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We report a case of superficial granulomatous pyoderma (SGP) treated successfully with infliximab. A 71-year-old woman developed erythema, erosions and cribriform scarring in the right periorbital area following enucleation of the right eye. Histology showed three-layered granulomas typical of SGP. The patient's disease was unusual in that it failed to respond to a wide variety of immunosuppressants and this condition is rarely reported to affect the face. Eventually she was treated successfully with infliximab, enabling her to undergo extensive surgery despite the fact that her disease was pathergic in onset.

We describe four patients in whom porokeratosis coexisted with lympoedema of the legs. A possible pathogenetic link between the two disorders is discussed, as well as the therapeutic implications and the novel physical sign of lymphoedema bulging through the porokeratotic lesions.

Between 1987 and 1989 the Cancer Research Campaign funded a health education programme for the early detection of cutaneous malignant melanoma in the general population in 6 health districts of England and 1 health board in Scotland (population of 3 million). The intervention was evaluated by studying its effects on annual and cumulative mortality rates for melanoma. Population-based data on mortality from melanoma were collected in the intervention areas, the health regions covering those areas, and 5 other health regions of England from 1981 to 1996. Deaths from melanoma in cases diagnosed after the start of the intervention were used to study cumulative mortality rates. The annual mortality rates for melanoma, 1981 to 1996, showed no significant difference in their trends between the intervention areas, and other areas of England and Wales. After adjustment for pre-intervention rates, there was also no significant reduction in cumulative mortality from melanoma in the intervention areas compared with the non-intervention areas: rate ratio 1.2 (95% Cl 0.9-1.7) in men, 0.9 (95% Cl 0.7-1.3) in females. The lack of a significant reduction in melanoma mortality associated with the intervention raises questions about this approach to early detection and emphasises the need for new strategies., (Copyright 2001 Cancer Research Campaign http://www.bjcancer.com.)

Background: Tinea capitis is a common childhood infection that has recently become more frequent in urban areas in Europe and the U.S.A. The current licensed treatment in children is griseofulvin 10 mg kg(-1) daily, which is usually given for 6--8 weeks., Objectives: To compare this treatment with a 4-week course of oral terbinafine., Methods: Terbinafine was given at the following doses: in children weighing < 20 kg, 62.5 mg daily; 20--40 kg, 125 mg daily; > 40 kg, 250 mg daily. Two hundred and ten children aged 2--16 years, with mycologically confirmed tinea capitis, were randomized to 4 weeks treatment with terbinafine or 8 weeks with griseofulvin, and followed for a total of 24 weeks to determine the difference between treatments with respect to short- and long-term efficacy and tolerability., Results: One hundred and forty-seven patients were evaluable (terbinafine 77, griseofulvin 70). Although the 4-week course of terbinafine resulted in a trend to more rapid clearance of tinea capitis, there were no statistically significant differences between the two drugs in terms of overall outcome or tolerability, apart from in a subgroup of patients with Trichophyton infections, and weighing > 20 kg, who responded better to terbinafine than to griseofulvin at 4 weeks. By contrast, there was a better response to griseofulvin than to terbinafine in patients with Microsporum audouinii infections., Conclusions: Overall, the study showed that 4 weeks of treatment with oral terbinafine has similar efficacy to 8 weeks of treatment with griseofulvin for the management of tinea capitis in children.

Background: Pyoderma gangrenosum (PG) is an uncommon necrotising, non-infective ulceration of the skin. The management of PG is aimed at limiting tissue destruction, promoting the healing of the wound, and providing an acceptable cosmetic result. However, skin grafting is normally avoided because of the potential risk of pathergy-the localization of skin damaged by trauma., Report: We describe the use of split skin grafts in the management of ulcerative pyoderma gangrenosum in 4 patients., Results: Our cases demonstrate that split skin grafts are a useful treatment modality in patients with ulcerative PG, producing a good cosmetic result. One case illustrates the importance of ensuring the disease is quiescent prior to grafting, to avoid pathergy. The other cases emphasise the need for prolonged immunosuppressive therapy to minimise the chance of reactivation of the disease process., Conclusion: Our preliminary experience of 4 cases of ulcerative PG indicates that split skin grafts have a role to play in its management. The ultimate cosmetic result is considered to be superior to allowing the wound to heal by secondary intention. To limit the risk of pathergy developing, our experience suggests a role for prolonged courses of immunosuppressive therapy. The most effective dose and duration of immunosuppressive therapy in patients with PG treated with split skin grafts remains to be determined. A controlled study would be of benefit to compare it with other current treatment options.

The demand for pigmented lesion clinics (PLCs) is increasing in view of improved skin cancer awareness following public health education campaigns. These clinics offer an effective way of screening a large number of patients. However, there is no evidence, as yet, that they have an impact on mortality due to malignant melanoma. With the lack of follow-up inherent to these busy screening clinics, there is some concern that melanomas may be missed. This study reports on 7874 patient visits to a PLC in a teaching hospital between 1985 and 1994. In total, 1705 biopsies were performed over the 9-year period. Lesions were more likely to be biopsied in men compared with women. The yield for picking melanomas was one in 36 patient visits. The mean age of patients attending the PLC was 10 years less than the mean age for population-based melanomas. Melanoma thickness did not significantly change over the 9-year period. Only 0.2% of patients (14 cases) re-presented to the PLC for a second or third visit with a final diagnosis of melanoma, but for five of these patients, the interval between the two visits was over 2 years. Most of these 're-attending' melanomas were early lesions. PLCs offer a fast, safe and efficient service for the screening of pigmented lesions but their role in reducing mortality due to malignant melanoma remains to be established. It is likely that these clinics have an important role in terms of public health education regarding sun avoidance and early recognition of skin cancer.

Objective: To assess the use of instant photography, in addition to clinical grading, as a method of screening for malignant melanoma during routine health examinations., Setting: A health screening clinic with an average throughput of about 12,000 patients a year., Methods: Suspicious pigmented skin lesions were judged clinically using the revised seven point checklist scoring system. They were then photographed with a Polaroid camera and the prints were graded independently by two consultant dermatologists with a special interest in malignant melanoma. A copy of the print was also given to the patient to keep for observation of any change in the lesion., Results: Over a 45 month period 39,922 patients of both sexes were screened and 1052 skin lesions were clinically assessed and photographed. Fourteen malignant melanomas were diagnosed--all, except one, were thin lesions with a good prognosis., Conclusions: The clinical opinions of non-dermatologists using the revised seven point checklist proved disappointing in screening because of the large number of benign lesions that were given high scores. Photography, on the other hand, detected 11 melanomas and succeeded in separating the majority of banal lesions from potentially malignant ones, thus greatly reducing the need for specialist referral. Nevertheless, three melanomas were missed on purely photographic grading, which emphasises the danger of placing too much reliance solely on a two dimensional image. Finally, the possession of a personal copy of the photograph by the patient proved popular and led to a diagnosis of melanoma in two instances. This procedure merits further study.

The immunobullous diseases bullous pemphigoid (BP) and epidermolysis bullosa acquisita (EBA) are very rare in childhood. Although case studies have been detailed, there are no reports of a large series of patients documenting the effectiveness of treatment and long-term prognosis. We report the clinical presentation, immunopathologic features, disease course, and long-term prognosis of BP and EBA in a series of 11 children. The initial diagnoses based on clinical features were BP (5), EBA (3), and chronic bullous disease of childhood (CBDC) (3). These were subsequently revised from BP to EBA (2), CBDC to BP (2), and CBDC to BP or EBA (1) following the results of direct and indirect immunofluorescence and immunoblotting. Analysis of IgG subclasses in eight cases showed that the predominant subclasses were IgG1 (8) and IgG4 (6). The clinical features appeared to be highly variable, and in patients presenting with inflammatory blistering, laboratory studies were required in order to differentiate between BP and EBA. All patients improved on treatment with corticosteroids and/or sulfones, although treatment regimens showed wide variation. Their diseases tended to remit within 2 years, and their long-term prognosis was good.

Acne agminata is a papulo-pustular eruption typically affecting the face of young adults and characterized histologically by the presence of caseating granulomata in the dermis. We now describe two adults who developed the condition in the axillae.

A patient is described with histopathological features in keeping with a diagnosis of Dowling Degos disease but with some unusual clinical features. Other members of the family are similarly affected.

Acquired autoimmune bullous diseases of childhood are rare, and can be difficult to distinguish clinically. We have studied 12 children, with an initial diagnosis of bullous pemphigoid (BP) in eight patients, cicatricial pemphigoid (CP) in one, chronic bullous disease of childhood (CBDC) in one, and epidermolysis bullosa acquisita (EBA) in two. All patients had positive indirect immunofluorescence (IIF) of the BMZ with IgG. Using 1 M NaCl split skin, six patients showed epidermal binding of IgG, with additional IgA in three cases, and in five patients IgG antibodies bound a dermal protein. Immunoblotting studies revealed an antibody to type VII collagen (EBA antigen) in three patients who had a dermal pattern on IIF. Six sera reacted with an epidermal protein of 180 and/or 220 kDa, characteristic of BP and CP. One of the three IgA-positive sera detected 220- and 180-kDa epidermal proteins using anti-IgA antibody. Following these studies the diagnosis was changed in three of the children. The diagnosis of CBDC was changed to either BP or EBA because of the presence of circulating IgG autoantibodies. In two children with an initial diagnosis of BP the diagnosis was changed to EBA. We conclude that the clinical picture in bullous disorders of childhood shows considerable overlap, and is often misleading. Additional circulating IgA autoantibodies seem to be more common in BP than has been recognized previously. Indirect immunofluorescence investigation on 1 M NaCl split skin may be helpful in differentiating between BP and EBA, but does not replace immunoblotting studies. EBA is apparently more common in children than in adults. No difference was found between the children with BP and EBA with regard to the duration of disease. The long-term outlook is good, although the course may be protracted.

Two cases of autoimmune bullous skin diseases in HIV-positive men are described. One man had bullous pemphigoid limited to his legs and the second man developed pemphigus herpetiformis. The possible association between autoimmune bullous diseases and HIV infection is discussed.

To assess the effect of a pigmented lesion clinic on referral patterns and thickness of melanoma at presentation, we have compared data from the centralized pathology services of the adjacent health authorities of Wandsworth, and Merton and Sutton. Both districts were the subject of a CRC public awareness campaign in 1987, but only Wandsworth is served by a pigmented lesion clinic. All patients presenting with malignant melanoma were included; from 1981 to 1990 for Wandsworth, and from 1984 to 1990 for Merton and Sutton. The Breslow thickness and clinic source of all melanomas was documented. Approximately equal numbers of melanomas were seen in the two districts, with no obvious difference in the numbers of thin (< 1.5 mm thick) 'good prognosis' tumours. Both districts saw an increase in the total number of tumours, and the number of thin tumours, after the CRC publicity campaign. However, there was considerable cross-boundary referral to the pigmented lesion clinic in Wandsworth, with 60% of all melanomas coming from outside the district. The presence of a pigmented lesion clinic within a given district confers no obvious benefit with regard to the number of thin, 'good prognosis' melanomas being seen as a whole, but the cross-boundary referral pattern suggests that it fulfils a demand from both general practitioners (GPs) and patients, and it does provide a centralized source for the collection of much-needed data.

A skin cancer screening programme involving 2150 employees based at the head office of a large UK retailer resulted in the detection of four melanomas at an early curable stage. In addition, three other malignant and three potentially malignant tumours were discovered, and individuals at greater risk of developing melanoma were identified and counselled accordingly.

A 29-year-old woman presented in the 31st week of pregnancy with an unusual bilateral, erythematous eruption on the posterior calves, which clinically resembled erythema annulare centrifugum. A biopsy showed features of a mild leucocytoclastic vasculitis. Within 2 days of delivery the rash had almost resolved, suggesting that its activity was related to the pregnancy. The diagnosis is consistent with 'annular vasculitis', which we suggest represents a distinct variant of leucocytoclastic vasculitis, and a distinct clinicopathological entity. We are not aware of any previous reports of an association between annular vasculitis and pregnancy.

A case of an elderly man with a large facial ulcer is reported. The diagnosis of Wegener's granulomatosis was made at post-mortem when evidence of a granulomatous vasculitis was found in both the skin and lungs. This case serves to illustrate the difficulty in making the diagnosis of Wegener's granulomatosis, especially when it presents in its 'limited' form.

We examined the effect of incisional biopsy on the subsequent histology of 15 benign melanocytic naevi. In all cases the histology of the residual lesion within the second specimen was unchanged apart from the presence of a surgical scar, and in general the definitive excision specimen showed a reduction in melanocytes at the dermo-epidermal junction overlying the scar. In no case were there any features suggestive of melanoma.

We report three infants with a rare syndrome of restrictive dermopathy, in which rigidity of the skin at birth is associated with characteristic facial anomalies, generalised arthrogryposis, bony abnormalities, and lung hypoplasia. The skin has a distinctive pathology with compaction of the dermal collagen and fibrosis of the subcutaneous tissue. The inheritance is likely to be autosomal recessive and the condition appears to be fatal in the early neonatal period.

A patient with arthritis is described who developed a dermatitis herpetiformis-like rash after 8 months of D-penicillamine therapy and which cleared soon after the drug was discontinued. The histopathological findings were compatible with a diagnosis of pemphigus, showing intra-epidermal vesicles and spongiosis but no acantholysis. Intercellular antibody was detected by indirect immunofluorescence at the onset of the eruption (titre 1 in 160) and also found in serum taken prior to penicillamine treatment (titre 1 in 20). It is now well known that D-penicillamine can induce pemphigus. The findings reported here suggest the possibility that the patient was predisposed to develop the eruption before the drug was given.