A large proportion of erythrodermic patients in this study were HIV positive. Inflammatory dermatoses were the commonest cause of erythroderma in all the patients studied. Drug reactions were the commonest cause in HIV positive patients. In the young black patient, erythroderma may be a marker for HIV infection.     

When the goal is palliative care

OBJECTIVE: An analysis of the literature regarding palliative care of patients with wounds. DATA SOURCES: Health care literature, including national and international reports, focusing on enhancing quality of life for individuals with wounds who are receiving palliative care. CONCLUSION: The literature on palliative care of patients with wounds is limited. Integration of palliative care concepts and chronic wound management is challenging; however, palliative care, which focuses on comfort and symptom management for quality of life, can provide the best quality care within the parameters of disease and individual patient wishes.     

When is a chrysanthemum dermatitis not a chrysanthemum dermatitis not a chrysanthemum dermatitis?

In order to provide a new reference point in the dermatological literature from which the naming of florists' chrysanthemums may be regularised and standardised, the case is presented for the use of the generic name Dendranthema together with a cultivar name in place of a specific epithet. A review of cultivar specificity in chrysanthemum dermatitis is also presented.     

Metal sensitivity: positive history but negative test indicates atopy

Among patients with a history of metal sensitivity, 50 were patch-test-negative to nickel, cobalt and chromate. 20 of them were further examined epicutaneously and intracutaneously. They were also studied with a clinical diagnostic method for symptoms and signs of atopy. Most patients in this category were found to be atopic.     

Classic Kaposi's sarcoma in Sardinia: HLA positive and negative associations

BACKGROUND: The incidence of classic Kaposi's sarcoma (CKS) in northern Sardinia is one of the highest in the world. METHODS: Sixty-two patients with CKS were typed for class I and class II antigens. All patients had been born and were living in northern Sardinia. RESULTS: In the Sardinian patients, we observed a positive CKS association with Cw7, DRB1*1104, DRB1*1302, DQA1*0302, and DQB1*0604, and a negative CKS association with A30, B58, Cw5, DRB1*1601, and DQB1*0502. CONCLUSIONS: The strong positive CKS association with DRB1*1104 and DQB1*0604 and negative association with B58 are particularly significant and further support the notion of a genetic predisposition to CKS.     

A comparison of IgA positive and IgA negative dapsone responsive dermatoses

A study of thirty-three patients with a clinical diagnosis of dermatitis herpetiformis (DH) referred to our DH clinic over the last 11 years is reported. Twenty-six were referred by other consultant dermatologists. The diagnosis had been made by the clinical features and response of the rash to dapsone. Seventeen patients were found to have IgA in the uninvolved skin (IgA positive) and in sixteen no IgA was found (IgA negative). The duration of the rash prior to referral to the DH clinic was 3 months to 19 years (mean 5.0 years) for the IgA negative patients and 2 months to 22 years (mean 5.2 years) for the IgA positive group. The length of follow-up was 3 months to 11 years (mean 5.0 years) for the IgA negative, and 2–11 years (mean 5.6 years) for the IgA positive group. During follow-up the rash cleared completely and required no treatment in seven of the sixteen IgA negative patients. Thirteen of these sixteen patients no longer required dapsone, but six patients were receiving alternative treatment. In the three patients still taking dapsone IgA has not been found on subsequent biopsy. Of the seventeen IgA positive patients only three were able to stop dapsone during follow-up and in these three the IgA was still detected in the skin. Small intestinal mucosa was abnormal in eight of eleven IgA positive patients, but was normal in all thirteen IgA negative patients in whom jejunal biopsies were performed. An alternative diagnosis to DH has subsequently been made in thirteen of the sixteen IgA negative patients. Although the significance of IgA in the skin in DH is not known it appears to be part of the disease process. Patients who have a rash suggestive of DH and which is dapsone responsive, but in whom IgA is not found in the uninvolved skin, usually turn out to have a dermatosis other than dermatitis herpetiformis. Referral to a unit with expertise in immunofluorescence techniques of skin biopsies would appear to be helpful.     

Cell trafficking in positive and negative patch-test reactions: demonstration of a stereotypic migration pathway.

The cellular and molecular events taking place during epidermal antigen exposure in sensitized individuals are principally well understood. Epidermal Langerhans cells (LC) are supposed to take up, process, and express a given foreign substance on their cell surface. The antigen is then recognized by T cells bearing the appropriate T-cell receptor (TCR). Because LC do not bear variable antigen (Ag)-specific binding sites, one could postulate that the epidermal exposure of any substance should activate LC and other cells of the skin immune system. To test this hypothesis, we analyzed immunophenotypically the cellular trafficking events in positive (n = 5) and negative epicutaneous patch-test reactions (n = 10), using a panel of monoclonal antibodies against CD1a, CD11c (Ki-M1, LeuM5), CD68 (Ki-M6), Ki-M8, and CD3 (Leu4). We can demonstrate that irrespective of whether or not an antigen will be responded to by the immune system (i.e., positive or negative test reaction), epidermal antigen exposure causes a decrease of LC density in the epidermis and simultaneously causes an increase of LC in the dermis. Moreover, monocytes and T cells immigrate into the dermis both in positive and negative patch-test reactions. As is to be expected, the degree of this cellular traffic is more pronounced in positive test reactions, which may be due to amplification mechanisms caused by antigen recognition of sensitized T cells. This finding demonstrates that human skin contains cell migration programs that ensure that any foreign substance will be accessible to the skin immune and phagocytic system.     

系统性红斑狼疮患者抗SSB抗体阳性和阴性患者的对比分析

目的分析探讨系统性红斑狼疮(Systemic Lupus Erythematosus,SLE)患者抗SSB抗体阳性和SSB抗体阴性对临床表现、实验室指标、治疗及疗效的影响,为更深入研究疾病的发展提供线索。方法采用回顾性调查方法,按不同性别、年龄[育龄期(15~49)岁,育龄期后≥50岁]分析l00名抗SSB抗体阳性及阴性的系统性红斑狼疮患者的临床表现、实验室检查、治疗及疗效的关系。结果 SLE患者中以育龄期女性为多,平均年龄28.6岁。汉族占88%。抗SSB抗体阳性的SLE患者蝶形红斑、抗ds-DNA抗体(+)、外周血中性粒细胞减少的比率明显高于抗SSB抗体阴性的SLE患者。结论抗SSB抗体阳性的SLE患者发生面部蝶形红斑、外周血中性粒细胞减少及抗ds-DNA抗体阳性的机率高于抗SSB抗体阴性的的患者。