Biomedical subjects
Publications and source records attributed to G B Colver.
We present three patients who experienced late, severe bleeding from the superficial temporal artery (STA) following uncomplicated removal of basal cell carcinoma (BCC) from the temple. This is a common site for BCC and the risk of damage to the temporal branch of the facial nerve and the STA are well known. However, delayed bleeding as described in these individuals is potentially dangerous but poorly reported.
These guidelines on the management of basal cell carcinoma have been prepared for dermatologists on behalf of the British Association of Dermatologists. They present evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation.
Ascending cellulitis of the leg is a common emergency. An audit was conducted in two district general hospitals to determine how it is managed and the long-term morbidity, and to formulate a treatment strategy. Case notes were reviewed for 92 patients admitted to hospital under adult specialties. Mean duration of inpatient therapy was 10 days. A likely portal of entry was identified in 51/92 cases, of which the commonest were minor injuries and tinea pedis. Pathogens were rarely identified, group G streptococci being the single most frequent organism. Benzylpenicillin was administered in only 43 cases. Long-term morbidity, identified in 8 of 70 patients with over six months' follow-up, included persistent oedema (6) and leg ulceration (2); an additional 19 patients had either suffered previous episodes or experienced a further episode subsequently. Ascending cellulitis of the leg has substantial short-term and long-term morbidity. Important but often neglected therapeutic suggestions are the inclusion of benzylpenicillin in all cases without a contraindication, assessment and treatment of tinea pedis, use of support hosiery, and serological testing for streptococci to confirm the diagnosis in retrospect. The high frequency of recurrent episodes suggests that longer courses of penicillin, or penicillin prophylaxis, might be useful.
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The infra-red contact coagulator was applied to the treatment of myxoid cysts. The area beneath and around each lesion was infiltrated with local anaesthetic before coagulating the cyst with overlapping pulses. Initially four cysts were punctured and emptied of mucin but coagulation was delayed for 7 days. In this group there were two recurrences. The protocol was then changed so that coagulation was performed immediately after emptying the cyst. Fourteen cysts were treated in this way and there were two recurrences. The technique was well tolerated and local complications arose in five individuals.
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The technique of infra red coagulation is well suited to the destruction of superficial blood vessels in the skin and/or mucosal surfaces. A method is described here for the destruction of resistant bleeding telangiectasia of the palate and lip in Osler-Weber-Rendu syndrome.
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Azathioprine has been available for 30 years and is used in a variety of dermatologic conditions. In common with other systemic immunosuppressant drugs, it has potentially serious side effects in both the short and the long term. It has a favorable therapeutic ratio, however, and most side effects can be avoided by administering low doses for short periods. This review describes azathioprine's chemistry, drug interactions, adverse effects, and oncogenicity and then deals with its clinical applications. The well-established uses are discussed first, followed by less conventional ones. In severe, potentially fatal blistering diseases, azathioprine has an undisputed place in management. For intractable, disabling actinic reticuloid and atopic eczema, it has a smaller part to play, and its role is less clear.
A 40-year-old man developed multiple longitudinal pigmented streaks in his nails. His sister was also found to have a single streak on a fingernail. Neither had any history of drug ingestion or recent illness and examination failed to reveal any other signs in the skin or mucosal surfaces. A biopsy of the nail matrix at the base of one streak showed no evidence of a naevus or lentigo, the principal finding being pigmentary incontinence and excess macrophages.
Unlike most morphological types of malignant melanoma, that of the nail apparatus is relatively rare--only 2% to 3% of one series. Although in the case of blacks and orientals, the incidence of malignant melanoma of the nail apparatus is proportionately more common. However, it is a serious disease with poor 5-year survival figures in the published series--21% to 50%. This poor prognosis may be an intrinsic function of the site and of other parts of the body, but the lateness of diagnosis in many of the published cases is of far more significance. In malignant melanoma at other body sites, late diagnosis usually relates to the patient not presenting early in the course of the disease; this may also apply to nail malignant melanoma. However, the frequency of failure of the first line physician or surgeon to recognize the clinical signs or to perform a biopsy from the correct site to obtain an accurate diagnosis is far more important.
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Mitomycin C is an alkylating agent, used by intravesical instillation to treat carcinoma of the bladder. Repeated instillations can induce cystitis and an eczematous eruption affecting the palms, soles and face. If these effects are due to delayed hypersensitivity with sensitization to mitomycin C occurring in the bladder wall, it should be possible to demonstrate antigen-presenting cells in the bladder wall and positive patch tests to the drug. Using an immuno-alkaline phosphatase method we have identified CDI+ cells in bladder epithelium and submucosa and have demonstrated Birbeck granules in a few cells. In further support of our hypothesis it was also possible to demonstrate delayed type hypersensitivity in 13 out of 26 patients who had received mitomycin instillations by applying the allergen as a patch test. These results indicate that the eczematous eruption in this group of patients is most likely a hypersensitivity reaction and that it may be mediated transvesically.
Interleukin 2 (IL-2) is a T-cell growth factor produced by activated T cells. The cellular receptor for IL-2 is also expressed on activated T cells and one of its component molecules can be shed from the cell and measured as a soluble protein (sIL-2R). Blood levels of sIL-2R can be used to monitor in vivo immune activation and have been shown to correlate with clinical disease activity in conditions such as rheumatoid arthritis and atopic eczema. The present study shows that serum sIL-2R levels are raised in patients with chronic plaque psoriasis. These elevated serum levels were maintained during successful treatment of the skin lesions with topical tar preparations. This is in contrast to atopic eczema where serum sIL-2R levels fall with treatment and may indicate that topical treatment of psoriasis does not correct the underlying state of immune activation, even when resolution of the skin plaques is achieved.
OBJECTIVE: To determine whether serum soluble interleukin 2 receptor concentrations are related to disease activity in atopic eczema. DESIGN: Single cohort longitudinal study with controls. SETTING: Outpatient and general medicine departments in secondary referral centre. PATIENTS: Of 15 patients aged 17-57 with severe atopic eczema, all with acute exacerbations of disease, 13 were admitted to hospital and two treated as outpatients until the skin lesions had resolved or greatly improved. Nineteen controls gave single blood samples. INTERVENTIONS: Daily skin dressing with betamethasone valerate (0.025%) and ichthammol paste and tubular dressings. END POINT: Resolution of or considerable improvement in skin lesions. MEASUREMENTS AND MAIN RESULTS: Enzyme linked immunosorbent assays (ELISA) were used to measure serum soluble interleukin 2 receptor concentrations in blood samples taken on admission, at intervals subsequently, and on discharge. Clinical scores of disease activity were also made. Median concentrations on admission were significantly higher (770 U/ml) in the patients than the controls (300 U/ml). Concentrations fell significantly during treatment. In 25 assessments made at different times in 13 patients serum soluble interleukin 2 receptor concentration correlated significantly (R = 0.73) with clinical disease activity. CONCLUSIONS: Cellular immunopathogenic mechanisms contribute to atopic eczema. Immune activation can be measured in atopic eczema by measurements of soluble interleukin 2 receptor, and this should facilitate assessment of response to treatment.
We present details of nine patients who developed morphoea after radiotherapy. In every patient morphoea began within the irradiated area and in four spread beyond it. We believe the irradiation triggered the morphoea despite the absence of any clear-cut relationship to dosage or severity of the acute reaction. Dermatologists and radiation oncologists should be aware that this condition may lead to the mistaken diagnosis of a local tumour recurrence.