J.F. Bourke

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.

An evaluation of the revised seven-point checklist for the early diagnosis of cutaneous malignant melanoma.

Summary The seven‐point checklist has been widely advocated as a sensitive screening test for malignant melanoma. A number of groups have questioned the sensitivity of this system, especially in the detection of early lesions. We have assessed the sensitivity and specificity of the revised seven‐point checklist when applied to lesions seen in our department over a 26‐month period and compared it with the American ABCDE evaluation system. All melanomas (n= 65) were detected using the revised seven‐point checklist and all were found to have at least one of the three major criteria defined by that system. Five (7·7%) melanomas were not picked up by the ABCDE checklist. Of 100 randomly selected patients who attended the clinic during the same period, with clinically diagnosed benign pigmented lesions, 63 had at least one major feature of the revised seven‐point checklist. Forty (62%) of the melanomas, compared with only (4%) of the benign lesions, had more than one major feature. This study confirms the sensitivity of the revised seven‐point checklist in the diagnosis of cutaneous malignant melanoma.

Cryotherapy of common viral warts at intervals of 1, 2 and 3 weeks

We studied the efficacy, and time to clearance, of more frequent cryotherapy of viral warts, by randomizing 225 patients to receive treatment at 1‐, 2‐ or 3‐weekly intervals. The mean times to clearance of warts in each group were 5.5, 9.5 and 15 weeks in the weekly, 2‐weekly and 3‐weekly groups, respectively (P < 0.01). Cure rates after 3 months correlated with frequency of treatment (P < 0.05). After 3 months, 43% (66% of non‐defaulters) had cleared in the group treated weekly, 37% (47%) of the group treated every 2 weeks, and 26% (30%) of those treated every 3 weeks. The mean numbers of treatments needed to achieve clearance were similar in each group (5.5, 4.75 and 5 treatments). After 12 treatments, cure rates were similar for all three groups: 43% for the weekly‐ treated group (3 months), 48% for the 2‐weekly group (6 months), and 44% for the 3‐weekly group (9 months). Percentage cure is related to the number of treatments received, and independent of the interval between treatments. A more rapid cure may, therefore, be achieved by more frequent treatment.

Value of a second freeze-thaw cycle in cryotherapy of common warts.

A study of open, randomized, parallel‐group design was performed to investigate the impact of a second freeze‐thaw cycle on the cure rate, at 3 months, from cryotherapy of common warts on the hands and feet.

Protection of children against sunburn: a survey of parental practice in Leicester.

The incidence of melanoma in the U.K. is increasing more rapidly than that of most other malignant tumours. Sunburn in childhood increases the risk of malignant melanoma in later life and it is herefore essential that protection of children is improved if primary prevention of melanoma is to be effective. We asked 238 parents in Leicester how they protected their children against sunburn, how often their children suffered sunburn, and whether they had heard of malignant melanoma. Although most (80%) had heard of melanoma. 47% did not regularly ensure that their children used a sunblock lotion, and only 34% regularly protected them from the midday sun. Forty‐eight percent of parents stated that their children burned at least once a year. New approaches to public education about melanoma may be needed to improve the protection of children against sunburn.

Urine calcium excretion during treatment of psoriasis with topical calcipotriol

Urine calcium excretion is a very sensitive method of detecting vitamin D intoxication, and may rise in the absence of any apparent change in the serum level. Little attention has been paid to urine calcium levels during the large trials performed to assess the efficacy and safety of calcipotrioi in psoriasis vulgaris. There are some urine calcium data from short‐term studies of average dose rates of calcipotriol. However, there are no published data on long‐term usage, nor on the use of dose rates at the upper end of the licensed range (100 g/week).

High-dose topical calcipotriol in the treatment of extensive psoriasis vulgaris

Summary Ten patients with extensive plaque psoriasis were treated with calcipotriol ointment (50 μg/g) for 2 weeks (200 g for 1 week, followed by 300 g during the second week). Mean improvement in psoriasis area and severity index (PASI) was 71%. Mean 24 h urine calcium rose from 4.79 mmol/24 h to 7.27 mmol/24 h (P<0.000l). Urine calcium returned towards baseline after stopping calcipotriol. Mean serum calcium also rose slightly, hut significantly, from 2.26 mmol/l to 2.32 mmol/l (P<0.005). and fell again in the washout phase. Individual serum calcium values remained within the normal range throughout the study. Topical calcipotriol is an effective, rapidly acting and safe in‐patient treatment for extensive plaque psoriasis.

An immunohistochemical study of the dermal infiltrate and epidermal staining for interleukin 1 in 12 cases of Sweet's syndrome.

Summary Interleukin 1 (IL‐1) has been proposed as a possible mediator in Sweets syndrome. We examined all cases of Sweets syndrome (M = 12) presenting to the department over a 10‐year period, from 1982 to 1992, for the presence IL‐l and also assessed the nature of the dermal inflammatory infiltrate in those cases. Staining for IL‐1α and TL‐1β was stronger in control tissues than in Sweets syndrome. This may possibly be explained by the release of IL‐1α and IL‐1β into the dermis in Sweets syndrome. Contrary to recent reports, we found that neutrophils predominated in all cases examined, although histiocytes were present in increased numbers indicating their possible role in the pathophysiology of Sweets syndrome.

Sweet's syndrome responding to cyclosporin

Summary We report a case of Sweets syndrome which responded to treatment with cyclosporin 4 mg/kg/day. Cyclosporin is effective in the treatment of many dermatoses, and although the immunosuppressive effects of cyclosporin are mainly attributed to inhibition of T‐lymphocyte proliferation, it has also been shown to affect the functions of both neutrophils and monocytes. Possible mechanisms of action of cyclosporin in Sweets syndrome are discussed.

High dose topical calcipotriol consistently reduces serum parathyroid hormone levels

OBJECTIVE Calcipotriol is a vitamin D analogue which is an effective topical treatment for chronic plaque psoriasis. It has been reported to have no effect on systemic calcium homeostasis provided the manufacturers guidelines are adhered to (maximum 100 g of calcipotriol ointment (50 μg/g) per week). However, there have been reports of hypercaicaemla in patients using topical caicipotriol even at recommended doses. The purpose of this study was to investigate the effects of topical calcipotriol in vivo using the recently developed ‘intact’ PTH assay as a more sensitive index of systemic calcium homeostasis.