M.J. Sladden

Extensive plaque psoriasis successfully treated with adalimumab (Humira).

nus and the dental metals is not clear. Several reports have demonstrated lichen planus in the nails, with involvement of the buccal mucosa and the skin, caused by dental metals, but our report is the first in which nail lichen planus (twentynail dystrophy) caused by gold fillings was demonstrated in the absence of oral or skin involvement. We recommend that metal fillings should be removed in patients presenting with nail lichen planus and metal allergy, because an improvement or complete cure of not only oral lichen planus but also the nail lichen planus can be expected.

Current options for the treatment of impetigo in children.

Impetigo contagiosa is a common, superficial, bacterial infection of the skin characterised by an inflamed and infected epidermis caused by Staphylococcus aureus, Streptococcus pyogenes or both. The less common bullous impetigo is characterised by fragile fluid-filled vesicles and flaccid blisters, and is invariably caused by pathogenic strains of S. aureus. In bullous impetigo, exfoliative toxins are produced, although these are restricted to the area of infection and bacteria can be cultured from the blister contents. In the rare variant, staphylococcal scalded skin syndrome, the exfoliative toxins are spread haematogenously from a localised source causing widespread epidermal damage at distant sites.

Longitudinal melanonychia and pseudo‐Hutchinson sign associated with amlodipine

the frenulum was detectable without any association to the canal. After incisional opening of the canal, more than 30 up to 3-cm-long black and blond hairs appeared (Fig. 1b). Histopathological evaluation of the canal at its proximal part demonstrated an almost normal hair follicle containing numerous hair shafts (Fig. 1c). No recurrence occurred at the site of excision, but after 6 months new hair growth was noted at a different location on the glans, which again required excision. The reported case of repeated hair growth at the glans penis seems to be a very rare finding; we failed to find comparable reports in the related literature. The folliculogenesis and hair growth at this location is completely unclear: a hamartomatous growth (by definition, tissue in an inappropriate quantity at a site of normal existence) does not explain the lesion, while neither the glans nor the inner prepuce is known to normally contain any hair follicles. A connection to the median raphe cyst, although clinically excluded, should not result in the formation of hair follicles, as raphe cysts are lined by either urothelium or stratified squamous epithelium, usually with infundibular differentiation. Traumatic dermal implantation of epidermal and appendageal structures may constitute cysts rather than normal follicles. An embryological misplacement of follicular epithelium, mentioned previously as the origin of naevus comedonicus at the glans penis, is theoretically possible, but clinically recognizable changes would be expected earlier in life. Not excluded could be the development from epithelial cells, which have still conserved their embryonic pluripotentiality harbouring follicular differentiation. As the genesis of this unusual finding is uncertain, we found the descriptive term of ectopic hair on the glans penis most appropriate.

Fumaric acid esters for severe psoriasis: the Leicestershire experience

A similar unexpected increase in TNF-a has been observed in the thalidomide therapy of oral aphthous ulcers in patients with human immunodeficiency virus infection. In vitro findings suggest that thalidomide, at concentrations achieved in vivo, could either enhance or suppress the synthesis of TNF-a depending on the cell types stimulated. Therefore, thalidomide could enhance TNF-a production in certain conditions such as TEN. On the other hand, TNF-a inhibitors pentoxifylline and N-acetylcysteine have been used successfully in the treatment of TEN, further supporting the involvement of TNF-a in the pathogenesis of this condition.

Alopecia areata: the need for guidelines and evidence‐based dermatology

itch in a patient suffering from HES-induced pruritus. This reaction was most pronounced in those skin areas in which spontaneous itch was perceived. As the tested skin sites did not show the expected spreading erythema during neurogenic inflammation induced by depolarization of sensory nerve fibres, there is no evidence for a peripheral sensitization process. In addition, peripheral sensitization would be expected to enhance pain sensitivity and therefore pain ratings would increase, sensations that were clearly not enhanced in our patient. Thus, we conclude that the most probable explanation for the electrically and mechanically induced itch is sensitization of the spinal processing of itch. Ongoing activity of peripheral ‘itch-neuron’ itch receptors has been proposed to induce and maintain the state of hypersensitivity to pruritic stimuli in the spinal cord. Our results cannot explain the mechanism by which the peripheral itch receptors are activated in the HES-treated patient. However, the identification of central sensitization as a component of this clinical itch condition might have therapeutic implications; in neuropathic pain conditions central sensitization has been successfully treated by gabapentin. It will be of major interest to explore further the therapeutic implications of central sensitization for the treatment of pruritus induced by HES.

Childhood sarcoidosis presenting with extensive cutaneous lesions, bilateral hilar lymphadenopathy and severe hypercalcaemia

A 9‐year‐old boy with a history of atopic dermatitis presented with a 4‐month history of an asymptomatic papular eruption. This was predominantly perioral in distribution with lesser involvement of the neck, arms and trunk. Investigations revealed severe hypercalcaemia of 3.77u2003mmol/L (normal range 2.10–2.60) and bilateral hilar lymphadenopathy. The diagnosis of sarcoidosis was supported by granulomata in skin and lymph node biopsies on histopathological examination. Prednisolone (2u2003mg/kg/day) rapidly normalized serum calcium.

The use of dietary manipulation in patients referred to a contact dermatitis clinic

reflects the activation of peripheral T lymphocytes. In summary, to our knowledge, we are the first group to have shown a positive correlation between telomerase activity in PBMC and disease severity of psoriasis, but not duration. Telomerase activity in PBMC may serve as an objective indicator of psoriasis severity, and inhibiting telomerase activity may become a new target for psoriasis therapy.

Complete resolution of dermatitis herpetiformis with the Atkins' diet.

diagnostic excision biopsy (50%). Only this latter approach and the single diagnostic 10-mm excision form part of the World Health Organization trial protocol on which the U.K. guidelines for a melanoma of this depth are based. The definitive surgery (defined as the single excision in one-stage procedures or the second excision in two-stage procedures) was performed by 71% of respondents down to fascia and by 22% down to fat. The remaining 7% stated that their excision would be down to fat ⁄ fascia which was further explained by some as referring to surgery undertaken down to either approximately 10 mm of fat or down to fascia, whichever came first. Clinical experience dictates that this would usually result in an excision down to mid-fat, particularly at a site such as the back. The surgical treatment of melanoma began about a century ago with surgeons such as Pringle excising tumour and adjacent skin down to and including deep fascia. Removal of deep fascia is no longer indicated. Clearance of subcutaneous tissue down to but not including fascia is now considered appropriate. The major trials addressing the surgical treatment of melanoma and the Scottish guidelines concur on this point. However, it is not clearly stated in either the U.K. or the American guidelines, presumably assuming this knowledge of the reader. This may contribute therefore to the significant number (29%) of respondents in our survey undertaking potentially suboptimal treatment of their patients. When marking their re-excision, 79% of respondents would take their measurement from the edge of the scar compared with 21% who would measure from the centre of the scar. The former approach seems logical and is in keeping with the concept of the excision margin referring to clinically normal skin. The actual shape of the re-excision also proved subject to variation, with a design maintaining the margin for the entire length of the scar with tapered ends being preferred by 72%. In our experience these exact practical details of the procedure are not clearly described in the literature or surgical texts and are generally passed on from surgical tutor to trainee. It can be argued that a number of different designs may be appropriate in individual circumstances and that the choice is dependent on the exact dimensions and orientation of the primary lesion within the diagnostic biopsy specimen. Some flexibility in approach should therefore be maintained. However, in clinical practice these details may not always be recorded in the notes or exactly recalled by the surgeon who may be required to make a best guess when designing the re-excision. In summary, this survey has demonstrated that some minor and some more significant variation in practice may be observed in terms of margin and, more notably, depth of excision when different British dermatological surgeons treat a thin primary melanoma. Whether this affects clinical outcome is not known but it results in varying amounts of skin and subcutis being excised in the same given clinical situation. Published guidelines undoubtedly do inform management, but do not and cannot ensure uniformity of treatment and are open to differing interpretations by individual clinicians. It is only through awareness of and adherence to clear recommendations regarding surgical margin, depth and technique by means of consistent teaching and accurate clinical audit that this can be achieved.

Melanoma in Leicestershire: effect of the 2-week wait system on presentation

SIR, Following the introduction of the 2-week wait (TWW) policy, we developed a one-page ‘tick-box’ ‘fax-back’ proforma to facilitate general practitioner (GP) referral of patients with suspected melanomas to our pigmented lesion clinic (PLC). The proforma included questions relating to the sevenpoint melanoma checklist as an ‘aide-memoire’, in the hope of improving the quality and content of the referral letter. However, GPs do not refer all suspected melanomas through the TWW system, potentially delaying diagnosis. We therefore screen all referral letters sent to our dermatology department and any lesions suspected to be melanomas based on the information supplied by the GP are allocated urgent PLC appointments. It is possible, however, that the diagnosis of some melanomas may be delayed using this referral route because it depends on the quality and content of the GP referral letter. Therefore, we performed a retrospective case note review of all melanoma patients presenting in Leicestershire for the 12-month period from October 2001 to September 2002, in order to evaluate the effect of the TWW policy on our melanoma referral patterns. Cases of melanoma were identified from the hospital’s computerized histopathology database. The following data were recorded: date of GP referral letter, hospital visit and melanoma excision; information on referral letter content; whether the dermatologist suspected melanoma based on the referral letter content; and the clinical details, excision margin and Breslow thickness of each melanoma. Data were entered on a computerized database and analysed using SPSS for Windows version 12.0 (http://www.spss.com 2003). Results from the present study were compared with those from a 10-year review (1984 and 1994) of all Leicestershire melanoma cases, before the introduction of the TWW, for whom the mean referral interval was 20 days. During the 12-month study period, there were 106 new cases of melanoma (46 male, 60 female). Only 58 (55%) patients with melanoma attended via the TWW route of referral. Only 7% of patients with melanoma were referred using the TWW proforma. Following the hospital appointment, the clinician thought that 36 (34%) lesions were definite melanoma, 50 (47%) probable melanoma and 20 (19%) possible melanoma/uncertain of diagnosis (this 19% is almost identical to the 18Æ5% false-negative rate we previously reported). This contrasts with assessment based solely on the content of GP letters, when we considered that 38% of lesions might be melanoma and that 7% would not be melanoma, but could not classify 55% of lesions due to inadequate clinical detail. The percentages of referral letters detailing clinical aspects of the lesion were as follows: site (100% of cases), size (60%), duration (18%), change of size (69%), change of pigment (44%), bleeding/weeping/crusting (56%), itching (35%), irregular pigmentation (59%) and irregular shape (51%). We found no correlation between any of the clinical features of the lesion (including data provided in the GP letter, whether or not the recommended checklist referral criteria were fulfilled, and specialist assessment) and use of the TWW route of referral. The mean ± SD referral interval (time between GP referral and clinic attendance) was 24 ± 31 days (median 13, range 1–210); this was similar to the mean interval of 20 days preTWW (P 1⁄4 0Æ5). Patients referred via the TWW route were seen significantly sooner than those who were not (mean 11 days vs. 39 days, P 1⁄4 0Æ02) and waited less time to have their lesions excised (mean 8 days from initial hospital visit to melanoma excision vs. 26 days, P 1⁄4 0Æ015). In summary, the introduction of the TWW system has had little overall impact on the mean referral interval for our patients with melanoma. Patients with melanoma who are referred via the TWW system benefit by having shorter referral and excision times, but this is at the expense of those patients who are not correctly referred via the TWW. It is of concern that the GP decision to use the TWW referral route does not appear to be made on logical clinical grounds, as evidenced by the lack of correlation with the clinical features of the lesion. Until GPs are supported and encouraged to use the TWW system correctly, and to supply adequate clinical details to hospital specialists to allow appropriate patient assessment and prioritization, patients remain at risk of delayed diagnosis and treatment of their melanomas.

Is melatonin useful in alopecia: critical appraisal of a randomized trial?

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