M.P. James

Percutaneous iontophoresis of prednisolone--a pharmacokinetic study.

Percutaneous iontophoresis of 1% prednisolone sodium phosphate through human skin and nail gives peak plasma levels of about one third of that produced by oral ingestion of 10 mg prednisolone. The presence of an epidermal reservoir of steroid was demonstrated by the retention of radio labelled prednisolone in stratum corneum for up to 2 weeks, and a high concentration of prednisolone in whole epidermis (24 h post‐iontophoresis) which was not present 24 h after oral ingestion of prednisolone. The possibility of using this technique for treating diseases of the skin and nails is discussed.

Treatment of severe acne with isotretinoin in patients with inflammatory bowel disease

Four patients with inflammatory bowel disease and severe cystic acne were treated with isotretinoin. Two patients had a successful course of treatment without any gastrointestinal side‐effects. One patient had two episodes of profuse rectal bleeding that were probably related to pre‐existing haemorrhoids. The fourth patient had a flare‐up of his Crohns disease after starting isotretinoin.

Diltiazem‐induced acute generalised exanthematous pustulosis

Pustulation is a major feature in several different dermatoses, and it may also occur as a manifestation of drug: hypersensitivity. Acute generalized exanthematous pustulosis (AGEP) is an uncommon eruption characterized by acute, extensive formation of sterile pustules, fever and peripheral blood leucucytosis. It shares several clinical and historical features in common with pustular psoriasis. Most reported cases have been triggered by ingestion of broad spectrum antibiotics, particularly betalactams and macrolides. There is usually rapid resolution of the eruption on drug withdrawal. We report the case of a 58 year‐old woman who developed AGEP shortly after commencing treatment with the calcium channel binder diltiazem hydro‐chloride. The eruption followed a biphasic course, and improved following treatment with systemic corti‐costeroids and methotrexate. AGEP appears to be a rare adverse cutaneous reaction to diltiazem, whereas a wide range of other skin eruptions have been reported more commonly with this drug.

Treatment of viral warts with cimetidine: an open-label study.

The immunomodulatory actions of cimetidine, an H2‐receptor antagonist, and its use in the treatment of viral warts has been described previously but its effectiveness is still debated. We report the results in 47 patients with multiple, nongenital viral warts who were treated with oral cimetidine in a 3‐month open‐label study. The drug was generally well tolerated and 87% of children and 68% of adults improved with treatment. Follow‐up data in 65% of the patients showed that there had been no recurrence in the majority of those whose warts had cleared completely during treatment, whereas warts tended to persist or recur in those who had stopped treatment before all the warts had resolved. Our data suggests that cimetidine may be helpful in the treatment of viral warts in both adults and children and supports the need for a randomized controlled trial.

Acquired kinking of the hair associated with etretinate therapy

We describe three patients in whom dose‐dependent, reversible kinking of the hair has occurred while receiving etretinate therapy. The morphological changes of the hair consist of incomplete twists, variation in bore and pigmentation. We propose that the changes may result from the drugs effect on the inner root sheath of the hair.

Extensive lichen sclerosus et atrophicus with bullae and ulceration--improvement with hydroxychloroquine.

A 55‐year‐old woman is described with a short history of generalized lichen sclerosus et atrophicus in whom extensive blistering and ulceration occurred. The disease was confined to extragenital sites at presentation, with no clinical evidence of mucosal involvement. The degree of blistering, rapid evolution and widespread involvement of non‐genital skin in this case are uncommon features. There was evidence of improvement following treatment with hydroxychloroquine, We suggest that this drug’ may be of therapeutic benefit in cutaneous lichen sclerosus.

Grover's disease, despite histological similarity to Darier's disease, does not share an abnormality in the ATP2A2 gene.

Sir, Epidermal grafting with suction blisters is used in treatment of stable vitiligo. Previous reports have shown various complications including postinflammatory hyperpigmentation, peripheral hypopigmentation and hypertrophic scarring. However, the risk of infection has not been reported to date. We report an unusual case of verruca vulgaris that appeared after epidermal grafting. It seems likely that virus particles might have been transferred from the operator, who had verruca vulgaris on his hand, to the patient during the surgical procedure. A 12-year-old girl with localized stable vitiligo was treated by epidermal grafting. Blisters on the recipient site formed within 24 h after three freeze±thaw cycles with liquid nitrogen. Blisters on the donor site were made by suction on the inner portion of the thigh. After approximately 3 h of suction at 200 mmHg, large unilocular bullae appeared. After removal of the blisters at the recipient site, the epidermal sheets were grafted to the denuded recipient site and held in place. Two weeks after grafting, once weekly systemic psoralen-ultraviolet A treatment was started. Almost complete repigmentation was observed 3 months after grafting. Four months after grafting, the patient noticed two verrucous plaques in the grafted site (Fig. 1). She denied warts on any other body sites. There was no history of similar lesions in her family or close friends. The operator, who wore gloves, had a verrucous papule on his hand during the surgery. Skin biopsy of two different lesions, on the patients back and the operators hand, demonstrated histological features of verruca vulgaris. Human papillomavirus (HPV) typing was not performed. Although epidermal grafting appears to be an effective and safe method for the treatment of vitiligo, various complications have been reported, of which some are associated with the application of liquid nitrogen, such as postinflammatory hyperpigmentation, hypertrophic scarring, peripheral hypopigmentation and uneven pigmentation. Koebner phenomenon and recurrence have also been considered complications of epidermal grafting. The possibility of transmission of virus from patient to patient or from patient to doctor has been reported. One study showed that virus may survive on a cotton swab dipped into liquid nitrogen and suggested that virus transmission from patient to patient may occur via this route. Charles and Sire reported the possibility of transmission of papovavirus indirectly by cotton-tipped applicators which had been used earlier to treat verruca in other patients. In our case, the same liquid nitrogen and cotton-tipped applicators were not used for multiple patients. Bergbrant et al. reported that there is a risk of contamination of the operator by HPV DNA, during both carbon dioxide laser and electrocoagulation treatment. Once an individual has been infected, new warts may develop in sites of inoculation over a period of weeks to months. After experimental HPV inoculation, it requires from 2 to 9 months for a verruca to become clinically apparent. This observation implies a relatively long period of subclinical infection. In our patient, the verruca appeared 4 months after grafting. It is unclear whether the verruca vulgaris resulted from direct contact with the operators hand during the surgical procedure, or with another person after grafting. However, there are several possible mechanisms of viral transmission from the operator to the patient: the operator may have palpated the lesion with his bare hand immediately after cryosurgery to evaluate the effectiveness of the freezing, or transmission may have occurred during application of a dressing after surgery. We suggest that the risk of transmission of infection from doctor to patient should be considered as a new complication of epidermal grafting.

Pseudopelade of Brocq occurring in two brothers in childhood

The cases of two brothers who both developed pseudopelade at the age of 7 years, with progressive patchy hair loss, are reported. Biopsy in the elder brother showed typical changes with reduced numbers of hair follicles and sebaceous glands, a sparse scarring. A third family member may have been affected. The absence of a family history in most cases suggests our patients may have a different aetiology. This report of two, possibly three, family members with pseudopelade suggests genetic factors may play a role in this family. Pseudopelade is very rare in children and we are not aware of any reports of familial occurrence. Atrophy rather than scarring is the primary feature of this condition and pseudopelade of Brocq should not be classified as a cicatricial alopecia.

Zosteriform atrophoderma of Pasini and Pierini

Astophoderma of Pasini and Pierini is generally regarded as an atrophic variant of morphoea. It arises most commonly on the trunk and abdomen. We describe a 53‐year‐old man who had a 12‐year history of unilateral atrophoderma of Pasini and Pierini affecting the left side of his trunk in a zosteriform distribution. Within these clinically atrophic lesions, there were localized areas of induration which were typical of morphoea. The patient also had a preceding history of balanitis xerotica obliterans. The occurrence of atrophoderma of Pasini and Pierini, morphoea and lichen sclerosus within the same individual supports the view that these conditions arc closely related, and suggests that common factors may be involved in their aetiologies.

Giant Becker's naevus with ipsilateral areolar hypoplasia and limb asymmetry

We report a case of giant Beckers naevus, ipsilateral areolar hypoplasia and limb asymmetry in a 48‐year‐old male. This is the first case in which Beckers naevus with areolar hypoplasia has been reported to be associated with other defects.