Robert R. Kierland

AN UNUSUAL VARIANT OF LUPUS ERYTHEMATOSUS OR LICHEN PLANUS

Four patients with a similar eruption of distinct livid plaques are presented. Clinically, the lesions were difficult to diagnose as either lichen planus or lupus erythematosus. However, histological studies with standard and immunofluorescence staining methods were more consistent with lichen planus. In contrast, certain laboratory findings and the clinical course were suggestive of lupus erythematosus.

Livedo Reticularis with Ulcerations

Idiopathic livedo reticularis may be associated with ulcerations of the lower extremities beginning primarily during the warmer or summer months, as well as the more usual occurrence of winter ulcerations. Summer ulceration apparently is a new and rare entity which has many clinical and histopathologic features similar to winter ulcerations. Hypertension, Raynauds phenomena, acrocyanosis and thrombosis of digital arteries were noted only in patients with winter ulcerations, while edema of the legs and feet was a more prominent feature in patients with summer ulcerations. Medical treatment, including rest in bed, elastic supportive bandages and a trial of hexamethonium (bistrium bromide) injections, seemed to be the treatment of choice. Lumbar sympathectomy did not seem to be of great permanent value.

PROGNOSIS IN CUTANEOUS PAGET'S DISEASE.

Mammary Pagets disease appears to be invariably associated with intraductal or parenchymal carcinoma of the breast; however, the nature of the extramammary form of the disease is still controversial.In a review of 145 patients with mammary Pagets disease and 10 patients with extramammary involvement, the authors found that (1) the average survival of patients in both groups was roughly equivalent; (2) regional or widespread metastatic involvement from underlying apocrine or regional carcinoma frequently occurs in extramammary Pagets disease; (3) metastatic lymphadenopathy reduces the survival rate by at least 50 per cent; (4) local recurrences seem the rule in extramammary involvement but are rare in mammary disease; and (5) metastatic carcinoma was the predominant cause of death in both groups of patients.

Lupus Erythematosus and Hashimoto's Thyroiditis

The possibility of a significant association between Hashimotos thyroiditis and systemic lupus erythematosus is of considerable interest. Two cases of coexisting Hashimotos thyroiditis proved by biopsy and systemic lupus erythematosus proved by the clinical picture and positive lupus erythematosus clot tests contribute to accumulating evidence suggesting such an association.

SOUTH AMERICAN ELASTOMYCOSIS: FURTHER OBSERVATIONS ON A CASE PREVIOUSLY REPORTED

Following the patients discharge from the Mayo Clinic in January, 1954, we had our next opportunity of seeing him during June, 1956. From 1956 to 1962 his progress was followed through frequent correspondence. He was seen at the Mayo Clinic for the last time during the fall of 1962. His terminal illness was caused by widespread metastasis from carcinoma of the left mainstem bronchus, and he died in May, 1963, more than 15 years after he presumably first acquired South American blastomycosis.

THE AGING SKIN

As with all other organs, the skin inevitably grows old. To many, especially women, this normal process of aging is unpopular for esthetic reasons, albeit it produces but slight discomfort; to others, the process may be annoying arid sometimes actually dangerous. The elderly patient escapes none of the cutaneous diseases to which younger people are prone, although some dermatoaes occur more frequently in the older than in the younger age groups, and only a few tend to become less severe because of the passage of time. The normal cutaneous changes of the aged, although of many types,, are all basically degenerative. The skin assumes a yellowish or cachectic hue, with mild degrees of diffuse pigmentation of the body folds. The skin loses its tone owing to the loss of elasticity; because of this it is furrowed and wrinkled and, when the condition is augmented by the loss of subcutaneous fat, tends to hang in folds. Senile lentigenes (freckles), keratoses (Fig. 1)-both actinic (senile) arid seborrheic-and small angiomas make their appearance. The skin may be dry, lusterless and slightly scaly, whereas the hair may be sparse or regress to the lanugo type. In women, however, especially after the menopause, body arid facial hair may become more obvious, while the scalp hair is lessened. There are factors other than age itself, which may produce certain of thcse changes. The sandy-haired, blue-eyed individual exposed frequently to the elements undergoes aging of the skin far more rapidly than does the individual with brown eyes and dark hair. This includes the genetic factors over which we have no control. The rare syndromes known as xeroderma pigmentosum, Werner’s and ltothmund’s syndromes are examples of premature aging. In fact we are convinced that many of the changes commonly associated with aging of the skin are not due to the age of the patient per se but rather to the type of skin with which he was born and the degree to which he exposed his skin to the physical agents, especially sunlight and wind. Pruritus hiemalis or winter itch is a common cause of skin discomfort in people past middle life who life in the Northern climates. As the name implies i t is a winter complaint in patients who bathe too often, have little humidity in their homes and wear short-legged underwear. The skin, especially on the legs, is dry and scaly and may show scattered small patches of dermatitis; the appearam-e of the trunk and arms may be the same. The avoidance of’ bathing, except a sponge bath in the groin and axillae, avoidance of soap, increasing the humidity in the home and wearing light-weight silk and cotton long-legged underwear help to ease the itching. Local applications in the form of a mild grease tjurh as olive oil and lime water (equal parts) are usually the o d y medication needed, although any mild, greasy ointment is helpful. Pruritus, which is one of the most unpleasant and annoying sensations man

Pomade Acne in Black Skin-Reply

To the Editor.— The May issue of theArchivescontained an editorial beautifully written by Mitch Sams to which a reply is warranted. Much of what he says is true, but the credit of whatever success theArchivesenjoyed during those five years belongs to others. The Editorial Board, the expert reviewers, and the authors of the papers submitted deserve and merit great credit. The greatest credit, however, belongs to Mitch Sams and Sig Muller who assumed my duties diligently and superbly during two periods of protracted illness. All of these people I now publicly, though belatedly, thank. I assure the readers that my stepping down does not detract in any way from the future of theArchives. The new chief editor and assistant chief editors are doing and will continue to do splendid work.

Hazards of Medication: A Manual on Drug Interactions, Incompatibilities, Contraindications, and Adverse Effects

This authoritative volume should be in the library of all physicians. Daily we are confronted by the possibility of drug interactions to the possible detriment of our patients, and we must be aware of these. The table of drug interaction covers more than 400 pages of this volume and includes more than 600 of the most widely used drugs. Another table details how many drugs interfere with the results of laboratory tests; this table comprises almost 50 pages. These two tables alone are worth the price of the entire volume. The distinguished group of authors and editors presents an overview of the numerous therapeutic, biopharmacuetic, legal, and scientific requirements for safe and effective medication of the patient. They point out that factors such as drug dependence, a genetic flaw such as an enzyme deficiency, a food constituent such as a pressor amine, psychosomatic disturbance, and others may negate therapy or

New Format For the Archives

THE enlarged format of theArchiveswas the result of several necessities. The change has followed in sequence identical changes made with four other of the AMAs ten specialty journals in internal medicine, surgery, psychiatry, and pediatrics. Of the two dominant features behind the change, one was the need for greater economy in printing costs; the other was the loss of income suffered by the nonprofit association publishers with respect to advertising income. No longer can income from one journal be spread to cover losses from other publications within the AMA family. The necessity of revising the format to comply with lowered income, and also with increased advertising competition, was predictably certain to provoke dissatisfaction among many subscribers. The larger size means that those accustomed to bind theArchivesnow need taller bookshelves! Probably this is the least of worries, which time will soften. The interspersed advertising, dictated entirely by