A.C. Pembroke

The U.K. Working Party's Diagnostic Criteria for Atopic Dermatitis. III. Independent hospital validation.

In order to qualify as a case of atopic dermatitis, we propose that an individual must have an itchy skin condition plus three or more of the following: history of flexural involvement, a history of asthma/hay fever, a history of a generalized dry skin, onset of rash under the age of 2 years, or visible flexural dermatitis. When tested in an independent sample of 200 consecutive dermatology outpatients of all ages, this arrangement of the diagnostic criteria achieved 69% sensitivity and 96% specificity when validated against physicians diagnosis. Based on the findings of this first exercise, minor modifications in the wording of the criteria were undertaken, and these were tested on a sample of 114 consecutive children attending out‐patient paediatric dermatology clinics. Overall discrimination improved, with a sensitivity of 85% and specificity of 96%. The simplified criteria are easy to use, take under 2 min per patient to ascertain, and do not require subjects to undress. These two independent validation studies suggest that the newly proposed criteria for atopic dermatitis perform reasonably well in hospital out‐patient patients. Further validation in community settings and in developing countries is needed.

Validation of the U.K. diagnostic criteria for atopic dermatitis in a population setting

Summary One reason why so little is known about the epidemiology of atopic dermatitis (AD) is lack of suitable diagnostic criteria. A simple list of diagnostic criteria for AD for use in epidemiological studies has recently been developed by a U.K. working party. These have performed well in hospital validation studies of subjects with skin diseases. This study sought to validate the newly proposed criteria for AD in a population setting by conducting a cross‐sectional survey of 695 schoolchildren aged 3–11 years in three randomly selected primary schools in West Lambeth, London. As a point prevalence measure, the U.K. criteria had a sensitivity of 70%, a specificity of 93%, and a positive predictive value of 47% when compared with a dermatologists examination findings. Subsequent analysis suggested that most children classified as false positives had suffered from AD in the last year, but were inactive at the time of examination. When adjusted for these cases, the sensitivity and specificity increased to 80 and 97%, respectively, corresponding to positive and negative predictive values of 80 and 97%, respectively. The U.K. diagnostic criteria for AD appear to work well as a 1‐year period prevalence measure in London schoolchildren. Further validation in adults and other countries are needed.

FACE - facial Afro-Caribbean childhood eruption

Five cases of a distinctive facial eruption in Afro‐Caribbean children are described. Distinctive features include monomorphic papules that are confined to the face, especially around the mouth, eyelids and ears, its greater prevalence in black children, and its tendency to persist for several months before spontaneous resolution. The aetiology of this condition is unknown and its importance lies in reassuring patients of the benign and purely cutaneous nature of the eruption.

Unusual cutaneous reactions following diphtheria and tetanus immunization

It is now the usual practice in the United Kingdom to immunize children against diphtheria and tetanus in the first 2 years of life, using three injections of vaccines adsorbed on aluminium salts; sometimes killed Bordetella pertussis is added to give protection against whooping cough as well. Transient inflammatory reactions are common and in a few cases subcutaneous nodules persist. Nodules following influenza vaccines adsorbed on aluminium oxide consist mainly of sclerotic coUagenous tissue, with a central area of finely granular or structureless necrosis surrounded by flbroblasts, macrophages, lymphocytes and occasional giant cells (Voss & Toiki, i960; Orell, 1962; Erdohazi & Newman, 1971). Similar granulomata were produced in guinea-pigs with fine-grained aluminium oxide with or without the vaccine, but not with the vaccine alone or with large grained aluminium oxide (Orell, 1962). The histology of nodules following triple vaccine or tetanus toxoid adsorbed on aluminium salts is similar. We have seen three children with persistent nodules following diphtheria and tetanus immunization with the additional features of itching, eczema and hypertrichosis.

Lichen sclerosus and the Köbner phenomenon.

Two patients with lichen sclerosus (et atrophicus) are described in whom there was conspicuous localization of lesions to sites subjected to friction from tight clothing. This was highly suggestive of the Köbner phenomenon. Both patients experienced symptomatic improvement following avoidance of pressure on the skin from tight clothing.

Epidermolysis bullosa with squamous cell carcinoma

A 55-year-old Turkish Cypriot man had had a tendency^ to blister, spontaneously or follow ing minor trauma., since the age of four. Blistering had predominantly affected the shins, where the blisters had a tendency to break down and form ulcers which healed only slowly. He had been admitted to the Middlesex Hospital in 1969, 1971, and 1976, and had failed to respond to treatment with systemic steroids, azathioprine, and dapsone. Histology

Phrynoderma and perforating folliculitis due to vitamin A deficiency in a diabetic.

Discussion The 5 cases previously reported were all males aged 57-77 years. Four out of the 5 had eosinophilia and 4 lymphopenia (2 marked and 2 borderline). The patient without eosinophilia had a normal lymphocyte Count. Only one patient had a past history and a family history of atopy. All the patients had similar clinical features and skin histology to the patient we now describe. Journal of the Royal Society of Medicine Volume 81 March 1988 171

Mycosis fungoides and Hodgkin's disease.

Three patients with the typical clinical course and pathology of Mycosis Fungoides (MF) were found also to have Hodgkin’s Disease (HD), nodular sclerosing type. In two cases, HD Was diagnosed 2 years after the diagnosis of MF; in the third case, both diseases were diagnosed simultaneously. Previous claims of MF transforming into second lymphomas are reviewed. The possible significance of our observed association of MF and HD is discussed. Cancer 44: 1408141 3, 1979.

A FATAL CASE OF CAPILLARY LEAK SYNDROME IN ERYTHRODERMIC PSORIASIS

treatment.^ These results prompted us to try griseofulvin for the treatment of progressive pigmentary purpura. All five patients who were able to tolerate griseofulvin treatment responded very well, despite the previous chronicity of their disease, although there was some variation in the response, possihiy due to different rates of absorption. There is interindividual variation in the absorption of griseofulvin. and if griseofuivin is ineffective in dermatophyte infection the dose should be increased.

Screening for glucose-6-phosphate dehydrogenase deficiency prior to dapsone therapy.

Dapsone is widely used in dermatological practice. The case of a Greek female patient is reported who had a severe, acute, haemolytic episode shortly after commencing dapsone therapy, despite a normal glucose‐6‐phosphate dehydrogenase (G6PD) screening test. A subsequent quantitative assay revealed reduced levels of G6PD consistent with the heterozygous state. This illustrates that routine screening tests may fail to detect the decreased levels of (G6PD) which occur in female heterozygotes. Since these patients are at risk of severe dapsone‐induced haemolysis, the need for quantitative G6PD assays in females from susceptible racial groups is emphasized.