A study of pathogenesis of acanthosis nigricans and its clinical implications

Background:

Acanthosis nigricans (AN) is a dermatosis characterized by thickened, hyperpigmented plaques, typically on the intertriginous surfaces and neck. Common in some populations, its prevalence depends on race. Clinicians should recognize AN; it heralds disorders ranging from endocrinologic disturbances to malignancy. In this review, we discuss the pathogenesis of AN and its clinical implications and management.

Materials and Methods:

We selected 30 patients for the study. Diagnosis of associated disorders was established by history, physical examination, body mass index (BMI), hormone measurements by radioimmunoassays of thyroidnfunction tests, free testosterone, 17 (OH) progesterone, dehydroepiandrosterone sulfate (DHEAS), cortisol, gonadotropins, prolactin, immunoreactive insulin, and C-peptide levels.

Results and Discussion:

In our study, the flexural involvement (flexures of groins, knees and elbows) was seen in 40% patients, lip involvement was seen in 6.6% patients, and dorsal involvement was seen in 3.3% patients each. Increased serum testosterone levels were seen in 13.3% patients and increased DHEAS levels were seen in 20% patients. Regarding the types of AN, obesity induced AN or pseudo-AN was seen 70% patients, syndromic AN was seen in 23.35% patients and malignant AN was seen in 6.6% patients. The commonest histopathological feature of patients with AN was hyperkeratosis, seen in 100% patients, papillomatosis was seen in 90% patients, dermal infiltrate of lymphocytes and plasma cells was seen in 60% patients, horn pseudocysts were seen in 30% patients, and irregular acanthosis was seen in 26.6% patients.     

A clinical and histopathological profile of patients with cutaneous tuberculosis

Extrapulmonary tuberculosis constitutes about 10% of all cases of tuberculosis, and cutaneous tuberculosis makes up only a small proportion of these cases. Despite prevention programs, tuberculosis is still progressing endemically in developing countries. Commonest clinical variant of cutaneous tuberculosis in our study was lupus vulgaris seen in 55% patients followed by scrufuloderma seen in 25% patients followed by orificial tuberculosis, tuberculosis verrucosa cutis, papulonecrotic tuberculid, and erythema induratum seen in 5% each. The commonest site of involvement was limbs seen in 50% patients followed by neck seen in 25% patients, face in 15%, and trunk in 10% patients. Maximum percentage of patients (55%) had duration of cutaneous tuberculosis between 6-12 months followed by 35% between 13-24 months, 5% had duration of cutaneous tuberculosis less than 6 months, and the rest 5% had duration more than 24 months. The commonest histopathological feature in our study was tuberculoid granuloma with epitheloid cell and Langhans giant cells seen in 70% patients, hyperkeratosis was seen in 15% patients and AFB bacilli were seen in 5% patients.     

Dermatological manifestations of chronic renal failure

Dermatological manifestations of chronic renal failure were studied in 35 cases. Xerosis was seen in 16 cases. Pruritus was observed in 12 cases and hyperpigmentation on exposed areas was seen in 8 patients. Acquired perforating disorder and half and half nail were seen in 6 cases each. Skin Biopsies performed in 6 cases of APD showed typical changes only in 3 cases.     

The cutaneous manifestations of violence and poverty.

BACKGROUND--Violence is a public health issue that disproportionately affects the poor. Homelessness, drug abuse, and physical violence are seen with increasing frequency in poor communities. This article reviews the cutaneous manifestations of violence and the dermatologic problems commonly seen in the homeless. Particular emphasis is placed on the experience of municipal hospitals serving the urban poor. OBSERVATIONS--Dermatologic diseases are common in the homeless, and foot-related problems such as cellulitis and pyodermas are frequent causes of hospitalization. Unusual patterns of scarring and bruises in different stages of healing are seen in victims of physical violence. Trauma and sexually transmitted diseases result from sexual abuse. Serious skin infection and self-mutilating scarring are seen in intravenous drug abusers. CONCLUSION--Dermatologists are able to diagnose and treat the many skin problems seen in the poor and to identify the physical manifestations of abuse during routine skin examination. Findings of violence should be documented and reported to the appropriate investigational agencies.     

Thymoma-associated multiorgan autoimmunity: a graft-versus-host-like disease

Graft-versus-host disease (GVHD) is a T cell-mediated disease seen most commonly after hematopoietic stem cell transplantation. Rarely, a GVHD-like disease can be seen in patients with malignant thymoma. We describe a 50-year-old man with malignant thymoma who developed skin, liver, and intestinal manifestations similar to that seen in GVHD. We also review other reported cases of GVHD-like manifestations in the setting of thymoma and propose "thymoma-associated multiorgan autoimmunity" as a name for this novel disease. Specifically, thymoma-associated multiorgan autoimmunity is defined as a disease of the liver, intestine, or skin, which on histopathology resembles GVHD but is seen in the setting of malignant thymoma and not after hematopoietic stem cell transplantation.     

Lupus vulgaris—a case report

Although lupus vulgaris is the most common form of cutaneous tuberculosis seen in Europe, the incidence has steadily declined and it is now rarely seen. We report a case in a 69-year-old lady who presented with a 10-year history of a slowly growing plaque on the left cheek. Skin biopsy confirmed caseating granulomata, and acid-fast bacilli were seen. She was commenced on triple anti-tuberculous therapy with good effect.     

Renal functional status in leprosy

Renal functional impairment is known to occur in lepsory, specially of multibacillary type. Pedal oedema was seen in 30% patients. Urine analysis showed proteinurea in 3.33%. epithelial casts in 13.33% and microscopic haematuria in 6.66%. A raised 24 hours urinary protein excretion was seen in 53.33%, 60% had a low 24 hours creatinine clearance rate. Abnormal serum creatinine was found in 16.66%, raised serum urea values were seen in 6.66% cases.     

Study of the skin disease spectrum occurring in an Afro-Caribbean population

BACKGROUND: There is a scarcity of recent up-to-date studies on the incidence of skin disease among Afro-Caribbeans. METHODS: One thousand patients were retrospectively studied for the commonest diagnoses made over a 5-month period from January to May 2001. RESULTS: The commonest skin diseases seen were acne vulgaris (29.21%), seborrhoeic eczema (22.02%), pigmentary disorders (16.56%), and atopic eczema (6.1%). Other notable common diagnoses included keratosis pilaris, tinea infection, hirsuitism, folliculitis keloidalis nuchae, viral warts, dermatosis papulosa nigra, and confluent and reticulate papillomatosis. CONCLUSION: The pattern of skin disease seen in the Afro-Caribbean population studied, more closely resembles those seen in developed countries than those seen in developing countries.     

Distribution of p230, an α-spectrin-related polypeptide in normal and psoriatic epidermis and in cultured human keratinocytes

We studied the localization of p230, an immunoanalogue of erythroid alpha-spectrin, in normal and psoriatic human epidermis and in cultured human keratinocytes. In immunofluorescence microscopy of frozen sections of normal skin a bright cytoplasmic staining was seen in the cortical area of the keratinocytes. Similar staining was also seen in lesional and uninvolved areas of psoriatic epidermis. The pericytoplasmic localization of p230 could also be seen in cultured human keratinocytes: a lamina-like reticular staining was seen mostly confined to the ventral cytoplasmic aspect and to junctional areas of the cells. Immunoblotting of electrophoretically separated polypeptides of epidermal cells revealed a distinct polypeptide of Mr 230 kD. The results indicate that alpha-spectrin-like polypeptides form a major cytoskeletal framework in human epidermal cells in both normal and psoriatic skin.     

The Incidence and Significance of Birthmarks in a Cohort of 4,641 Newborns

An unselected cohort of 4,641 newborns was ascertained prospectively for the purpose of detecting any cutaneous lesion. These were catalogued into pigmented lesions, vascular lesions, and miscellaneous lesions. Several important findings were elucidated: congenital nevocellular nevi are speckled at their borders; no white newborn in the study had more than one café au lait mark; a hypopigmented tuft of hair was seen in one infant with tuberous sclerosis but is found more commonly in normal individuals; a previously undescribed lesion called zosteriform melanocytic nevus was seen as a normal pigmentary variant in blacks; and hypopigmented macules seen at birth are seen primarily in normal infants. It is hoped that these findings will allow the pediatrician and dermatologist to offer more meaningful prognostic information to their patients.     

Porokeratosis ptychotropica: a lesser‐known variant

We report a case of the rare porokeratosis variant porokeratosis ptychotropica (PP). A circumferential perianal plaque and the characteristic histology of multiple cornoid lamellae with underlying dermal amyloid deposition were seen. Amyloid deposition was seen in the biopsied intertriginous area of the plaque only, which, in concordance with other cutaneous amyloid deposition disorders, may suggest a role for friction in the pathogenesis of this histological finding. We review the literature on PP and summarize the poor response seen to treatments.     

Adverse reactions following pulsed tunable dye laser treatmentof port wine stains in 701 patients

The pulsed tunable dye laser (PTDL) is generally considered to have a very low incidence of adverse effects, allowing it to become the treatment of choice for the majority of port wine stains (PWS). The low incidence of adverse effects has led to difficulties in determining the true incidence and type of adverse effect seen with this laser. We therefore undertook a retrospective study of 701 patients with PWS, who received 3877 full treatments to determine the incidence and type of adverse effects seen following treatment with the PTDL. Blistering and crusting were seen in 5·9% and 0·7% of patients, respectively, but were transient events which usually healed without permanent sequelae. Hyperpigmentation was the most frequently observed adverse effect seen in 9·1% of patients but generally showed gradual resolution over 6–12 months. Hypopigmentation was infrequent, seen in 1.4% of patients. The most significant adverse effects were atrophic and hypertrophic scarring seen in 4·3% and 0·7% of patients, respectively. Our observations show that there is a small but definite risk of atrophic scarring with a predisposition for younger patients. Hypertrophic scarring can occur albeit rarely and there may be a predisposition towards the neck. In most cases test areas were not predictive of scarring. This underlines the need for a full discussion of scarring risk in patients with PWS undergoing treatment with the PTDL.     

Childhood lichen planus: a report of fifty cases

Lichen planus is an uncommonly encountered dermatosis in children. In the present study of 50 children the limbs were the most common site of involvement (70.0%). A majority of the children (60.0%) presented with the classic form of the disease. Hypertrophic lesions were present in 26.0% of children while linear lesions were seen in 8.0%. There was no scalp, nail, or hair involvement in any child. The Koebner phenomenon was observed in 28.0%, and mucosal involvement, which is very uncommon in children affected by lichen planus, was seen in 30.0%. In this subset of children, hypertrophic lesions were seen in 53.4% while widespread disease was present in only 6.7%. The response to treatment and the course of the disease were similar to that seen in adults.     

Milia occurring in lichen sclerosus et atrophicus

Large numbers of milia were seen in areas of skin affected with bullae in a 68-year-old woman who had extensive lichen sclerosus et atrophicus. Although milia are frequently seen in other sub-epidermal bullous disorders, they have not previously been reported in lichen sclerosus et atrophicus.     

Testicular dysfunction in leprosy: relationships of FSH, LH and testosterone to disease classification, activity and duration

Luteinizing hormone (LH), follicle-stimulating hormone (FSH) and testosterone levels were determined by radioimmunoassay (RIA) in leprosy patients and analysed for effect of disease classification, disease activity and duration of disease. LH and FSH levels were found to be significantly elevated in lepromatous patients compared to borderline-lepromatous, midborderline and borderline-tuberculoid patients. A positive correlation was seen between LH and FSH and a negative correlation was seen between testosterone and both LH and FSH. No correlation was seen between hormone levels and measures of disease activity: bacillary index and IgM to phenolic glycolipid I, a Mycobacterium leprae antigen. A significant correlation was seen between duration of disease and FSH when age was taken into account, indicating that testicular dysfunction is probably cumulative and irreversible. It is recommended that LL patients be routinely screened for hypogonadism using FSH, LH and testosterone levels.     

Further experience of public education for the early diagnosis of malignant melanoma in Leicestershire

Publicity campaigns alerting the public to the need for early attention to malignant melanoma (MM) were conducted in Leicestershire, England during the summers of 1987, 1988 and 1989. There was a marked, and statistically significant, rise in the number of referrals with good prognosis MMs in the period immediately after the first campaign. In the 2 subsequent years, despite further publicity campaigns, the number of MMs diagnosed per week remained lower than the postpublicity peak of 1986/87. The postpublicity rise was less marked in 1987/88 and 1988/89. In the next year (1989/90), in which there was no publicity campaign, the total number of MMs seen was higher than in 1988/89. Numbers of MMs seen per week remained relatively steady throughout the year. There was again no publicity in 1990/91, and the total number of MMs diagnosed was about the same as in the previous year. There was a rise in the number of MMs seen per week in what would have been the postpublicity period of this year. The initial results would he consistent with the initial postpublicity rise in numbers of MMs seen being made up of lesions seen‘early', that is, in 1986/87 and 1987/88. Since these lesions were seen earlier than they would have been had there been no publicity, the number of MMs seen in 1988/89 w as lower than it would otherwise-have been and the publicity effort appeared to have less effect. By 1989/90 and 1990/91 this effect seems to have been wearing off. It may be that, at least in low MM incidence areas like the UK, it is better to pulse public-education for the early diagnosis of melanoma rather than to use annual or continuous campaigns. However, longer-term experience, and the pooling of data between centres will be necessary to test this conclusion.     

Oral Stenosis in Measles

ABSTRACT: Gangrenous stomatitis and noma as complications of measles are regularly seen in certain tropical nations. The progression of the frequently seen, simple stomatitis to oral stenosis is a serious complication requiring surgical intervention to prevent starvation.     

Lucio leprosy with lucio phenomenon

Leprosy is one of the commonly seen disease in any dermatology outpatient department in our country. India accounts for a major portion of the leprosy patients in the world. All types of the disease, such as tuberculoid, borderline, lepromatous, neuritic and indeterminate leprosy, are seen. However, "lucio leprosy" which is considered a special type of lepromatous leprosy characterised by diffuse involvement has not been reported from India. We are presenting here two cases of "lucio leprosy" with "lucio phenomenon", the lucio phenomenon being a special type of lepra reaction seen in lucio leprosy.     

Access to genitourinary medicine clinics in the United Kingdom

OBJECTIVES: To assess the variability in time taken for a patient to be seen in a genitourinary (GUM) clinic in the United Kingdom having contacted that clinic by telephone and compare this with GUM physicians' expectations. METHODS: A postal questionnaire was sent to lead GUM physicians asking when they thought patients with two specific clinical scenarios would be seen in their clinics. Following this, healthcare personnel contacted individual units posing as patients with the same clinical scenarios and asked to be seen as soon as possible. RESULTS: 202/258 (78%) lead clinicians responded to the postal questionnaire. All clinics claimed to have procedures allowing patients with acute symptoms to be assessed urgently and estimated that such patients would be seen within 48 hours of the initial telephone contact. In 243 of 311 (78%) clinic contacts, the patient was invited to attend the clinic within 48 hours. For the remaining 68 contacts (22%) the patient could not be accommodated within 48 hours and, of these, 49 could not be seen for more than 1 week. CONCLUSIONS: No clinician estimated that patients with acute severe symptoms would be seen more than 48 hours after the initial telephone contact, but in reality, for 22% of the patient contacts this was the case. This study may well underestimate the difficulties the general public may have in accessing GUM services. We hypothesise that this situation could be ameliorated by establishing process standards and addressing issues of resource allocation.     

Netherton综合征一例

患儿,女,4岁。患儿出生即出现全身干燥、红斑、鳞屑,伴渗液。头发、眉毛稀疏,口周皮沟加深,呈放射状,双手、双足可见片状、环状或多环状的红色斑片,其周边有小片灰白色“双边”鳞屑。光镜下见头发呈竹节状改变。血常规中嗜酸粒细胞计数增高,血清IgE增高。诊断：Netherton综合征。给予保湿剂外用。