John A. A. Hunter

Benign melanocytic naevi as a risk factor for malignant melanoma.

Examination of 180 patients with cutaneous malignant melanoma and 197 control patients in a case-control study showed that the risk of melanoma is strongly related to numbers of benign melanocytic naevi (moles). Some unusual features of naevi--a diameter exceeding 7 mm, colour variation, and irregular lateral outline--also showed a strong association with the risk of melanoma, but the relation of numbers of naevi to risk was present even in the group of patients whose naevi had none of these unusual features. Biopsy of clinically atypical naevi from several of the patients at highest risk generally did not show dysplastic histology. Thus a group of people at high risk of melanoma may be identified by using simple clinical assessment of naevi.

Human papillomavirus infections in a group of renal transplant recipients

One hundred and twenty renal transplant recipients were investigated. Fifty‐eight (48%) were found to have warts, 13(11%) keratoses and six (5%) to have, or recently to have had cancers. The longer the time of immunosuppression, the greater the prevalence of warts; of those patients who had had their transplant for at least 5 years, 87% had warts. Those with a graft survival time of 10 years or more are at special risk of warts, keratoses and malignancy. Five (10%) of 50 women had genital warts, four of whom had internal lesions (vaginal, cervical or anal) and one developed a carcinoma of the vulva. These findings indicate the advisability of colposcopy for all female renal transplant recipients, a high risk group. Eighty‐eight specimens from 42 patients were examined by DNA restriction enzyme analysis and cross hybridization for the presence and type of human papillomavirus (HPV). HPV DNA was detected in 66% of the warts examined, HPV2 and HPV4 occurring most often and HPV1 and HPV3 only infrequently. In sequential specimens from common hand warts of one individual, an HPV was found which could not be precisely identified but was related to HPV4. HPV16 was detected in a vaginal wart from one patient and an HPV6‐related virus in a vulval wart of another. HPV DNA of an unknown type was demonstrated in one of 11 keratoses examined. With the probes used to examine the few samples of skin cancers available, HPV 16 was found in a squamous cell carcinoma of the vulva, and faint bands from an unidentified type of HPV were detected in two squamous cell carcinomata from a patients hand. One woman had plaque lesions morphologically and histologically resembling those found in epidermodysplasia verruciformis (EV). HPV5 was identified in these lesions. This is only the third reported case of HPV5, previously thought to be unique to EV, in a renal transplant recipient.

Fluorescent lights, ultraviolet lamps, and risk of cutaneous melanoma.

Exposure to solar radiation is increasingly being associated with a risk of cutaneous melanoma, and some risk has also been attributed to exposure to fluorescent lights. The risk of cutaneous melanoma associated with exposure to some sources of artificial ultraviolet radiation was examined in a case-control study in a Scottish population with fairly low exposure to natural ultraviolet radiation. The risk was not significantly or consistently raised for exposure to fluorescent lights at home or at work. The use of ultraviolet lamps and sunbeds, however, was associated with a significantly increased risk (relative risk = 2.9; 95% confidence interval 1.3 to 6.4), and the risk was significantly related to duration of use. The risk was particularly raised among people who have first used [corrected] ultraviolet beds or lamps more than [corrected] five years before presentation (relative risk = 9.1; 95% confidence intervals 2.0-40.6), in whom it was significantly related to cumulative hours of exposure. The risks associated with exposure to ultraviolet lamps and sunbeds remained significant after adjustment for other risk factors for melanoma.

Cutaneous malignant melanoma in Scotland: incidence, survival, and mortality, 1979-94. The Scottish Melanoma Group.

Abstract Objective: To determine the changing incidence of and mortality from cutaneous malignant melanoma in Scotland from 1979 to 1994. Design: Detailed registration of clinical and pathological features, surgical and other treatment, and follow up of all cases of cutaneous malignant melanoma diagnosed from 1979 to 1994 and registered with specialist database for Scotland. Setting: Scotland. Subjects: 6288 patients with invasive primary cutaneous malignant melanoma diagnosed between 1 January 1979 and 31 December 1994. Results: The annual age standardised incidence of cutaneous malignant melanoma rose significantly from 3.5 to 7.8 per 100 000 per year in men and from 6.8 to 12.3 per 100 000 per year in women (P<0.001 for both). World standardised rates increased from 2.7 to 6.0 per 100 000 per year in men and 4.6 to 8.50 per 100 000 in women. The incidence of melanoma continued to increase significantly in men of all ages during the study, but the rate stabilised in women after 1986. Mortality from cutaneous malignant melanoma was 1.3 per million per annum in men in 1979, rising to 2.3 per million per annum in 1994 (P<0.01); it was 2.4 per million per annum in women in 1979, falling to 1.9 per million per annum in 1994 (P=0.09). The underlying mortality trends showed a continuing rise for men but a downward trend for women that was not significant (P=0.09). In men, melanoma free survival was 69% at 5 years and 61% at 10 years; in women the corresponding rates were 82% and 75%. Younger patients had higher survival rates, which were not entirely explained by thinner tumours. Over the 15 year period, survival rates improved by 12% overall, only partly owing to thinner tumours. Conclusions: In Scotland the incidence of melanoma in women has stabilised, while mortality associated with melanoma in women shows a downward trend. Key messages Data from Scotland based on 6288 patients with primary invasive cutaneous malignant melanoma show a rise overall in the incidence of melanoma over 15 years but a stabilisation in the incidence of melanoma in women under 65 since 1986 Mortality associated with melanoma is now falling in women of all ages, especially in women under 65 Survival prospects remain strongly related to tumour thickness at the time of diagnosis: disease free survival at 5 years for patients with melanoma thinner than 1.5 mm was 96% in women and 91% in men, while for those with tumours thicker than 3.5 mm survival was 54% and 42% respectively

Prevalence of atopic eczema in the community: the Lothian atopic dermatitis study

Summary An epidemiological study of atopic eczema (AE), based on a semirural community in Scotland, using sound diagnostic criteria, has yielded prevalence data for all age groups including infants and adults. The overall 1‐year period prevalence, age‐standardized to the Scottish population, was 2.3%. The 1‐year period prevalence was highest in the under 2s(9.8%), and showed a continuous reduction with increasing age. Over the age of 40, AE was found to be relatively rare, with a 1‐year period prevalence of 0.2%. Adults over 16 years made up 38% of all patients with AE.

The cost of atopic eczema

Summary Atopic eczema affects 2.3% of the U.K. population. We have carried out a community study in a semi‐rural area to assess its economic impact. One hundred and fifty‐five patients with atopic eczema were identified and expenditure was assessed over a 2‐month period. The mean personal cost to the patient was £25.90, while the mean cost to the health service was £16.20. There were 58 lost working days and 17 lost school days. A cohort of 10 severely affected patients attending the Royal Infirmary of Edinburgh were studied; each patient spent, on average, £325 in 2 months, and lead to a mean health service expenditure per patient of £415, in 2 months. If these results were extrapolated to the U.K. population, the annual personal cost to patients with atopic eczema would be £297m, the cost to the health service would be £125m, and the annual cost to society of lost working days would be £43m, making the total expenditure on atopic eczema £465m.

A rational approach to melanoma follow-up in patients with primary cutaneous melanoma

From the Scottish Melanoma Group database for south‐east Scotland we evaluated 5‐year follow‐up in patients with cutaneous malignant melanoma excised between 1979 and 1994 and devised an ‘evidence‐based’ review protocol. Of the 1568 with stage I melanoma, 293 (19%) developed a recurrence, 32 had a second primary melanoma and 97 had an in‐situ melanoma. The disease‐free interval shortened progressively with increasing tumour thickness. Overall, 80% of recurrences were within the first 3 years, but a few patients (< 8%) had recurrences 5 or 10 years after the initial surgery. In‐situ melanomas did not recur. Almost half (47%) the recurrences were noted first by the patient, and only 26% were detected first at a follow‐up clinic. One hundred and thirty‐nine patients (89%) were still under review when their recurrences were detected, and 102 (65%) had been seen within the previous 3 months. Questionnaires were completed by 120 patients: sun protection and avoidance, and mole examination were more likely after melanoma excision. We recommend 3‐monthly review of patients with invasive lesions for the first 3 years. Thereafter, those with lesions ≥ 1.0 mm need two further annual reviews. Patients with in‐situ lesions should be reviewed once, to confirm adequate excision (0.5 cm margins) and to give appropriate education. Surveillance beyond 5 years is only justified if there are special risk factors.

Measurement of quality of life in atopic dermatitis: correlation and validation of two different methods

Atopic dermatitis is a chronic relapsing condition that can have considerable effects on the lives of sufferers. It is apparent that good, valid measures of life quality are necessary for quantifying the patients’ perspective of the severity of their disease and the Dermatology Life Quality Index is often employed in clinical research. In a community study of atopic dermatitis we have assessed disability using the Dermatology Life Quality Index and the Patient Generated Index and compared the results from both indices. The results were significantly correlated and reflected the range of disability in patients in the community. Some items of the Dermatology Life Quality Index were not relevant for atopic dermatitis patients in the community and others, including swimming and sleep loss, were often cited in the patient Generated Index but are not included in the Dermatology Life Quality Index. The Patient Generated Index is a novel, flexible approach to quality of life measurement that may be suitable for reflecting the wide variety of disability that is experienced by dermatological patients.

The discrimination between nickel-sensitive and non-nickel-sensitive subjects by an in vitro lymphocyte transformation test.

A lymphocyte transformation test (LTT) was able to distinguish between nickel‐sensitive subjects and non‐nickel‐sensitive controls. Sixty‐one out of 66 (92%) nickel‐sensitive subjects had positive stimulation indices in 6‐ and/or 7‐day assays using 5 μg/ml of nickel sulphate, whereas none of the 43 controls gave positive results. Stimulation indices were not enhanced by the patch testing of subjects to nickel before performing the LTT. A weak correlation was seen between the results of the LTT and the macroscopic degree of patch‐test reactivity. The concentration of nickel sulphate used (5 μg/ml) did not have a significant non‐specific mitogenic effect.

Light and electron microscopic studies of physical injury to the skin II. Friction

Frictional injury to the skin causes inter‐ and intra‐cellular oedema of the epidermis, and if severe produces membranous rupture and formation of an intra‐epidermal blister. The appearances arc consistent with direct physical damage to the cells.