J.S. Comaish

Nail is produced by the normal nail bed: a controversy resolved

Nail thickness and mass (dry weight/unit surface area) of 21 toenails, removed from 19 patients after accidental injury, were measured over the mid point of the lunula at the nail plate immediately distal to the lunula and at the distal end of the nail bed. Nail thickness increased from 43% of the final thickness over the mid‐point of the lunula to 81% at its distal margin, the remaining increase in thickness being formed by the nail bed. The changes in nail mass were comparable. We conclude that ventral nail produced by the nail bed comprises about one‐fifth of the terminal nail thickness and mass.

Excision of skin tumours without wound closure.

Sixty‐two patients with 67 large or poorly defined skin tumours predominantly on the head and neck (58 basal cell carcinomas) were treated by excision of the lesion and allowing the defect created to heal by second intention. Histological control of the adequacy of excision was monitored using routine vertical sections of formalin‐fixed tissue. Further re‐excisions were performed in 17 patients in whom tumour extended up to or within 1 high power field (approximately 0.44 mm) of the excision margin. The formalin‐fixed specimens ranged from 6‐60 (mean 21) mm in diameter and 2‐12 (mean 5) mm in depth. After one excision the time to complete re‐epithelialization was directly proportional to the surface area (r= 0.73) and ranged from 13 to 60 days (mean 33 days). Measurements of the movements of fixed reference points tattooed at the wound edges in six patients showed that movement of surrounding tissue into the defect accounted for 39–62% (mean 45%) of the reduction in surface area of the defect during healing. Post‐operative complications were rare and the cosmetic results were considered good or excellent in 48 patients, fair in nine and poor, i.e. requiring corrective surgery, in three patients. Poor results were due to distortions of free margins, e.g. lower eyelid and nasal margin. The major benefit of this technique is the ease with which further excisions can be performed when histologically indicated. In selected areas this simple and quick technique avoids the need for repair with full thickness grafts or flaps, and the defect shrinkage and excellent contour and colour matching produce cosmetic results superior to those of split skin grafts or following radiotherapy.

A hand-held friction meter

A portable hand‐held friction meter has been devised which will measure the coefficient of friction between a reference material and skin at any body site regardless of position. The reference surface can be made of any of a number of materials, such as steel, nylon, PTFE, leather or even fabrics. The effects of disease and topically applied medicaments on the skin are being studied quantitatively with this machine, which may also have industrial applications.

Three cases of eccrine porocarcinoma

We report three cases of eccrine poroma, present for many years, in which features were seen suggesting transformation from a benign to a malignant tumour. These changes ranged from in situ Bowenoid dysplasia to frankly invasive squamous carcinoma. The most helpful diagnostic feature in distinguishing the origin of the tumours was the presence of strong cytoplasmic staining for carcinoembryonic antigen (CEA) in cells surrounding, and giving rise to, neoplastic ducts and clefts. Dermatopathologists examining eccrine poromata should examine the lesions carefully for any evidence of malignant change.

Familial Behçet's syndrome

Behçets syndrome is reported in a family of which four generations have so far been affected. The index patient also exhibited an unusual schizo‐affective disorder. The histocompatibility antigen haplotype 1–17 was common to four with the disease. Genetic transmission may be responsible for the familial nature of the syndrome and the associated schizophrenia.

Woody hands in a patient with pancreatic carcinoma : a variant of cancer-associated fasciitis-panniculitis syndrome

We report an elderly woman with rapidly progressive painless, woody induration ofthe hands. Mild diabetes mellitus was demonstrated. Skin biopsy features included broad fibrous bands extending deeply into subcutaneous fat, a mild mononuclear cell infiltrate, and post‐thrombolic recanalization of a deep vessel in one specimen. The patietU developed uncontrolled haematemcsis and was demonstrated at laparotomy to have disseminated pancreatic carcinoma. The unusual clinical features and lemporal relationship between the skin changes and the tumour suggesi a paraneo‐plastic eruption, whieh appears besl classified as an example of cancer‐associated fasciitis—panniculitis syndrome.

The inhibiting effect of soft paraffin on the Köbner response in psoriasis

White soft paraffin has been shown to inhibit the development of the isomorphic response (Köbner phenomenon) in psoriasis. The possible reasons for this are discussed and it is suggested that this finding has implications which should lead to a greater understanding of the nature of psoriasis.

Precocious puberty in a boy with a widespread linear epidermal naevus

Summary A 7‐year‐old boy with a systematized verrucous epidermal naevus, multiple pigmented naevocytie naevi and precocious puberty is deseribed. The possible basis for this previously unreported association of abnormalities IS discussed.

Quantification of skin transparency

SIR, Drug-induced coma is a well recognized cause of bullous eruptions (Mandy & Ackerman, 1970) but the mechanism of their production is still unknown. We have recently seen a patient in whom direct immunofiuorescence performed on a biopsy of such lesions demonstrated intercellular staining for IgG, IgA and C3. A 55-year-old man was admitted to hospital in Grade IV coma following a drug overdose. He was known to be taking amitriptyline, dothepin hydrochloride, nitrazepam and lorazepam for anxiety and depression and he had taken a combination of all four tablets, 8 hours prior to admission. It was also noted that he had an erythematous blistering eruption over his left knee, right lower buttock and right calf. He was maintained with supportive therapy and regained consciousness after 18 hours. He was referred to the Dermatology Out-patient Department 2 weeks later as a result of the persisting erythematous bullous lesions affecting the right lower buttocks, the lateral aspect of the right calf and overlying the patella of the left knee. The remainder of his skin was normal, as was the rest of the physical examination. A biopsy was taken from the lesion on the right calf and the histology showed a subcorneal vesicle of the epidermis with no abnormal features of the basal layer or dermis. Direct immunofiuorescence showed patchy intercellular staining for IgG, IgA and C3 with fibrin deposition along the basement membrane. Serum complement levels and immunoglobulins were normal and circulating anti-basement membrane, desmosome and reticulin antibodies were not demonstrated. There have been no previous reports of positive direct immunofluorescence in bullous lesions due to drug-induced coma, although certain drugs such as penicillamine (Marsden et al., 1976), rifampicin (Gauge et al., 1976) and phenylbutazone are known to be capable of inducing pemphigus. Direct intercellular immunofiuorescence has also been found in non-fixed bullous eruptions due to nalidixic acid and fixed bullous eruptions to phenolphthalein (Shelley, Schapner & Heiss, 1972). Clinically the bullous lesions occurred over areas of pressure in the unconscious patient. The presence of direct immunofiuorescence raises various possibilities. The drugs themselves may interact with intercellular antigens resulting in complexes which behave as immunogens or pressure itself may be capable of altering antigen structure to result in antibody formation. It has been recently shown that traumatizing normal skin can induce complement and immunoglobulin IgM deposition along the basement membrane zone (Miller & Griffiths, 1982). Further immunofiuorescence studies on bullous lesions in drug-induced coma are indicated.

The Editor, ‘The British Journal of Dermatology’. Aldolase activity of psoriatic skin.

Dr. R. D. Sweet in 1965, also had chronic lymphatic leukaemia, from which the pa,tient later died. Both conditions had apparently developed at about the same time Histological examination of the skin shortly before his death showed the changes of both Norwegian scabies and chronic lymphatic leukaemia. The diagnosis had been confused on his first attending the clinic three years previously, as lie was found to have pediculosis corporis, and the irritating eruption was assumed to he due entirely to this.