Walter B. Shelley

Botulinum toxin therapy for palmar hyperhidrosis

BACKGROUND Severe palmar hyperhidrosis is a chronic disease, resistant to conventional therapy. Botulinum toxin inhibits sweat production by blocking release of acetylcholine from presynaptic membranes. OBJECTIVE Our purpose was to evaluate the short- and long-term effectiveness of botulinum toxin therapy in treatment of palmar hyperhidrosis. METHODS Four patients with severe palmar hyperhidrosis were treated with subepidermal injections of botulinum toxin. Fifty injections, 2 mouse units each, were used in each palm. Regional nerve blocks of the median and ulnar nerves were performed before the procedure. Patients were observed for 12 months after treatment. RESULTS Botulinum toxin injections significantly reduced sweat production in the treated areas of the palms. Anhidrosis lasted for 12 months in one patient, 7 months in two patients, and 4 months in one patient. Mild weakness of the thumb lasting 3 weeks occurred in one patient. No other side effects were observed. CONCLUSION Botulinum toxin provides an effective, safe, and long-lasting alternative therapeutic modality for treatment of severe palmar hyperhidrosis. Additional studies are needed for optimization of the technique.

Uncombable hair syndrome: Observations on response to biotin and occurrence in siblings with ectodermal dysplasia

Three children are reported with uncombable hair syndrome, consisting of slow-growing, straw-colored scalp hair that could not be combed flat. The hairs appeared normal on light microscopy but on scanning electron microscopy were triangular in cross section, with canal-like longitudinal depressions. Oral biotin, 0.3 mg three times a day, produced significant improvement after 4 months in one patient, with increased growth rate and with strength and combability of the hair, although the triangular shape remained. The other two patients were unique in having associated ectodermal dysplasia. Their hair slowly improved in appearance and combability over 5 years without biotin therapy.

Argyria: the intradermal "photograph," a manifestation of passive photosensitivity.

X-ray microprobe and electron microscopic study was made of the remarkable blue-black pigmentation that sunlight elicits in patients with argyria. The patient under study had developed argyria following injection of silver nitrate as a sclerosant into his varicose veins 41 years ago. Similarities are demonstrated between the darkening of the skin and the darkening of a photographic film following light exposure. In both instances, colorless silver salts and compounds present in an inert matrix (collagen versus gelatin) are reduced by incident light to black metallic silver. This passive photosensitivity reaction leads to silver tattooing of the light-exposed skin and to photographic imaging in the film.

Demonstration of a unique viral structure: the molluscum viral colony sac

Using scanning electron microscopy to study molluscum contagiosum lesions, it has been possible to demonstrate a unique, well defined sac enclosing the virion colony of each infected keratinocyte. This confirms the presence of a structure demonstrated over 50 years ago by micro‐dissection, but ignored since it is not seen on either light or transmission electron microscopy. It is postulated that this sac, of unknown origin, favours replication of the virions by providing a site that is both anatomically and immunologically privileged. Such relatively unimpeded growth of the virions results in an enlarged cell in which the cytoplasm and nucleus are compressed into a thin outer shell. In the aggregate, this produces a tumour of virus‐packed cells rather than a tumour composed of virus‐induced cell hyperplasia.

Long-term antibiotic therapy for balanitis xerotica obliterans

In an open uncontrolled study of 3 patients with balanitis xerotica obliterans we have observed significant improvement after long-term systemic antibiotic therapy. Two of the patients noticed softening of the skin as well as disappearance of pruritus, tenderness, and inflammatory changes within 3 weeks of receiving oral and intramuscular penicillin. The third patient experienced the same degree of improvement after a regimen of dirithromycin, 500 mg/day. Stopping the antiobiotic for 1 month resulted in relapse, with improvement again on resumption.

Aquadynia: Noradrenergic pain induced by bathing and responsive to clonidine

We describe two women in whom bathing was regularly followed by intense, widespread burning pain that lasted 15 to 45 minutes, which we term aquadynia. This water-induced pain was not caused by any skin or systemic diseases. We view it as a type of noradrenergic pain induced by contact with water, because it can be blocked with clonidine or propranolol. It appears to be an extension of the phenomenon of aquagenic pruritus, which we have also found to respond to clonidine or propranolol.

Essential progressive telangiectasia in an autoimmune setting: Successful treatment with acyclovir

A unique, progressive syndrome of muscle weakness, ascending telangiectasia, and venous ectasia of the legs developed in a 55-year-old woman with autoimmune thyroiditis. Myopathy was documented by electromyography and electron microscopy. Her constellation of findings is considered to be of autoimmune origin. Treatment with acyclovir eliminated the patients generalized telangiectasia. Cyclosporine therapy resulted in a marked but temporary reduction of the enlarged thyroid and of her elevated thyroglobulin and microsomal antibodies. Neither acyclovir nor cyclosporine had any demonstrable effect on the patients muscle function or venous ectasia.

The infected hairs of tinea capitis due to Microsporum canis: Demonstration of uniqueness of the hair cuticle by scanning electron microscopy

Scanning and transmission electron microscopic studies were done on scalp hairs of four patients infected with ectothrix Microsporum canis. Both freeze fracture and cross-sectioning of hairs revealed a thick sheath of fungal spores encircling the hair shaft beneath an intact cuticle. These spores were not visible on surface inspection but became apparent only where the cuticle had been rubbed off or broken. Daily selenium sulfide shampoos removed all of the spores from these sites. The cuticle is viewed as being an effective barrier to the penetration of fungi, so that the hair is vulnerable to fungus infection only deep within the hair follicle below the level of the mature cuticle. Once the fungus enters the hair cortex just above the hair bulb, it produces myriads of spores that remain trapped and hidden beneath the cuticle for the length of the intact hair.

The transverse nasal line : an embryonic fault line

The transverse nasal line has long been neglected and frequently overlooked. This narrow pink or hyperpigmented line or groove extends transversely between the upper two‐thirds and the lower third of the nose. It is often hereditary and may be the locus of comedones and milia. Eighteen examples are reported by us, along with a possible embryological interpretation.

Pseudolymphoma at site of clonidine patch

An 83-year-old woman consulted us for evaluation of a 1·0 cm nodule on her right anterior shoulder (figure). It was symptomless and had arisen at the site of clonidine patches applied during the past year. No lesions were seen on her legs where the patches are now being applied. Her past history included left hemiplegia, aphasia following a right cerebrovascular accident 5 years ago, and bullous pemphigoid. Her blood count was normal. A skin biopsy specimen showed no changes in the Mutations in the MEN I gene in sporadic neuroendocrine tumours of gastroenteropancreatic system