Michael Feiwel

AUTOANTIBODIES IN PATIENTS WITH VITILIGO

Abstract Patients with vitiligo show a tendency to increased autoantibody formation. Those patients with adrenal autoantibodies may be clinically at risk for the development of adrenal insufficiency. Vitiligo may be regarded as a member of the family of autoimmune disorders.

Vitiligo and its aetiological relationship to organ-specific autoimmune disease.

SUMMARY.— The association of vitiligo with organ‐specific autoimmune disorders has been examined with particular reference to pernicious anaemia. A significantly increased incidence of gastric parietal cell antibody was found in serum of sixty‐two patients with vitiligo. There is now sufficient clinical and investigative evidence to suggest that absence of melanocytes from lesions of vitiligo results from immunological disturbance.

Pemphigus controlled by sulphapyridine

A patient with an II‐year history of a generalized blistering eruption is described. The eruption was completely controlled within I week of taking sulphapyridine and recurred within 4 days of with‐drawal of this drug. On account of these observations a diagnosis of dermatitis herpetiformis was made. Histological, immunological (and small intestinal) studies now show that this patient had pemphigus.

A REVIEW OF THE CONCEPT OF WEBER‐CHRISTIAN PANNICULITIS WITH A REPORT OF FIVE CASES

SUMMARY. —Five patients with Weber‐Christian panniculitis (W.C.P.) are described. These illustrate the great variability of the clinical course of cases to which this diagnosis is applied. In two (one fatal) no aetiological factor was found, one case was considered to be an artefact, one was related to tuberculosis and another was possibly a manifestation of systemic lupus erythematosus.

PITUITARY-ADRENAL FUNCTION AFTER OCCLUSIVE TOPICAL THERAPY WITH BETAMETHASONE-17-VALERATE

Abstract Six adult patients with widespread, acute, skin disease were treated with topical betamethasone-17-valerate ointment under polyethylene occlusion for 14 days. The levels of urinary and plasma steroid fell—presumptive evidence of systemic absorption of topically applied steroid. This clinically effective therapeutic regimen, however, did not appreciably diminish hypothalamopituitary-adrenal function after the treatment was stopped.

XANTHOMATOSIS IN CRYOGLOBULINAEMIA AND OTHER PARAPROTEINAEMIAS WITH REPORT OF A CASE

SUMMARY.— The occurrence of xanthomatosis in paraproteinaemias is rare but is now reasonably well documented. Thirteen cases from the literature and a case associated with cryoglobulinaemia, which is more fully described, are discussed. Some were hyper‐and others normolipidaemic. Most had generalized plane xanthoma, regarded as a normolipidaemic xanthomatosis. To explain the varied findings, it is postulated that certain paraproteins may interfere with lipoprotein metabolism and also behave as autoantibodies to elicit generalized plane xanthoma. These 2 attributes may coincide in some patients but occur separately in others.

PERIORAL DERMATITIS: AETIOLOGY AND TREATMENT WITH TETRACYCLINE

Summary.— “Perioral dermatitis” has been studied in 29 patients; all were females in their child‐bearing years, with ages ranging from 18 to 39 (mean 27).

30) Benign hyperglobulinaemic purpura of Waldenstrom

There is no previous history of skin disease, no acne vulgaris. His mother and sister have been similarly affected. Examination. There are folliculo-papular lesions on his right cheek in a circular pattern occurring around a diffuse centrally scarred area (Fig. i). Biopsy. There are prominent piloscbaceous follicles with keratin plugging, and a chronic inflammatory reaction in the corium with a whorled fibroblastic proliferation in one area. No pustular, granulomatous or giant cell foci are seen, but some plasma cells and Russell bodies are present among the inflammatory cells. Treatment. July 1973, Tabs, Dcteclo 1 twice daily produced some improvement after 3 months, Dec. 1975. After a recurrence of his facial rash, erythromycin by mouth was prescribed with slight improvement. Feb. 1976. Prednisone 10 mg on alternate days was started and the erythromycin continued. Comment. The clinical appearance and histological changes arc compatible with a diagnosis of lupoid sycosis.

PERCUTANEOUS ABSORPTION OF TOPICAL STEROIDS IN CHILDREN

SUMMARY.— Percutaneous absorption of topical steroids occurs more readily in children than in adults. Potent topical steroids may be used in infantile eczema in order to bring, it under control as soon as possible and to restore the barrier function of the stratum corneum. If, however, the eczema is unresponsive, then prolongea and excessive applications should not be made, for adrenal function is likely to become depressed. In such cases it is advisable to have recourse to bland therapy.

Dermatitis herpetiformis and gluten enteropathy: a unifying concept.

Party report and cash limits have curtailed the ability to meet such increases. The increase in expenditure in real terms is no doubt due to several factors among which are the tendency to use higher doses of individual drugs or more drugs in combined regimens; real increases in the cost of some drugs; and the application of chemotherapy by an increasing number of clinicians to a progressively widening spectrum of cancers. These last two are probably the most important factors. There are now few cancers where chemotherapy is not being used to some degree, either speculatively or under clinical trial conditions; given the extreme complexity of many of the multi-drug regimens there seems much to be said on both clinical and economic grounds for them to be used primarily in the latter mode within the context of the multidisciplinary oncological team. Increasing experience in the use of cytotoxic chemotherapy and in the control of toxicity have made this expansion feasible, and though results so far are perhaps rather disappointing, the possibility of a major advance in the management of solid tumours using cytotoxic drugs can by no means yet be discounted. This might come from the development of new ways of using existing drugs or from the discovery of new drugs. The costs appear high but costs are relative. If, for example, there was clear evidence that spending £16 million on chemotherapy for breast cancer brought sufficient dividends in terms of lives saved or usefully prolonged then it might become a sustainable cost. If that cannot be demonstrated in respect of any cancer then the use of intensive chemotherapy becomes economically difficult to justify and difficult to justify also on clinical grounds in view of the high non-monetary costs of the treatment (British Medical Journal 1978). The only way we can get the evidence required to make rational decisions on this is through good clinical trials. It is vitally important that there is a carefully coordinated programme of high quality clinical trials set up at the earliest opportunity in relation to any cancer where it is suggested that chemotherapy may be of benefit and for any new cytotoxic agent released for clinical use. It is an urgent problem and it is encouraging that coordination is already happening under the aegis of the Medical Research Council and the Cancer Research Campaign. The results of these trials must of course be published as soon as a scientifically valid conclusion has been reached, but it is essential that early results are treated with the utmost caution. A very prolonged period of observation is necessary to demonstrate improved survival, the ultimate criterion of benefit, and long-term toxic effects (Williams & Carter 1978): without good evidence on both counts a great deal of highly toxic and expensive therapy may be given to no avail. R J Wrighton Senior Medical Qfficer Department of Health & Social Security