D.A. Burns

Dietary manipulation in childhood atopic dermatitis

The dietary habits of 73 children seen consecutively in a dermatology out-patient department were studied to ascertain the nature and frequency of dietary manipulation and to assess any potential hazards. Although most children had only mild flexural dermatitis, 71% had had significant alterations made to their diet before attendance at hospital. Almost all diets were unsupervised and only six children had seen a dietitian. Over half had been started on diets before any professional advice had been sought. Information on diet had come from media, books or magazines (51%), friends (32%), general practitioners (27%) and district nurses or health visitors (18%). The major dietary alterations included the exclusion of eggs, dairy products and food additives, and the use of soya and goats milk. Under 10% of patients claimed benefit from these largely unsupervised diets. Harmful practices included the frequent use of unboiled, unpasteurized goats milk, unmodified goats milk in a baby of 4 months and the use of severely restricted diets. Three children (6%) in the diet group had been on diets which were considered by a hospital dietitian to be particularly dangerous. However, there was no evidence of growth retardation, failure to thrive or specific deficiency syndromes in the group we studied. Uncontrolled, unsupervised and often prolonged dietary alterations are commonplace in children with atopic dermatitis. This is a potentially serious health problem.

Prolidase deficiency: a case report and literature review

We describe a patient in whom chronic leg ulceration was due to prolidase deficiency. The clinical features of this condition are described and we discuss the metabolic abnormality and the treatment regimes which have been employed. We also report the further finding of erosive cystitis, which we consider should be added to the list of clinical features of prolidase deficiency.

The treatment of human ectoparasite infection

Original articles 94 The DEBR rat: an animal model of human alopecia areata H,J,MICHIE, C,A,B,JAHODA, R,F.OLIVER AND B,E,]OHNSON 101 Detection of a novel basement membrane antigen by GDA-J/F3 anti-human sperm fibrous sheath monoclonal antibody A,JASSIM, O,SCHOFIELD, P,WHITEHEAD, P,PURKIS, A,H,M,HEAGERTy, J,A,SACHS, R.A.J.EADY AND I,M,LEIGH 108 Interleukin-5-induced granulocyte activation in atopic patients A,KAPP AND GABRIELE ZECK-KAPP 116 In-vivo administration of reeombinant IL-2 increases the number of Thy-1* dendritic epidermal cells N. SHIBAGAKI, K,TAMAKI AND S,SHIMADA 123 Measurement of human hair growth by optical microscopy and image analysis S,HAYASHI, I.MIYAMOTO AND K,TAKEDA 130 Decreased sweat-gland number and function in patients with alopecia areata D.ELIEFF, S.SUNDBY, W.KENNEDY AND MARIA HORDINSKY 136 Phenytoin has little effect on in-vitro models of wound healing SARAH M.VIJAYASINGHAM, P.J.DYKES AND R.MARKS 140 Skin susceptibility in uninvolved skin of hand eczema patients and healthy controls T.AGNER 147 The differentiation and proliferation of newly formed epidermis on wounds treated with cultured epithelial allografts ANNE M.OLIVER, W,KAAWACH, EVA WEILER MITHOFF, ALISON WATT, D,R,ABRAMOVICH AND C,R,RAYNER 155 Platelet and coagulation studies in EhlersDanlos syndrome A.ANSTEY, K.MAYNE, M.WINTER, J.VAN DE PETTE AND F.M.POPE Case reports 169 Dowling-Degos disease and Kitamuras reticulate acropigmentation: support for the concept of a single disease N.H.COX AND E,LONG 172 Linear IgA disease with haemorrhagic pompholyx and dapsone-induced neutropenia P,DUHRA AND R,CHARLES-HOLMES 175 Baciilary angiomatosis associated with cytomegalovirus infection in a patient with AIDS C.LOPEZ-ELZAURDIA, J.FRAGA, MIRIAM SOLS, E,BURGOS, M.SANCHEZ GARCIA AND A.GARCIA DIEZ 178 Precocious puberty in a boy with a widespread linear epidermal naevus CELIA MOSS, J,M.PARKIN AND J.S.COMAISH 183 Recurrent facial oedema associated with a silicone-rubber implant MARION I,WHITE, LOUISE M,SMART, DIANA M,MACGREGOR, C,R,W,RAYNER AND F.W.SMITH 186 Palmopiantar and perioroflcial keratoderma with corneal epithelial dysplasia: a new syndrome M.R.JUDGE, K.MISCH, P.WRIGHT AND J,I,HARPER

An outbreak of scabies in a residential home

An outbreak of scabies in a residential home for the elderly is described, and the investigation and management of the problem discussed. Multiple cases of scabies in this type of community are almost invariably associated with the presence of an unrecognized case of crusted (Norwegian) scabies. Unless such an individual is recognized, attempts to eradicate the problem may prove unsuccessful.

The treatment of Pthirus pubis infestation of the eyelashes.

The crab louse, Pthirus pubis ̂ is an insect adapted to living in coarse, widely-spaced hair. It is the louse of pubic, axillary, and body hair, and will also live in the beard and eyelashes. It does not favour scalp hair, although i „ of louse infestations ofthe scalp prove to be with Pthirus sp rather than Pediculus sp.^ Eyelash infestation with crab lice is occasionally encountered by the dermatologist. The eyelashes are the usual site of crab louse infestation in children,^^ in whom the lice may also be found in scalp hair.*̂ Eyelash infestation with crab lice may occasionally be a manifestation of child abuse. ̂ The adult lice arc often difficult to see with the naked eye, as they are in close proximity to the lid margins, but they are readily seen on slit-lamp examination. Louse eggs and egg-cases are visible as tiny, pearly objects on the lashes (Fig. i). Many dermatology texts either do not mention treatment of eyelash infestation with pubic lice, or suggest the use of insecticides but give no guidance as to which preparation to employ. Ophthalmology texts may provide more information, and Duke-Elder** devotes a section to this problem in a chapter on the causes of inflammation ofthe eyelids. Couch et al.^^ provide a useful review of treatment methods culled from the ophthalmology literature. An obvious method for dealing with crab lice on the eyelashes is mechanical removal of the adults and eggs with fine forceps, or epilation of the lashes with their attached eggs. A tolerant adult may endure this procedure, but it is not usually feasible in children, unless performed under a general anaesthetic, and it is not to be recommended. Awan^^ used cryotherapy under the slit-lamp to destroy adults and eggs on the lashes of a cooperative 5-year-old child, but took the precaution of applying i n gamma benzene hexachloride cream a few days later to deal with any lice emerging from eggs which might have escaped destruction by the cryoprobe. A chance observation by Mathew et al.^^ that 20,, fiuorescein rapidly killed crab lice on the lashes led them to try this agent on seven cases. They claimed that a single application of one or two drops of 2Oo fluorescein to the lid margins would kill both adults and eggs. They assessed the insecticidal capability of fluorescein experimentally by exposing head lice to concentrations of from 2,, to 20,,. Only concentrations of io-2o, proved effective pediculicides. No data was offered on the ovicidal capacity of fiuorescein. This treatment was said to be non-toxic and nonirritant.

Ectopic cutaneous schistosomiasis and schistosomal ocular inflammatory disease

We describe a patient with unilateral ectopic cutaneous schistosomiasis as a feature of Schistosoma mansoni infection. In addition to skin lesions he also suffered from schistosomal ocular inflammatory disease. The infection appeared to have been acquired during a visit to Tanzania. Ectopic cutaneous lesions usually affect the perineal area or trunk, and our patient is unusual in the localization of his skin lesions to the forehead.

Lichen sclerosus: a review of 14 cases in young girls with emphasis on symptomatology

We have noticed a recent increase in referrals of girls with lichen sclerosus (LS). This may be due to the recent increase in awareness of childhood sexual abuse, for which LS has sometimes been mistaken.^ Concern regarding the possibility of sexual abuse was often expressed by referring doctors and parents were sometimes very concerned about the possibility of misdiagnosis. The disease developed as early as 2 years of age. The prominent presenting complaints were pain, pruritus, bleeding, blistering, pain on defaecation and dysuria. The latter two symptoms were often the most prominent features, leading to problems such as severe constipation, nocturia and nocturnal enuresis. These symptoms are not emphasized in the literature. The clinical features were diagnostic in all our cases, so that the diagnosis of childhood LS seems to be straightforward to those familiar with the condition. However, LS presents to many medical disciplines, and the diagnosis had often been considerably delayed under the care of other specialities. One case had undergone two anal dilatations for fissures prior to the diagnosis being established; these were not helpful. Three patients had undergone biopsies, which did not assist in the diagnosis. We therefore consider it important that all cases are seen at an early stage by a dermatologist. The majority of our patients are slowly improving, in keeping with the generally favourable prognosis of this disease in children.

A closer look at Pthirus pubis

Pthirus pubis, commonly referred to as the pubic louse or crab louse, and delicately designated papillon damour by the French, is an insect whose biology has been rather neglected in comparison with the attention lavished on the head louse and clothing louse. Even its name is frequently misspelled. The generic name was intended to be Phthirus, but as a result of a misprint, Pthirus was confirmed as the official name by the International Commission on Zoological Nomenclature.1 It has no close relatives other than a similar species found on gorillas.

Herpetiform napkin dermatitis: napkin dermatitis simulating an acute herpes simplex infection

E L O N , J . , JACOBS, G.P., WITZTUM, E . & GREENBLATT, C . L . (1984) Dfve]opment of topical treatment for cutaneous leishmaniasis caused by Leishmania major in experimental animals, Amimicrobiat Agents & Chemotherapy, 26,745. E L O N , J . , WEINRALXH, L . , LIVISHIN, R . , EVAN-PAZ, Z . & JACOBS, G . P . (1985) Topical treatment of recurrent cutaneous leishmaniasis with ointment containing paromnmycin and methylbenzethonium chloride. British Medical Journal, 291, 704. EVANS, D . A . (1978) Kinetoplastida. In: Aiethods of Cultivating Parasites in vitro (Ed. by A.E.R.Taylor and J.R.Baker), p.55. Academic Press, London. EVANS, D.A,, LANHAM, S , M . , BALDWIN, C.I. & PETERS, W . (1984) The isolation and isoenzyme characterization of Leishmania braziliensis subsp, from patients with cutaneous leishmaniasis acquired in Belize. Transactions, of the Royal Society of Tropical Medicine and Hygiene, 78, 35. GODFREY, D , G . & KILGOCR, V, (1976) Enzyme electrophoresis in characterizing the causative organism of Gambian trypanosomiasis. Transactions of the Royal Society of Tropical Medicine and Hygiene, 70, 219, PETERS, W . , EVANS, D , A , & LANHAM, S , M . (1983) Importance of parasite identification in cases of leishmaniasis. Journal of the Royal Society of Medicine, 76, 540, Rioux, J,A,, LANOTTE, G , , MAAZOUN, R . , PERELLO, R, & PRATLONG, F . ;I98O) Leishmania jw/aiiMwNicolle, 1908, Agent du bouton dOrient autochtone, A propos de iidentification biochemique de deux souches isolees dans les Pyrenees-Orientaies, Comptes Rendus des Seances de IAcaderme des Sciences Paris t.291 f 2j Octobre 198OJ Serie D-

(16) A syndrome consisting of vanishing bile ducts, diabetes mellitus, acanthosis nigricans and pachydermal-like changes: a new entity?

Treatment and progress. No specific treatment was given and the calf lesions healed spontaneously. However, she re-presented in August 1987 with sporotrichoid spread of infection and suppurating lesions on the left medial thigh. Culture of a repeat biopsy identified Mycobacterium chelonei highly resistant to standard antituberculous drugs. She was treated with rifampicin, ciprofloxacin and erythromycin. Despite initial remission, a further lesion developed 12 months later while on erythromycin. Further culture confirmed Mycobacterium chelonei resistant to all antibiotics except erythromycin. The lesion was surgically excised. Within the past year she has developed two large fluctuant nodules on dorsal left hand and wrist highly suggestive of further chronic infection.