C.C. Long

Sweet's syndrome and malignancy in the U.K.

Acute febrile neutrophilic dermatosis (Sweets syndrome) is reported to be a marker for underlying malignancy. Much of the evidence for this is based on case reports, small series of cases and reviews of the literature. In order to clarify the association with malignancy and determine the common clinical features of Sweets syndrome, we reviewed the case notes of patients presenting to six dermatology units in the U.K. Eighty‐seven cases of histologically proven Sweets syndrome were reviewed. Fourteen patients (16%) developed associated malignancy, predominantly haematological, two patients (2%) had a history of previous malignancy and four patients (5%) had premalignant conditions (monoclonal gammopathy, two: myelodysplasia, two). Malignancy developed up to a year after presentation with Sweets syndrome. Patients with associated malignancy were more likely to be anaemic (P<0·01) at presentation, had a lower mean platelet count (207 × 109/L vs. 332 × 109/L: P<0·003) and were, on average, older (59 years vs. 49 years: P = 0·002). Contrary to previous reports, a greater percentage of females developed malignancy than males.

Minimizing the risk of post‐operative pyoderma gangrenosum

Summary A 61‐year‐old woman with seropositive rheumatoid arthritis developed numerous ulcers due to pyoderma gangrenosum at suture entry/exit sites following an arthroplasty of the right hip when interrupted silk sutures were used to close the skin. When a subsequent arthroplasty was performed on the left hip and subcuticular Dexon sutures were used to close the skin only two small ulcers developed. Sixteen cases of pyoderma gangrenosum developing in surgical wounds have previously beeb reported.

Detection of latent variegate porphyria by fluorescence emission spectroscopy of plasma

Summary The plasma of patients with overt variegate porphyria contains porphyrin with a fluorescence emission maximum at about 626 nm, which is diagnostic for the condition. We have evaluated qualitative fluorescence emission scanning of saline‐diluted plasma as a method for the identification of asymptomatic carriers of the gene for variegate porphyria. Plasma from 36 unrelated patients with variegate porphyria. 136 of their asymptomatic first‐ and second‐degree relatives aged 15 years or over, and 322 normal subjects was scanned. An emission maximum between 621 and 627 nm was observed in the 36 patients with variegate porphyria and 54 of their relatives, but not in any normal subject, nor in 56 patients with other types of porphyria. For the detection of asymptomatic adult carriers of the gene for variegate porphyria. fluorescence emission scanning of plasma appears to be 100% specific, with a sensitivity of 86% (95% confidence interval 71–98%). In contrast, the sensitivity of faecal porphyrin analysis as a test for adult gene carriers was 36%. These results suggest that fluorescence emission scanning of plasma should replace faecal porphyrin analysis as the test of first choice for this purpose.

Taking the ‘sting’ out of local anaesthetics

Summary in order to investigate factors influencing the discomfort caused by the injection of different lignocaine preparations, a randomized, double‐blind comparison of paired injections was performed in 32 patients. In all subjects 2% plain lignocaine was found to be more painful than 0·5% plain lignocaine. Lignocaine with adrenaline 1:200,000 was found to be significantly more painful than plain lignocaine. The presence of sodium metabisulphite (the antioxidant in commercial adrenalized lignocaine) significantly increased the discomfort. Neutralization of acidic 0·5% lignocaine (pH 4·7) reduced the discomfort caused in 44% of patients, but this was not statistically significant.

Suprabasal acantholysis—an unusual feature of necrolytic migratory erythema

A 67‐year‐old man with diabetes, weight loss and anaemia initially presented with a widespread scaling erythematous rash; a skin biopsy demonstrated marked suprabasal acantholysis. A subsequent biopsy showed localized upper epidermal necrolysis and the diagnosis of glucagonoma syndrome was later confirmed. Glucagonoma syndrome should he considered in patients with diabetes, weight loss and anaemia who present with a scaling rash, the histology of which shows suprabasal acantholysis. The extent of any upper epidermal necrolysis may be be very limited.

Curettage of small basal cell pepillomas with the disposable ring curette is superior to conventional treatment

SIR. Basal cell papillomas are a common cosmetic problem in dermatology. One method which has been advocated for their removal is rapid curettage, without anaesthesia, using a sharp ring curette. A disposable ring curette (Stiefel Laboratories. High Wycombe, Bucks., U.K.; Fig. 1) has recently become available in the U.K. (current retail price £18.50 per box of 10). The aim of this study was to compare curettage using the new ring curette with our conventional technique of curettage and light cautery under local anaesthesia. Ethical approval for this study was granted by the Local Research Ethics Committee of South Glamorgan Health Authority, and informed consent was obtained from each patient. Two treatment techniques were used.

Congenital dysmorphism of finger and toenails associated with acro‐osteolysis

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How to reduce the discomfort caused by local anaesthetics.

SiK, Dr Arndt correctlv reminds us that several factors nia> influence ihe degree n( discomfort caused by local anaesthetic injections, including: the depth of the injection; rate of injection; and needle gauge, However, the choice of local anaesthetic agent is also extremel) imporiant. We investigated possible causes ofthe discotnfort in 32 individuals by means of comparing paired injections of uniform depth and rate, using 27-gauge needles.^ In all 32 individuals injeciion of 1%, lignocaine was more painful ihan 0 5% lignocaine, Lignocaine with adrenaline I in 200 000 was more painful than plain lignocaine, and the addition of sodium metabisulphite (the aniioxidant present in commercial adrenalized lignocaine) also significantly increased the degree of discomfort. Tbe acidic pH ot most local anaesthetics is claimed to he a major cause of the discomfort associated with injection. ^ However, 1̂ , procaine pH 4 3 is less painful than 1% lignocaine pH 6-3.̂ We found rhat 0-5,, lignocaine with sodium metahisulpbite pH 3-1 was less painful than O-S-,, lignocaine with adrenaline 1 in 200000 pH 4-13. Neutralization of acidic 0-5;, lignocaine pH 4-7 by ihc addition of sodium bicarbonate reduced the discumfort in 14 (44%) of our patients, hut the results were not statistically significant. Thus the concentration oflignocaine, the presence of adrenaline, the presence of sodium tnetabisuiphitc, and possibly the pH all influence the degree of discomfort. Plain lignocaine, 0-5/,, causes the least discomfort, and thus should he used as firsf choice for most minor procedures.