Elizabeth Higgins

Analysis of Chinese herbal creams prescribed for dermatological conditions

Abstract Objective: To determine whether Chinese herbal creams used for the treatment of dermatological conditions contain steroids. Design: 11 herbal creams obtained from patients attending general and paediatric dermatology outpatient clinics were analysed with high resolution gas chromatography and mass spectrometry. Setting: Departments of dermatology and clinical biochemistry. Main outcome measure: Presence of steroid. Results: Eight creams contained dexamethasone at a mean concentration of 456μg/g (range 64to 1500μg/g). All were applied to areas of sensitive skin such as face and flexures. Conclusion: Greater regulation needs to be imposed on Chinese herbalists to prevent illegal and inappropriate prescribing of potent steroids.

Diagnosis and management of scalp ringworm

Scalp ringworm is reaching epidemic proportions in parts of Britains cities. Prompt diagnosis is needed to stop it spreading from child to child, but the varied presentation makes it easy to miss

Saccharomyces cerevisiae emboli in an immunocompromised patient with relapsed acute myeloid leukaemia

In humans, Saccharomyces cerevisiae (bakers yeast) is found infrequently as a commensal of mucosal surfaces and rarely causes infections. We describe a case of cutaneous septic emboli developing in a patient with relapsing acute myeloid leukaemia M6 who had recently been treated with clofarabine. Yeast forms were seen on skin biopsy and S. cerevisiae was isolated from her Hickman line. We are not aware of any previous case reports of cutaneous emboli associated with this organism.

Cutaneous Leishmaniasis: Three Children with Leishmania major Successfully Treated with Itraconazole

Abstract:  We report the rare instance of four family members with numerous cutaneous lesions of Leishmania major contracted while on holiday in Algeria. Treatment was successful with oral itraconazole for the children and intralesional sodium stibogluconate for the mother. Cutaneous leishmaniasis should be considered in those with apparently sterile plaques returning from endemic areas. These results suggest that itraconazole, which is ideally suited for use in children, is an effective monotherapy for L. major.

Polymorphic eruption of pregnancy in a photodistribution: a potentially new association?

Polymorphic eruption of pregnancy (PEP) is the commonest dermatosis specific to pregnancy, occurring in 1 in 240 pregnancies. It typically occurs in the third trimester, usually of a first pregnancy but occasionally is seen postpartum. It is not known to be associated with light exposure. A 19-year-old Chinese woman presented with a 1-week history of an intensely itchy eruption on the abdomen with mild involvement of the back and thighs. She was 30 weeks into her second pregnancy, had no past dermatological history and was on no medication. The same partner was the father in both pregnancies. The first pregnancy had been uneventful, delivering at full term. On physical examination, the patient was found to have severely urticated, erythematous papules and plaques on the abdomen, particularly prominent within the striae, with satellite lesions on the upper back and thighs (Fig. 1a). The periumbilical skin was spared, with no evidence of associated vesicles, target lesions or bullae (Fig. 1b). Histological examination of a skin biopsy from the abdomen found a normal epidermis with a moderate perivascular lymphocytic infiltrate in the upper and mid dermis, with a smaller number of eosinophils. There was no fibrinoid necrosis, eosinophilic abscesses or subepidermal blister formation (Fig. 2). Direct immunofluorescence of perilesional skin was negative. The changes were consistent with PEP. The patient was treated with topical 0.05% clobetasol propionate ointment and regular emollients. On review 7 days later, the pruritus and abdominal eruption had settled, but the patient had developed florid involvement of the neck with patchy involvement of the arms and legs (mainly the extensor areas) in a photosensitive distribution. The face was spared. There was no history of photosensitivity. Topical treatment with 0.05% clobetasone butyrate ointment was started, and because the weather was sunny at the time, the patient was given advice on sun avoidance. The eruption resolved soon afterwards. She was well for the remainder of her pregnancy, but has since been lost to follow-up. To our knowledge, she delivered a full-term baby of normal weight without complication. The aetiology and pathogenesis of PEP is uncertain although an association with multiple pregnancy and maternal and newborn weight gain has been suggested. A retrospective analysis of 181 patients with PEP in a large mixed ethnic population found that 13% of patients had multiple gestation pregnancies, with excessive maternal weight gain in 78%. The majority (88%) of women were white women, with 70% being in their first pregnancy. Most cases presented in late pregnancy (83%; mean

43 Serum S-100 protein: a potentially useful prognostic marker in cutaneous melanoma

S-100, an acidic calcium-binding protein, is present within cells of neuroendocrine origin. Its value in the immunohistochemical diagnosis of tumours of melanocytic origin is well established. More recently, a potential role has been proposed for the serum concentration of this protein as a marker of metastatic melanoma disease activity. In the present study, the concentration of serum S-100 protein was measured in 97 patients with histologically proven malignant melanoma who were attending a dermatology and/or oncology department for the follow-up of their disease. Serum S-100 was also measured in 48 control subjects without malignant melanoma. The clinical stage of the patients was classified according to the criteria of the American Joint Committee on Cancer into stages I-IV. The median (range) serum S-100 protein concentration was significantly higher in stage I (0.11 (0.1-0.21) microgram/L, P < 0.001), stage II (0.11 (0.05-0.22) microgram/L, P < 0.001), stage III (0.24 (0.07-0.41) microgram/L, P < 0.0001) and stage IV (0.39 (0.06-15.0) microgram/L, P < 0.0001) compared with the control group (0.1 (0.05-0.15) microgram/L). At a threshold value of 0.2 microgram/L, the sensitivity and specificity for detection of advanced disease were 82% and 91%, respectively. Thus serum S-100 protein may be a valuable prognostic marker for malignant melanoma and for monitoring therapy. Serum S-100 protein concentration was also compared with the Breslow thickness of the tumours. There was a significant correlation between these variables (n = 72, rs = 0.32, P < 0.01). Combining a serum S-100 threshold value of > 0.22 microgram/L and a Breslow thickness of > 4 mm improved the sensitivity and specificity for the presence of secondary spread to 91% and 95%, respectively. Therefore, a combination of both baseline serum S-100 protein and Breslow thickness may provide a better indication of the prognosis at diagnosis.