A. M. Skellett

The incidence of basal cell carcinoma in the under-30s in the UK.

Background.  Basal cell carcinoma (BCC) is the commonest cancer in many countries, but the current incidence in young people from the UK is unknown.

A randomized, double-blind, negatively controlled pilot study to determine whether the use of emollients or calcipotriol alters the sensitivity of the skin to ultraviolet radiation during phototherapy with narrowband ultraviolet B

Background  There is contradictory evidence suggesting that emollients increase, decrease or have no effect on minimal erythema dose (MED) or minimal phototoxic dose values prior to phototherapy. Few studies have looked at the in vivo use of emollients or calcipotriol prior to narrowband ultraviolet (UV) B (NB‐UVB) treatment.

Beclometasone inhaler used to treat pyoderma gangrenosum

Pyoderma gangrenosum (PG) is a neutrophilic dermatosis, often associated with underlying systemic disease. We report the use of a corticosteroid inhaler to successfully treat peristomal PG.

British Association of Dermatologists’ guidelines for the investigation and management of generalized pruritus in adults without an underlying dermatosis, 2018

G.W.M. Millington iD , A. Collins, C.R. Lovell, T.A. Leslie, A.S.W. Yong, J.D. Morgan, T. Ajithkumar, M.J. Andrews, S.M. Rushbook, R.R. Coelho, S.J. Catten, K.Y.C. Lee, A.M. Skellett, A.G. Affleck, L.S. Exton, M.F. Mohd Mustapa and N.J. Levell Dermatology Department, Haematology Department, Nephrology Department and Hepatology Unit, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, U.K. Dermatology Department, Royal United Hospital, Combe Park, Bath BA1 3NG, U.K. Dermatology Department, Royal Free Hospital, Pond Street, London NW3 2QG, U.K. General Practitioner, Chet Valley Medical Practice, 40–48 George Lane, London NR14 6QH, U.K. Oncology Department, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 2QQ, U.K. Dermatology Department, St George’s Hospital, Blackshaw Road, London SW17 0QT, U.K. Dermatology Department, Ninewells Hospital, Dundee DD1 9SY, U.K. British Association of Dermatologists, Willan House, 4 Fitzroy Square, London W1T 5HQ, U.K.

Sudden whitening of the hair: an historical fiction?

Sudden hair whitening (canities) was first reported centuries ago. Although a rare event, it has affected well-known historical figures, including Sir Thomas Moore and Queen Marie Antoinette of France. Early reports are substantiated by more recent cases in the scientific literature. Often, there is association with psychological stress; in the two historical cases above, the condition is thought to have been a reaction to the sentence of execution. In this paper, we examine some case histories of those afflicted throughout history and discuss hypotheses to explain the phenomenon.

Radiotherapy-induced morphoea of the breast responding to photodynamic therapy

A 78-year-old white woman presented with a tender, pruritic rash of the left breast, 4 months after cessation of therapy for breast cancer. She had been diagnosed with carcinoma of the left breast (pT1b N0), which was oestrogen receptor-positive and HER2negative. She received radiotherapy, with 40 Gy delivered to the left breast in 15 fractions over 21 days, without a boost. On physical examination, a sharply demarcated erythematous area was seen, corresponding to the previous radiotherapy field. There was no personal or family history of autoimmune conditions. Laboratory investigations, including full blood count, kidney and liver biochemistry, erythrocyte sedimentation rate, antinuclear antibodies, extractable nuclear antigens, rheumatoid factor and Borrelia serology, all gave normal results. Histological examination of an initial skin biopsy of the area showed a perivascular and periadnexal chronic inflammatory infiltrate within the superficial and deep dermis, consisting of lymphocytes and occasional plasma cells, with no evidence of malignancy (Fig. 1a). A diagnosis of radiotherapy-induced morphoea was made, which was treated with several courses of high-dose oral prednisolone and potent topical corticosteroids over the next 5 years. There was some temporary improvement, with softening of the affected areas. Nonetheless, the condition progressed, leading to several painful ulcerations of the left breast (Fig. 2a). Other treatment agents tried subsequently included doxycycline 100 mg daily, methotrexate 15 mg weekly and hydroxychloroquine 200 mg twice daily, but all were unsuccessful. Histological examination of a skin biopsy taken 5 years following onset of the rash showed progression of the condition, with deposition of thick collagen bundles across the dermis, associated with complete absence of adnexal structures, together with a mild inflammatory infiltrate, rich in plasma cells, but no radiation fibroblasts (Fig. 1b). The patient was offered either psoralen ultraviolet A (PUVA) photochemotherapy or UVA-1 phototherapy at this point, but she declined these owing to time commitments and practical difficulties accessing the hospital. A literature review at this stage revealed two prospective trials that had previously shown some improvement in conventional morphoea after treatment with photodynamic therapy (PDT), and the patient was offered PDT on this basis. Local anaesthesia was achieved with 10 mL of plain lignocaine 2%, and methyl aminolaevulinate 16% cream was applied to the affected area, which was irradiated with red light at 37 J/m 3 h after application on two occasions. The only adverse effect was pain during treatment. There was a very good response to PDT, with evidence of re-epithelialization of the ulcerated areas and reduction in pain (Fig. 2b) within a month of completion of the first PDT treatment. Six months after the initial PDT treatment, the ulcerated areas had completely re-epithelialized, the patient was not requiring a pad anymore and she was using emollients only topically. Radiotherapy-induced morphoea (RIM) is a rare condition, which primarily affects patients treated for Correspondence: Dr George W. M. Millington, Department of Dermatology, Norfolk and Norwich University Hospital, Colney Lane, Norwich, NR4 7UY, UK E-mail: george.millington@nnuh.nhs.uk

Cold-induced rashes.

A 56-year-old woman presented with a 4-month history of arthralgia, purpura and leg ulceration. She experienced transient painful and pruritic weals on her neck, thighs and upper arms, precipitated by cold exposure, on rewarming. There were palpable purpura and healed ulcerations on her lower legs, with livedo reticularis and perniotic discolouration over her thighs (Fig. 1). An ice-cube test was positive after 5 min, producing a transient weal. IgG(k) monoclonal paraprotein was detected (11.1 g/L; normal range 5.9–15.6 g/L) consisting mainly of cryoglobulin. C3 and C4 complement were reduced due to consumption by immune complexes. Bone marrow and skeletal survey did not show myeloma.

Erosive pustular dermatosis and osteoradionecrosis: complications of radiotherapy

A 70-year-old man presented to dermatology in 2003 with scalp ulceration. He had previously received radiotherapy to the left frontoparietal area on four occasions from 1986 to 1990 to treat a recurrent moderately high-grade T-cell lymphoma. From 1990 to 2003, plastic surgeons had managed areas of exposed skull that had never healed after the radiotherapy. The patient had undergone a left radial forearm flap in 1990, with burring of exposed bone on three occasions to encourage granulation. The surgical wound broke down to expose the skull. Granulation tissue was seen in multiple biopsy specimens. On physical examination, the patient had extensive erosions, pustules and ulceration, with a purulent exudate of the left frontal scalp and an asymmetrical pulsatile depressed area (Fig. 1a). There was movement coincident with respiration and arterial pulses. The patient reported that the ulceration had deteriorated after sustaining a trauma to the head 6 years previously. Skin swabs intermittently grew Staphylococcus aureus. Histological examination of a skin biopsy found a lymphoplasmacytic infiltrate in the dermis, and ectasia of dermal vessels with cellular fibrosis, findings consistent with radiation-induced changes. A skull X-ray showed lytic changes of the left frontal and parietal bone, consistent with previous surgery or radiotherapy. Based on the clinical appearance of sterile pustules, erosions and a purulent exudate, an additional diagnosis of erosive pustular dermatosis (EPD) was made. Treatment over 6 years included antiseptics, 3–6 week courses of mild to potent topical corticosteroids, 9 months of treatment with calcipotriol cream, and 1–3 week courses of oral flucloxacillin, with limited success. Topical calcineurin inhibitors were not used because of the intermittent infection, previous lymphoma and lack of skull beneath the ulceration. The erosions and ulcers never healed. In May 2008, a wing of bone 80 mm in length fell off the parietal area of the skull during a dressing change. Histological examination of the bone showed osteoradionecrosis (Fig. 1b-d). The patient repeatedly declined neurosurgery or other surgical intervention. In February 2009, he developed right-sided leg weakness due to a cerebral abscess, and died despite surgical treatment. EPD is a rare, inflammatory condition often occurring after trauma, usually on the scalp. Triggers include bruising, sunburn, shingles, and surgery with skin grafting. There are two case reports of EPD after radiotherapy. The mean interval between onset of trauma and presentation of EPD was 12 months in one case series (range 1–55 months). The radiation-induced cases occurred after 25 days in one case (total dose 5000 cGy) and 4 months after treatment in the second (total 89 600 cGy). Radionecrosis and skin tolerance of radiotherapy is usually 5000 cGy. Our patient received doses at overlap sites of 9000 cGy. Histological changes in EPD are nonspecific but include inflammatory changes in the epidermis and dermis, ulceration, atrophy or hyperkeratosis, and reduced or absent hair follicles. There is no correlation between disease severity and colonization by S. aureus. Antimicrobial treatment does not consistently clear disease. Reported treatments for EPD include potent topical corticosteroids and topical tacrolimus. In this case, the previous lymphoma, repeated secondary infection, and severe radionecrosis with absent bone resulting in close proximity between the brain and the ulcerated skin limited the therapeutic options.