Biomedical subjects
Publications and source records attributed to J M Marks.
A patient with psoriasis developed bronchoconstriction after oral 8-methoxypsoralen given as part of his photochemotherapy with PUVA. It was possible to treat the patient with PUVA whilst he was on prophylactic anti-asthmatic therapy. Twenty one further patients on photochemotherapy were studied in detail and none had evidence of impaired pulmonary function as a result of therapy.
We describe a 66-year-old lady who presented with tender nodules on her trunk and limbs which were histologically proved to be sarcoid. Following steroid therapy the skin lesions remitted, but renal failure developed due to a severe granulomatous interstitial nephritis. Clinical and biochemical improvement followed treatment with high dose steroids, although renal function and renal biopsy remained abnormal.
The response of psoriasis to ultraviolet radiation and dithranol was compared with the response to dithranol alone in 24 patients. The difference in rate of response, measured as change in plaque thickness, and the difference in time to complete clearance of psoriasis between irradiated and non-irradiated forearm lesions was significantly greater for patients treated using fluorescent lamps with negligible ultraviolet C emission (Wolff Helarium) than for those patients treated with a medium pressure mercury arc lamp (p less than 0.01) or an array of fluorescent sunlamps (p less than 0.05). The difference in therapeutic response shows that ultraviolet B phototherapy is effective when used in combination with dithranol. Nevertheless, radiation sources with substantial ultraviolet C emission, such as the medium pressure mercury arc lamp most commonly used to treat psoriasis in the United Kingdom, have little effect because delivery of therapeutic doses of ultraviolet B is limited by erythema induced by ultraviolet C.
Plasma alpha-melanocyte stimulating hormone (alpha-MSH) concentrations were measured in patients receiving PUVA therapy as treatment for mycosis fungoides, and PUVA or UVB as treatment for psoriasis. Skin immunoreactive alpha-MSH was also measured in those patients who received PUVA. The mean plasma and skin alpha-MSH concentrations after 2-3 weeks of PUVA were not significantly different from pre-treatment values and showed no relationship either to skin type or to the degree of tanning that occurred in response to PUVA. Plasma alpha-MSH concentrations were also unchanged after UVB. There was also no short term change in plasma alpha-MSH concentrations in patients after receiving their first treatment with PUVA. It would appear that circulating and skin alpha-MSH levels are unaffected by UV and show no causal relationship to PUVA induced pigmentation.
Twenty patients with palmoplantar pustular psoriasis were treated initially for 4 weeks with 70 mg etretinate daily. This led to clinical improvement and a significant fall in pustule count. The patients were then allocated randomly to 30 mg etretinate daily or placebo for a further 12 weeks. There was a rapid deterioration in the clinical condition and a rise in pustule count in the placebo group. The etretinate-treated group still showed clinical improvement and a significantly lower pustule count after 12 weeks. Clinical side-effects were few and adverse effects on liver function and serum lipids were not found.
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Thirty-four patients with a clinical diagnosis of plaque stage mycosis fungoides, poikiloderma atrophicans vasculare (poikiloderma) and parapsoriasis en plaques (parapsoriasis) were investigated for evidence of extracutaneous disease using a biochemical screen, blood films, bone marrow examination, chest radiograph, abdominal ultrasound, isotope liver scan, liver biopsy and lymphangiography. Skin biopsies were also taken from these patients and, in order to rule out non-specific histological change, from 29 controls with inflammatory skin disease; the slides were examined blind by two independent observers for evidence of mycosis fungoides or poikiloderma and graded accordingly. Both observers were able to differentiate significantly histological grades of mycosis fungoides corresponding to the clinical diagnosis although exact histological grades only corresponded on 35 per cent of slides. Features graded as classical or probable mycosis fungoides were found in between 22 and 67 per cent of patients with parapsoriasis and between 67 and 100 per cent of those with poikiloderma. We found no evidence of extracutaneous disease in any of our patients. Lymphangiograms were abnormal in 30 of 31 examinations but the changes were non-specific and did not correspond to disease type, duration or extent. Four patients had apparently unrelated co-existing disease including chronic lymphatic leukaemia in two, a monoclonal gammopathy and autoimmune haemolytic anaemia. This study shows that in its early stages mycosis fungoides is predominantly if not primarily a cutaneous disease. The findings also suggest that parapsoriasis and poikiloderma are part of the same disorder as mycosis fungoides or evolve into it. Aggressive treatment to prevent progression to mycosis fungoides plaque and tumour stage should therefore be tried. The findings support the idea that mycosis fungoides is a reactive rather than a neoplastic disorder.
A randomised double-blind placebo-controlled study showed improvement of scalp psoriasis with oral ketoconazole, although the study had to be stopped before completion because of the possibility of drug toxicity. The common appearance of psoriasis in the scalp and certain other sites may be due to pityrosporal colonisation that also causes seborrhoeic dermatitis and dandruff.
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In a double-blind controlled study of patients with pustular psoriasis of palms and soles who were allocated at random to etretinate or placebo, we found that etretinate improved the condition as assessed by pustule count and overall clinical response. Side-effects occurred but were accepted by the patients in the short-term. The clinical usefulness of etretinate in this condition will depend on time to relapse, and whether this can be prevented or postponed by continuous treatment. Toxicity in the long-term will also be important.
Forty one patients whose psoriasis cleared with dithranol were given prophylatic photochemotherapy with psoralens and ultraviolet A once a week. With life table analysis the chance of remaining in remission for 16 months was shown to be 42% for these patients, compared with 13% for a group of patients who were not given prophylactic photochemotherapy.
We report a case of the association of Coombs'-positive haemolytic anaemia with mycosis fungoides. The patient was found to have polyclonal elevation of B lymphocytes in the peripheral blood but infiltration by T helper cells in the skin.
Autoantibodies reacting with endocrine cells in the gastrointestinal mucosa were found by indirect immunofluorescence in 22 out of 268 sera (8.2%) obtained from patients with coeliac disease, Crohn's disease, ulcerative colitis, irritable bowel syndrome, and from subjects without bowel disease. A double immunofluorescence technique showed that the autoantibodies reacted with cells secreting gastric inhibitory polypeptide (glucose dependent insulinotropic polypeptide, GIP), secretin, somatostatin or enteroglucagon. Most sera contained antibodies against more than one cell type. Neither the presence of a particular antibody nor the pattern of antibody combinations appeared to be specific for any diagnostic category. The mean plasma GIP concentrations, however, both fasting and two hours after a test meal, were significantly lower in subjects with GIP cell autoantibodies. Thus gut hormone cell autoantibodies may be markers of impaired hormone secretion.
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A new wax formulation of anthralin was compared with anthralin as used in the Ingram regimen for the treatment of chronic discoid psoriasis. In 16 out-patients 12 of the 13 who responded to the Ingram regimen also showed a satisfactory response to the wax preparation. The latter could be applied more rapidly and simply and may thus have a useful place in the domestic management of chronic psoriasis.
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