Kevin Y. C. Lee

Turning the tide: a history and review of hyperhidrosis treatment

Summary Hyperhidrosis is a potential cause of severe physical and psychological distress, interfering in activities of daily living. Over the past 100 years, advances have been made regarding the treatment of this debilitating condition with some success. Surgical treatment with sympathectomy was successfully performed for hyperhidrosis in the early part of the 20th century, with various modifications of the technique over the past 100 years. Topical aluminium salt antiperspirants, anticholinergic medications, iontophoresis and botulinum toxin introduced less invasive ways to manage this condition. This historical review will enable dermatologists and non-dermatologists to manage this distressing condition.

Intracostal neuralgia as a previously undescribed symptom of Schnitzler's syndrome.

1 Sugimoto M, Masutani S, Seki M et al. High serum levels of procollagen type III N-terminal amino peptide in patients with congenital heart disease. Heart 2009; 95:2023–8. 2 Trivedi P, Cheeseman P, Portmann B et al. Variation in serum type III procollagen peptide with age in healthy subjects and its comparative value in the assessment of disease activity in children and adults with chronic active hepatitis. Eur J Clin Invest 1985; 15:69–74. 3 Hørslev-Petersen K, Bentsen KD, Engström-Laurent A et al. Serum amino terminal type III procollagen peptide and serum hyaluronan in rheumatoid arthritis: relation to clinical and serological parameters of inflammation during 8 and 24 months’ treatment with levamisole, penicillamine, or azathioprine. Ann Rheum Dis 1988; 47:116–26. 4 Guha N, Erotokritou-Mulligan I, Burford C et al. Serum insulin-like growth factor-I and pro-collagen type III N-terminal peptide in adolescent elite athletes: implications for the detection of growth hormone abuse in sport. J Clin Endocrinol Metab 2010; 95:2969–76. 5 Crofton PM, Wade JC, Taylor MRH, Holland CV. Serum concentration of carboxyl-terminal propeptide of type I procollagen, amino-terminal propeptide of type III procollagen, cross-linked carboxyl-terminal telopeptide of type I collagen, and their interrelationships in schoolchildren. Clin Chem 1997; 43:1577–81. 6 Erotokritou-Mulligan I, Bassett EE, Cowan DA et al. Influence of ethnicity on IGF-I and procollagen III peptide (P-III-P) in elite athletes and its effect on the ability to detect GH abuse. Clin Endocrinol 2009; 70:161–8. 7 Barker J, Horn EJ, Lebwohl M et al. Assessment and management of methotrexate hepatotoxicity in psoriasis patients: report from a consensus conference to evaluate current practice and identify key questions toward optimizing methotrexate use in the clinic. J Eur Acad Dermatol Venereol 2011; 25:758–64.

British Association of Dermatologists’ guidelines for the investigation and management of generalized pruritus in adults without an underlying dermatosis, 2018

G.W.M. Millington iD , A. Collins, C.R. Lovell, T.A. Leslie, A.S.W. Yong, J.D. Morgan, T. Ajithkumar, M.J. Andrews, S.M. Rushbook, R.R. Coelho, S.J. Catten, K.Y.C. Lee, A.M. Skellett, A.G. Affleck, L.S. Exton, M.F. Mohd Mustapa and N.J. Levell Dermatology Department, Haematology Department, Nephrology Department and Hepatology Unit, Norfolk and Norwich University Hospital, Colney Lane, Norwich NR4 7UY, U.K. Dermatology Department, Royal United Hospital, Combe Park, Bath BA1 3NG, U.K. Dermatology Department, Royal Free Hospital, Pond Street, London NW3 2QG, U.K. General Practitioner, Chet Valley Medical Practice, 40–48 George Lane, London NR14 6QH, U.K. Oncology Department, Addenbrooke’s Hospital, Hills Road, Cambridge CB2 2QQ, U.K. Dermatology Department, St George’s Hospital, Blackshaw Road, London SW17 0QT, U.K. Dermatology Department, Ninewells Hospital, Dundee DD1 9SY, U.K. British Association of Dermatologists, Willan House, 4 Fitzroy Square, London W1T 5HQ, U.K.

Uremic pruritus is improved by gabapentin.

encompass obsessive thoughts. Stressful events prior to the onset of the condition may act as triggering or aggravating factors. Young women comprise the majority of patients. The present case demonstrates the importance of acquiring a complete history and a review of systems analysis, including psychological aspects of the patient’s condition. It also demonstrates how interdisciplinary collaboration among dermatologists, psychologists, and psychiatrists is important in managing these cases in order to achieve optimal results.

An historical account of dermatology in Buddhist Sri Lankan literature

Buddhist teachings were transferred down the generations through the oral tradition as Sutras. They were written onto ola leaves for the first time in 29–30 BCE in Sri Lanka. The language used was Pali, now understood by few people other than Buddhist monks. A copy of this ola leaf manuscript, known as the Thripitaka (Pali Canon), is kept in each Buddhist temple. There are many writings of interest and relevance to dermatology in Buddhist teachings, but they have received relatively little attention, particularly in the West.

Acute febrile neutrophilic dermatosis(Sweet's syndrome) in a patient with biliary sepsis.

Robert Sweet first described acute febrile neutrophilic dermatosis (Sweets syndrome (SS)) in 1964 affecting eight women. They had four cardinal features: fever, neutrophilia, tender plaques and dermal infiltrate of neutrophils histologically.1 SS is rare and occurs worldwide with no racial predilection.2 Associations include infections, drugs, malignancy, inflammatory bowel disease and pregnancy.2 We present a case of SS in a patient with biliary sepsis. A 54-year-old Caucasian man developed pyrexia, leukocytosis with neutrophilia and raised C-reactive protein one day after transhepatic biliary stent insertion. Intravenous piperacillin/tazobactam (Tazocin, Pfizer, USA) was started for presumed biliary sepsis. He remained pyrexial 2 days later. The antibiotic was changed to meropenem. He remained unwell with swinging pyrexia while his leucocytosis, neutrophilia and C-reactive protein worsened over the following 5 days. Two days after he became unwell, …

Photoletter to the editor: Dermatitis herpetiformis co-localised with vitiligo in a patient with autoimmune polyglandular syndrome.

We report a case of dermatitis herpetiformis co-localised with segmental vitiligo in a 37-year-old woman with a background history of autoimmune polyglandular syndrome type 2. We propose genetic mosaicism as a possible mechanism. There has only been one previous case report in which dermatitis hepetiformis co-localised in close proximity but not exclusively within vilitigo in a patient with autoimmune thyroiditis. To our knowledge, this is the first case report of dermatitis herpetiformis co-localised exclusively to segmental vitiligo in the presence of autoimmune polyglandular syndrome.

A brush with danger: historical review of topical immunotherapy for alopecia areata

Topical immunotherapy – the therapeutic application of a topical allergen to induce an immune response – is indicated for the treatment of alopecia areata (AA). Its use in this area has developed as a result of successful treatment of viral warts. The current contact sensitizer of choice is diphencyprone, following a serendipitous discovery. The mechanism of action remains unknown, although antigenic competition has been suggested.

Eccrine Porocarcinoma of the Skin is Rising in Incidence in the East of England

Eccrine porocarcinoma (EPC) was first described by Pinkus & Mehregan in 1963 (1) as “epidermotropic eccrine carcinoma” and is the malignant counterpart of eccrine poroma. It is a rare tumour (0.005–0.01% (2, 3) of cutaneous tumours), thought to arise from the acrosyringium of the sweat gland of the skin. The term “porocarcinoma” was first used by Mishima & Morioka in 1969 (4). Although initial case series suggested that this was a highly aggressive tumour, with approximately 60% of cases reported to have local recurrence, metastases or death, later larger case series of 18, 24 and 27 patients, respectively, did not support such an aggressive natural history (3, 5, 6) The largest case series to date (69 cases) in 2001 (7), reported EPC as a less aggressive tumour, with 17% local recurrence, 19% lymph node metastasis and 11% distant metastases or death. This study analysed the age-standardised incidence rates for the population of the East of England (East Norfolk and Waveney), and estimated the numbers of cases likely to be found here and in the UK for 2020, 2025 and 2030. This cohort (n = 152) is the largest reported so far and there are long-term follow-up data for recurrences, metastases and survival/death, thus helping to clarify the natural history of this tumour.

A case of subcutaneous dirofilariasis presenting in the UK: an unexpected finding

essential hypertension on treatment. Of the remaining 20 patients, 9 were excluded because they did not attend follow-up, their ABPI was > 1 or they had died. The remaining 11 patients comprised 3 women and 8 men (63.1 18.2 age mean SD years, range 39–94) who fulfilled the criteria for chronic resistant ulceration, 8 of whom had hypertension. One patient with hypertension also had Klinefelter syndrome and declined full testosterone replacement, and another patient with hypertension also had chronic venous hypertension, which was thought to be the main ulcer aetiology. A clinical diagnosis of HLU was made in the remaining six patients with hypertension. A skin punch biopsy was taken in three cases to exclude malignancy. These biopsies were not considered deep enough to assess arteriolar hypertensive changes. Of the three patients with chronic ulcer who were not hypertensive, one had Klinefelter syndrome and was on testosterone replacement, one was thought to have chronic venous ulceration and the other was an intravenous drug user who had continued to inject. Hypertension was strongly associated with chronic resistant ulceration (Table 1). The HLUs were all on the lateral or posterior calf above the ankle and some were multiple. At presentation, an ischaemic-looking purplish edge was typical. Ulcers were painful in all cases (Fig. 1). These results show that when other causes of leg ulceration have been excluded, hypertension is strongly associated with chronic ulcers unresponsive to conservative topical therapy. In keeping with the findings of Hafner et al. and an earlier study from our own department, HLU may account for as many as 7% of leg ulcers seen in our service, and chronic hypertension may be a contributing factor in others. As such it appears to be commoner than PG, from which it must be distinguished as the therapeutic interventions for each are very different.