Andrew L. Wright

Nickel sensitivity: the influence of ear piercing and atopy

In a group of 612 consecutive patients undergoing routine patch tests for suspected allergic contact dermatitis, more than four‐fifths of the 364 women had had their ears pierced, over half gave a history of cutaneous reactions to metallic jewellery and almost one‐third were sensitive to nickel. The increase in the frequency of nickel sensitivity in women with pierced ears compared to those with unpierced ears was highly significant (P < 0.001). In men, nickel sensitivity was much less frequent; occupational factors were often implicated and few cases were related to ear piercing. Jewellery dermatitis was more frequent in atopic than non‐atopic women but atopy did not appear to influence the propensity for developing nickel sensitivity in either sex. Ear piercing seems to induce nickel allergy which may result in lifelong morbidity and difficulty in employment. Jewellery suppliers should be encouraged to provide nickel‐free earrings to reduce the frequency of this apparently avoidable problem.

Granuloma Formation in Herpes Zoster Scars

An 82-year-old male with chronic lymphocytic leukaemia developed an erythematous papular eruption over the trunk. Lesions occurred at the site of scars related to a disseminated herpes zoster infection 3 months previously. Biopsy of a lesion showed granuloma formation. The rash resolved spontaneously over 6-8 weeks.

Quantification of allergic and irritant patch test reactions using laser-Doppler flowmetry and erythema index

The laser‐Doppler blood flow and erythema index were assessed in 16 patch test reactuibs caysed by irritants (1% aq. Sodium lauryl sulphate and 1%aq. Benzalkonium chloride) and in 13 varied allergic reactions, at 2 or 4 days. Both irritant and allergic responses produced satistically significant increases in laser‐Doppler flow index and erythema index compared to control sites (p<0.05 or less, using the Wilcoxon rank‐sum test). A disproportionately greater increase in erythema index than in laser‐Doppler flow was seen in mild irritant reactions, compared to allergic, though the two could no be reliably distinguished by these tests. 2 non‐allergic nickel sulphate sites produced an increase in both blood flow and erythema without any clinical change. Petrolatum alone produced no significant change in either measurement. The laser‐Doppler flow showed an overall correlation with the erythema index (product moment method: r=0.55. p<0.001), but there was little correlation between these indices and patch test reactivity as judged clinically by conventional scoring. Generally, allergic and irritant patch test reactions could not be differentiated on the basis of laser‐Doppler flow index for mild irritant responses warrants further study in other irritant models.

Esophageal Lichen Planus Presenting with Dysphagia

A 79-year-old woman presented with a 7-year history of dysphagia and odynophagia to solids and to a lesser extent liquids. Pain on swallowing radiated to the right jaw. She also complained of an unpleasant taste, and of a 12 kg weight loss over the preceeding 6 months. There was a long history of pruritus vulvae. Hyperthyroidism had been diagnosed 10 years previously and was treated initially with carbimazole and thiouracil. Because of poor compliance, however, radioiodine therapy was instituted 2 years later. There was no history of dyspepsia. At presentation she was clinically and biochemically euthyroid. At onset, the dysphagia was clinically investigated. Indirect laryngoscopy and barium swallow at that time revealed no abnormality. Re-examination 6 years later revealed a white patch on the floor of the mouth and direct laryngoscopy and pharyngo-esophagoscopy demonstrated a raised lacey pattern of striae on the posterior pharyngeal wall and other multiple raised white areas in the upper esophagus up to 20 cm from the incisors. An upper esophageal lesion was biopsied. Histology revealed a mildy thickened squamous epithelium but no significant atypia. In the upper dermis there was a lymphohistiocytic inflammatory infiltrate most marked at the epithelial-submucosal interface (Fig. 1), Several colloid bodies were present. These findings confirmed the clinical diagnosis of lichen planus. There were no cutaneous signs of lichen planus, although there was a bluish discolouration of the labia majora. Treatment with oral prednisolone and a steroid mouth wash produced considerable improvement in the dysphagia. She is currently controlled on 12,5 mg daily of prednisolone, eating normally, and gaining weight.

Computer‐assisted image analysis of skin surface replicas

Using a rubber‐based dental impression material, negative surface impressions were made of demarcated areas of skin and prepared as dry specimens for scanning‐electron microscopy. Electron micrographs were taken at low magnification and, using a programed computer‐assisted image analyser, it was possible to represent quantitatively the topography of that particular body site according to the degree of circularity of the various geometric subunits. This technique was most applicable to skin topography with a reliable geometrical pattern of triangles and squares, a feature of hair‐bearing surfaces in general and in particular, the antecubital fossa. Using standardized trauma of various types the origin of skin surface markings were found to be located in the dermis. The technique was applied to the healing of experimental trauma produced by tape stripping, the resolution of clinical eczema and a comparison of steroid‐treated and untreated tape‐stripped skin.

Self-healing epitheliomata of Ferguson-Smith: cytogenetic and histological studies, and the therapeutic effect of etretinate.

212 epitheliomata developed in two unrelated women with self-healing epitheliomata of Ferguson-Smith. Most of the lesions appear on the face, often in crops; they enlarge over 4 weeks and, without treatment, resolve over 4 months to leave a ragged scar. One of the patients developed an unusual syringoma, a papillary carcinoma of the thyroid and a mucosal squamous cell carcinoma which failed to involute spontaneously. Cytogenetic studies did not reveal any abnormality of DNA repair. Surgical excision of the epitheliomata is successful but time consuming. X-irradiation should not be used, but cryotherapy of early lesions is helpful. One patient, treated with etretinate for 24 months, has developed only 8 epitheliomata over this time, compared with 23 in the previous 24 months. Etretinate therefore appears to prevent new lesions from developing.

An immunophenotypic study of lichen nitidus

Skin biopsies from three patients with lichen nitidus were studied using a battery of monoclonal antibodies against cells in the dermal infiltrate. In each case the findings were identical with a marked excess of CD4+ cells over CD8+ cells and the presence of large numbers of CD1+ cells. These results are very similar to those seen in lichen planus reinforcing the association between rhese two conditions.

Factor XIIIa in nodular malignant melanoma and Spitz naevi

The distribution of factor XIIIa‐positive dermal dendritic cells was studied in a series of nodular malignant melanomas and compared with that seen in Spitz naevi. Two patterns of distribution were recognizable: (a) diffusely spread through the tumour and (b) located mainly at the periphery of the tumour. These did not correlate with the diagnosis of melanoma or Spitz naevus and the distribution appeared to be a function of growth pattern of the tumour. The diffuse pattern was the most common regardless of diagnosis and the distribution of factor XIIIa‐positive cells is the same in malignant melanoma and Spitz naevi.

Malignant Melanoma at Sites of Therapeutic X-Irradiation

Two patients are reported in whom malignant melanoma developed at sites of low-dose superficial X-ray therapy given for treatment of benign dermatoses. No causal link has been established between melanoma and X-irradiation, but previous reports of a possible association are reviewed. The probably importance of ultraviolet exposure after X-irradiation in such patients is emphasised.

Perforating granuloma annulare

A 47-year-old white woman with a 7-year history of diabetes mellitus that had been well controlled with insulin, presented with a 1 -month history of a well-circumscribed, tender eruption on her right forearm. Examination of the area revealed a group of umbilicated papules 1-2 mm in diameter, each with a central crust (Fig. 1). A lesion more typical of granuloma annulare was seen on the right palm (Fig. 2). Both lesions resolved spontaneously over a period of 3 months. The lesion on the forearm left an area of hypopigmented scarring.