P. Todd

Hidradenitis suppurativa, Dowling-Degos and multiple epidermal cysts: a new follicular occlusion triad

This case illustrates the rare association between hidradenitis suppurativa (HS) and Dowling–Degos disease (DDD). Furthermore the association of HS, DDD and multiple epidermal cysts has not to our knowledge been described before, but their coexistence in the same patient is likely to reflect the same follicular anomaly. It is possible that a single underlying defect of follicular proliferation may account for the coexistence of these conditions.

T-cell lymphoma presenting with severe digital ischaemia.

We report a case of T‐cell lymphoma which presented with sudden severe digital ischaemia.

Patch testing in lichenoid reactions of the mouth and oral lichen planus

The role of allergic contact dermatitis in the pathogenesis of orai iichen pianus/lichenoid reactions remains controversial. The standard European, dental (Chemotechnique), organic mercurial and food batteries were appiied to 53 patients with biopsy proven, symptomatic oral lichen pianus (or iichenoid reactions in the mouth) between 1983 and 1988. There were 91 positive reactions in 39 patients: mercury/organic mercurials (22 positives in 15 patients), fragrances (20 reactions in 13 patients), foods (12 reactions in 10 patients: eight cinnamaidehyde, four benzoic acid), medicaments (11 positives in seven patients), metals (19 positives in 17 patients: nine CUNO3, six nickei, four other), rubber mixes (four reactions in four patients), and coiophony (three patients). In addition, there were several irritant reactions, mostiy to mercury and CUNO3. The patch test reactions were thought to be reievant in 21 patients, not relevant in 10 and undetermined in eight patients. Ofthe 21 patients with relevant positive reactions, 13 were thought primariiy to be due to mercury (seven patients had amaigams repiaced and all improved, three patients deciined replacement and three were lost to followup), four to cinnamaldehyde/benzoic acid (ail improyed on dietary restriction/change in toothpaste), two to rubber mixes (both improved on replacement of rubber pillows), one to nickel (patient with rheumatoid arthritis on gold injections who fiared after each injection) and one to formaidehyde (improved after change in toothpaste). Although the aetioiogy of oral lichen planus is still unknown the results of the present study would support the view that contact aiiergy plays a significant roie in its pathogenesis.

Generalized granuloma annulare in a photosensitive distribution resolving with scarring and milia formation.

We describe an unusual case of generalized granuloma annulare (GA) in a 70‐year‐old man. This occurred in a photosensitive distribution, responded rapidly to topical and systemic treatment, and resolved leaving residual scarring and milia. To our knowledge, this is the first report of the occurrence of milia formation and scarring in association with GA.

Cyclosporin and gingival hyperplasia.

SIB, GinjiCival hyperplasia is a well-recognized side-effect of cyclosporin therapv. As cyclosporin is being used more frequently in tbe management of dermatological conditions, tbose prescribing this drug should be aware of this side-effect and seek early specialist advice for ibeir patients. We sbould like to report a recent case wbicb illustrates tbis feature. In June 1988, a 28-year-old Caucasian female was admitted to our ward as an emergency witb an acute onset of acbing limbs, genera! malaise and abdominal pain. Examination revealed a peri-orbital beliotrope rasb and a maculopapular erythematous rash on ber forehead, anterior cbest, dorsal surface nf ber fingers and metacarpophalangeal joints. Sbe bad periungual erythema and capillary dilatation, .\ symmetrical proximal muscle weakness and tenderness was noted in both upper and lower limbs. Extensive investigations confirmed tbe clinical diagnosis of dermatomyositis. Treatment was commenced with high doses of steroids, but despite tbis ber myositis worsened rapidly, and in July 1988 cyclosporin (oral suspension) was introduced at a dose of 5 mg/kg body wt daily. A furtber deterioration in ber condition in August 1988 prompted an increase in tbe cyclosporin (oral suspension) dose to 7-5 mg/kg daily, which was followed by marked, sustained improvement in ber condition. In October 198S ber cyclosporin was changed to tbe capsular form and, as tbis caused an elevation in whole blood levels of cyclosporin above tbe recommended target concentrations suggested by Sandoz, ber cyclosporin was reduced to 3 mg/kg daily, resulting in acceptable cyclosporin levels, Sbe developed bypertension, and metoprolol was commenced in January 1989, Beta blockers did not adequately control her hypertension, so nicardipine was added in February 1989 at a dose of 20 mg t,d,s. Nicardipine caused a further increase in her cyclosporin levels necessitating an additional reduction in ber cvclosporin dose to 2 mg/kg daily. Currently sbe is maintained in remission on this do.se of cyclosporin, prednisolone baving been discontinued December 1989,

Four cases of allergic contact dermatitis caused by methylchloroisothiazolinone/methylisothiazolinone in ironing water.

Methylisothiazolinone (MI) (CAS no. 2682-20-4) and methylchloroisothiazolinone (MCI) (CAS no. 26172-55-4) have been widely used as preservatives in cosmetics, household products and industrial products since the late 1970s. The first cases of contact allergy to the MCI/MI combination were noted in 1980 (1). Ironing water is being increasing used as a product designed to making ironing more enjoyable. The role of ironing water is to bring a fresh, outdoorsy fragrance to the ironing process; it is also claimed that these products smooth away creases, and protect the iron from limescale. We report four cases of allergic contact dermatitis caused by MCI/MI found in ironing water, an usual source of exposure. There has been only a single previous case report in the literature (2).

Five cases of cutaneous leishmaniasis in Cambridge, U.K.

SIR, We thank Dr Solomon for taking the time and interest to write after reading our article. He clearly has considerable expertise in injecting Botox under regional anaesthesia, and the few cases I have done have been performed using a Bier block (performed by one of our anaesthetists). We are generally funded in our hospital to do axillae only, hence our limited experience of injecting palms. It was one of our patient’s comments that she had paraesthesia lasting a couple of days that prompted me to think of alternative methods of Botox delivery. We agree that ice is ineffective and barbaric. The comment that Botox injection ‘invariably causes a transient weakness of small hand muscles’ was based on our reading of the literature and on verbal communications from colleagues, but we are pleased to be corrected if we overstated. The cost of Botox in the U.K. at present is not inexpensive at £130 (

Case 2. Cutaneous leishmaniasis, leishmania amastigotes.

260) per 100 IU for National Health Service hospital practitioners. What is more expensive, however, is the anaesthetist’s time, although there are some dermatologists who perform their own regional block. We have not undertaken to learn the technique until our hospital approves funding for such patients, and there has been some concern that repeated injection of regional nerves may be damaging. The technique described by Dr Solomon obviates that risk, and indeed, intravenous regional anaesthesia for the same indication was brought to attention in the correspondence section of this Journal a few years ago. We appreciate that the method of applying a small tourniquet to the wrist, while using a small dose of lignocaine, allows the tourniquet to be let down over 5 min after injections, without fear of a rapid infusion of a large dose of lignocaine. Finally, we believe that novel methods of painless drug delivery are worth testing, and should we manage to get this method to work easily, one could envisage a role for nurseled Botox iontophoresis, as is currently in use for tap water or glycopyrrolate.

An immunohistological study of cutaneous lymphocytes in vitiligo

A 50-year-old veterinary surgeon presented with an asymptomatic nodule on her right upper cheek. This lesion did not respond to self-medication with topical steroids, antifungals or antibiotics. She was also prescribed oral fluconazole for 2 weeks with no benefit. She gave a history of travel to Egypt 21 months ago and Southern Spain 10 months ago. She had numerous insect bites on her Spanish trip. She was otherwise in good general health and did not take any medications regularly. On examination, she had a nontender 9-mm nodule with an erythematous edge and central keratotic area on her right upper cheek (Fig. 1). She had no other lesions elsewhere. Haematological, biochemical and baseline immune function tests were unremarkable. Mycology of skin scrapings was negative.