Timothy J O'Brien

Polydactylous Bowen's disease of the nail bed

A case is presented with tender swelling and nail bed hyperplasia in 2 fingers. Histopathology revealed Bowens disease in both fingers and after amputation, invasive squamous cell carcinoma in one finger.

The use of visual language as a search pattern in dermoscopy.

Visual language can be used as a tool to describe the structural components of visual information. The basic elements are: dot; line; shape; and colour. Such elements will make up any visual image, even if the object cannot be named further, for example in abstract art. In abstract art there may be no linguistic equivalent, in other words there is visible form without a recognisable object (Fig. 1). For the novice, the dermoscopic image may appear like abstract art, impossible to name. Because the dermoscopic image is flat or 2D and any 3D textural feature has been hidden by the application of oil, the basic elements of visual language can be easily segmented and identified (Fig. 2). Visual language can therefore provide a starting point for learning dermoscopy. Visual language also provides a simple template or search pattern for the experienced dermoscopist to avoid perceptual errors through the viewer’s failure to be cognisant of all of the visual information in an image. The basic question to be asked by the novice and puzzled expert when approaching a dermoscopic image therefore should be: Are there dots, lines, shapes and colours?

CONTACT DERMATITIS TO EPOXY RESIN IN ILEOSTOMY BAG

Dermatitis under an ileostomy bag and speading to other areas was found to be due to epoxy resin in the bag. This problem has been reported by other authors.

AUSTRALIAN DERMATOPATHOLOGY SOCIETY WIDESPREAD PUSTULAR ERUPTION

A fifty seven year old man was commenced on phenytoin following hospital admission for a generalised convulsion. Ten days later he developed a large erythematous plaque on his buttock and a widespread eruption of papules and small plaques with associated pustules. Some pustules were noted to be perifollicular (Figs 1-2). The eruption was both itchy and painful. He felt generally unwell and had symptoms suggesting a fever. There was no past history of skin disease and in particular no history of psoriasis. He was readmitted to hospital and treated with oral and topical corticosteroids and antihistamines. Sodium valproate had been substituted for phenytoin. A full blood count revealed a mild neutrophilia and an eosinophilia. Liver function tests showed marked elevations of alkaline phosphatase and gamma glutamyl transferase which returned to normal after four weeks. Electrolytes, urea and creatinine were normal. A swab taken from a pustule was sterile. Several punch biopsies were taken from his back. In one there was suppuration in the superficial portion of a hair follicle, and deep to this neutrophils were present in the reticular dermis (figs 3-4). Elsewhere there was a superficial and deep infiltrate of lymphocytes and neutrophils with an occasional eosinophil. The epidermis was acanthotic and showed diffuse spongiosis with one intraepidermal pustule (fig 4). A gram stain showed a few gram positive cocci with this pustule. No fungi were identified on PAS stain. The second biopsy showed a similar mixed infiltrate, acanthosis and spongiosis (fig 5). In addition, the papillary dermis was oedematous and there were extravasated red blood cells. There were a few neutrophils on the surface of the intact stratum corneum. Despite examination of multiple levels in this second biopsy a suppurative folliculitis was not identified.

IMIDAZOLIDINYL UREA (GERMALL 115) CAUSING COSMETIC DERMATITIS

Imidazolidinyl urea is a preservative used commonly in cosmetics. Although there have been few reports of contact sensitivity, it does seem to be an important contact allergen. Sensitivity should be considered in any woman with dermatitis of the face.

Targetoid spongiotic reaction pattern: A case series of seven paediatric patients

We present seven cases of a targetoid eruption, clinically mimicking erythema multiforme, occurring in paediatric patients aged 12 months to 14 years. All patients presented with a pruritic targetoid eruption on body and acral sites which spared mucosal areas. All patients demonstrated a spongiotic reaction pattern on histology without lichenoid change and demonstrated excellent responses to either oral prednisolone or topical corticosteroids. We propose the term ‘targetoid spongiotic reaction pattern (TSRP)’ for our subset of paediatric patients. We review the literature regarding targetoid eruptions in the paediatric population.

Probable chloracne with the use of a cow udder ointment

A 55 year old lady presented with a 6 month history of an itchy eruption on her scalp, face and arms. The appearance was eczematous with areas of probable lichenification; however, it was somewhat atypical and therefore biopsies were taken. The specimen from the arm showed epidermal spongiosis while that from the back showed a dilated follicular structure containing plasmatic material and many neutrophils. The epithelium was spongiotic. The eruption responded to topical and oral steroids to some degree but the patient subsequently developed burning (not itching), well demarcated erythematous plaques on her cheeks. She was patch tested negative and because she had a history of

BROWN PIGMENTED PAPULES IN THREE GENERATIONS OF A FAMILY

A 40 year old lady developed brown warty lesions on her abdomen at puberty and these subsequently spread to her neck, axillae and inner thighs. It was known that her mother had a similar problem which was said to improve late in life. A daughter aged 15 had developed flesh coloured mildly verrucous papules on her abdomen (Fig. 1) and a son aged 19 had a similar eruption inthe groin. Examination showed a mottled reticulate pattern of brown mildly keratotic plaques (Figs. 2 and 3). Biopsies were taken from the inner thigh and axillae. The low power view (Fig. 4, H & E, x 6.6) showed irregular elongations of the rete ridges with a branching pattern. This is highlighted in the medium power view (Fig. 5, H & E, x 13.2) where in addition a small pseudohorn cyst is present centrally. At high power (Fig. 6, H & E, X 33) basal layer hyperpigmentation is evident without any significant increase in basal melanocytes. There are a few lymphocytes in the papillary dermis with occasional melanophages.

Pigmented Lesion Conference

The Victorian Faculty of the Australasian College of Dermatologists conducted a conference in pigmented skin lesions at the Royal Childrens Hospital, Melbourne on November 19, 1988. The meeting was attended by Victorian and interstate dermatologists, pathologists, surgeons, oncologists and registrars. Dr. A. Kopf from New York discussed risk factors for the development of malignant melanoma using data from published case control studies. Factors reported to be significant in over half the studies included phenotypic factors (blue eyes, blond or red hair, light complexion, freckles, sun sensitivity and inability to tan), personal history of non-melanoma cutaneous cancer or pre-cancer, high socioeconomic status, increased number of naevocytic naevi and bursts of sun exposure. Dr Robin Marks from the Anti Cancer Council of Victoria presented the results of a retrospective histopathological study suggesting that the majority of melanomas (possibly 70%) do not arise from a pre-existing naevus. For public education programs Dr. Marks emphasised the feature of an unusual flat freckle rather than a raised lesion as the sign of an early melanoma. Dr. Abe Dorevitch from Melbourne spoke about the simulants of melanoma. Nucleolar organising regions which are represented as dots in the nuclei of melanocytes, may be important in diagnosis as they are more frequent in melanoma cells (8 or 9) compared with benign naevus cells (1 or 2). Several papers on the oncolystate aspects of melanoma were presented from the Peter McCallum Cancer Institute, Melbourne. Dr. David Jose presented data on the use of a melanoma oncolysate vaccine in patients with regional lymph node metastases. The vaccine is given monthly for 2 years. Toxicity is low and survival rates are improved when compared with matched controls. Dr Ian Olver spoke on chemotherapeutic agents. Dacarbazine (DTIC) is the best single agent with response rates of 14-25%. In the future high dose therapy using various agents combined with colony stimulating factor to alleviate neutropenia, alpha interferon and interleukin 2 may be useful. Dr Adele Green from the Queensland Institute of Medical Research presented some findings on the epidemiology of melanocytic naevi. She highlighted the problems of defining naevi clinically and the variations of methods of counting used in different studies. There is a need for cohort studies to define more exactly the natural history of naevi.

CONTACT PHOTOALLERGY TO MUSK AMBRETTE

Photoallergic dermatitis due to musk ambrette is reported in six patients, and the literature on this sensitivity is reviewed. The condition presents with a typical pattern involving the neck and cheeks, and the diagnosis can be confirmed by photopatch testing with musk ambrette.