Anthony du Vivier

Cancer Research Campaign health education programme to promote the early detection of cutaneous malignant melanoma. II. Characteristics and incidence of melanoma

The effect on the detection and characteristics of melanoma, resulting from the Cancer Research Campaigns health education programme to promote the early detection of melanoma in the general population, was studied from 1987 to 1989. The seven study areas in England and Scotland yield a target population of 3.6 million. Data were collected from local clinic‐based registers, pathology laboratories, and the cancer registries. The average annual incidence rates of melanoma were seven and 12 per 105 in males and females, respectively, age‐standardized to England and Wales, 1988. These rates are similar to the national figures for Scotland, where there is a national melanoma register, but higher than those reported by the English and Welsh cancer registries. The incidence was significantly higher in females than males (P<(0.001), and increased with age. Fifty‐three per cent and 65% of cases in males and females, respectively, were thin (Breslow thickness ≤1.5 mm), similar to the national figures from Scotland. No significant decrease in the incidence of late‐stage tumours was found in either sex as a result of the campaign. Because of difficulties with ascertainment of cases in England, the main evaluation will focus on future trends in mortality rates for melanoma.

Cancer Research Campaign health education programme to promote the early detection of cutaneous malignant melanoma. I. Work-load and referral patterns.

From 1987 to 1989 a campaign to promote the early detection of cutaneous malignant melanoma was conducted in the areas of seven health authorities in England and Scotland (total population 3.6 million). Data were collected on 17.155 patients attending pigmented lesion clinics (PLCs) in each study area during the campaign. After a dramatic rise in PLC referral rates in the first month of the campaign the average monthly referral rate among the target population in the study period settled to an average of l3 per 105, a twofold increase compared with the pre‐campaign period. Over 85% of patients at all PLCs were seen within 4 weeks of referral from their general practitioners. The melanoma to non‐melanoma detection ratio was (1:33). The organization of future early detection initiatives needs careful review and planning, in order to improve their effectiveness in all sections of the population, and to enable health services to cope with the increased work‐toad.

Lesson of the week: Tinea capitis in adults

Tinea capitis should be considered in all adults with a patchy inflammatory scalp disorder Tinea capitis (scalp ringworm) is uncommon after puberty. When it occurs in adults the clinical features may be atypical and this may delay the diagnosis.1 Unless the possibility of dermatophyte infection is considered, unnecessary investigations may be performed and inappropriate treatment prescribed, as illustrated in the four cases described below. ### Case 1 A 45 year old Afro-Caribbean woman had had an itchy pustular eruption of the scalp with associated hair loss for several months. Her general practitioner had treated it unsuccessfully with neomycin and gramicidin ointment and oral flucloxacillin and metronidazole. During this period the woman underwent lymph node aspiration and chest radiography because she had an enlarged but painless cervical lymph node. Cytological examination showed a mixed population of lymphocytes, indicating reactive changes; in addition, the surgical house officer observed that the woman had “quite a nasty rash on her scalp.” At the time of her referral to the dermatology clinic she had circumscribed areas of hair loss over the crown, with peripheral inflammation, pustules, and scaling (fig 1). Culture of bacterial swabs had negative results and a presumptive diagnosis …

Alcohol intake and other skin disorders

The classical cutaneous stigmata of alcoholism have been well recognized for over a century. Most stigmata are in fact manifestations of the end stage of cirrhosis, rather than of alcohol itself, and as such are discussed in more detail in chapter 18. Over the past decade alcohol has become recognized as a causal or aggravating factor in a wide variety of skin diseases, particularly those of inflammatory origin. The exacerbation of psoriasis by alcohol has received greatest attention of late (see chapter 12), but many other chronic dermatoses may also be associated with excess drinking.1–3 However, these are not always widely appreciated and can be easily overlooked. A careful history is often required to elucidate the patient’s alcohol consumption, as these patients are often regular heavy drinkers (alcohol misusers) rather than alcoholic, and in particular will not exhibit any features of dependency. In fact, they may be quite surprised when it is suggested that drinking could have a pivotal role in their skin disease, as they would not personally consider themselves to be “at risk” or drinking to excess. Having a high level of awareness of the role of alcohol in skin disease is important for the clinician, as clues are rarely gleaned from standard screening tests, biochemical and hematological parameters being usually normal in these patients.3

Investigation of the pharmacokinetics of clobetasol propionate and clobetasone butyrate after a single application of ointment

Using new radioimmunoassay methods, the plasma levels of clobetasol propionate and clobetasone butyrate have been measured following application of ointment to in‐patients with psoriasis or eczema.

Photochemotherapy and topical nitrogen mustard in the treatment of mycosis fungoides

Eight patients with mycosis fungoides limited to the skin have been treated with either topical nitrogen mustard alone or in combination with photochemotherapy. This regime does not prevent contact sensitization to nitrogen mustard but will clear sanctuary sites of disease which may develop when photochemotherapy is used alone.

Topical immunotherapy: unapproved uses, dosages, or indications

Topical immunotherapy involves the therapeutic use of contact sensitizers on the skin, and it has been tried in a wide variety of disorders in which alterations in cutaneous immunology are thought to be central to the pathogenesis, including autoimmune diseases, inflammatory dermatoses, infections, and cutaneous malignancy. Topical immunotherapy, however, has been most widely used in the treatment of alopecia areata (AA) and recalcitrant viral warts, and this review will focus on these two areas.

Proteus syndrome : diagnosis in adulthood

We describe a 24‐year‐old woman with many of the classical features of the Proteus syndrome. In childhood she had undergone bilateral forefoot amputations because of massive bilateral cerebriform hypertrophy of the feet. Other features include abnormally large fingers on one hand, a lymphangioma circumscriptum, an epidermal naevus, prominent venous varicosities and scattered lipomas. The disorder occurs sporadically and is thought to be secondary to a postzygotic mutation that survives by mosaicism.

Erythromelalgia following pergolide administration.

Two patients are described in whom treatment of Parkinsons disease with the ergot derivative pergolide was associated with the development of erythromelalgia. The possible mechanism of pergolide‐induced erythromelalgia is briefly discussed.

Chronic relapsing remitting Sweet syndrome - a harbinger of myelodysplastic syndrome

Sweet syndrome (SS) is an acute febrile neutrophilic dermatosis. It has been associated with malignant disease, especially acute myeloid leukaemia (AML), infections, autoimmune disorders and drugs, particularly granulocyte colony‐stimulating factor (GCSF). No cause is found in the rest, which are labelled idiopathic. We describe 15 patients with SS, which we believe represent ‘immune dysregulation’ secondary to myelodysplastic syndrome (MDS). We initially identified 31 patients with SS in a cohort of 744 patients with MDS and 215 with AML seen over a 6‐year period (2004–10). The cause in 16 patients could be attributed either to administration of GCSF or chemotherapy. The eruption was brief and resolved spontaneously or following withdrawal of GCSF. Fifteen patients however, had a chronic debilitating illness dominated by the skin eruptions. Diagnosis of chronic relapsing SS was delayed because the pathology was not always typical of classical neutrophil‐rich SS and included lymphocytic and histiocytoid infiltrates and bone marrow was not always performed because the relevance of the eruption to MDS was often not immediately appreciated. All these patients had ‘low risk’ MDS, diagnosed at a median of 17 months (range 0–157) following the diagnosis of SS. We describe a chronic debilitating episodic clinically distinctive skin eruption with features of SS but not always definitive histopathology often associated with immunological abnormalities affecting other systems related to underlying low risk MDS.