[Stab and cut lesions among general practitioners in the county of Funen]

In a questionnaire sent out to general practitioners (GP) in the County of Funen they reported a yearly incidence of lesions penetrating the skin of 1.2 per practitioner. Approximately half of these lesions were potentially infectious. Sixty percent of the lesions were due to accidents involving needles. Only 52% of the GPs with the risk of a potentially infectious lesion tried to prevent infection. We estimate that the risk of becoming infected with HIV or Hepatitis-B infection is very low. It is necessary to get GPs to change procedures in an attempt to minimize the risk.

Keratosis lichenoides chronica

Keratosis lichenoides chronica is a rare dermatosis characterized by a distinctive seborrheic dermatitis-like facial eruption, together with violaceous, papular, and nodular lesions on the extremities and trunk typically arranged in a linear and reticulate pattern. We describe a patient with KLC who had the typical features of this disease and responded partially to treatment with oral isotretinoin.

Oral terbinafine in toenail dermatophytosis. A double-blind, placebo-controlled multicenter study with 12 months' follow-up

The treatment of onychomycosis has previously often been protracted and unsuccessful. Terbinafine has been shown to be effective in short-term regimens. In this double-blind, placebo-controlled study, 148 patients with toenail dermatophytosis were randomized to treatment with either 250 mg terbinafine daily or placebo for 3 months. An additional treatment was given for 3 months to patients whose infection had not responded. The patients were followed clinically and mycologically through 12 months. After 3 months 82% of the terbinafine-treated group, versus 5% of the placebo group, showed significant improvement, i.e. negative culture and growth of unaffected nail more than 2 mm (p = < 0.0001). After 12 months clinical and mycological cure was seen in 40% of the patients treated with terbinafine for 3 or 6 months, while 67-81% were clinically cured, but with positive microscopy. Side-effects occurred in 13.5% of the terbinafine group, versus 5.4% of the placebo group, and were mild. 250 mg terbinafine daily for 3 months was significantly more effective than placebo. The efficacy did not appear to improve with additional treatment for 3 months.

Ethnic and geographic differences and similarities of HIV/AIDS-related mucocutaneous diseases. Danida Study Groups

BACKGROUND

A study on HIV/AIDS-related mucocutaneous manifestations has been carried out in three different ethnic and geographic areas, namely Brazil, Denmark, and Thailand.

METHODS

The Brazil cohort comprised 110 patients, the Danish cohort 150, and the Thai cohort 206 patients. The majority of the Brazil and Thai cohort patients belonged to groups III and IV according to the CDC clinical staging system, whereas the patients in Denmark called their doctors earlier and only 8% were classified in groups III and IV.

RESULTS

In all three areas the number of mucocutaneous diseases correlated well with the progression of the HIV disease. Ethnic differences were not identified, whereas geographic differences related to skin infections were marked. In the Asian cohort a generalized fungal infection was detected with characteristic mucocutaneous symptoms caused by Penicillium marneffei.

CONCLUSIONS

Teaching efforts about mucocutaneous signs as markers of HIV infection may be of value, particularly in developing areas, to allow earlier diagnosis. In future guidelines for classification of HIV/AIDS-related mucocutaneous diseases geographic considerations should be included.

Age-related diurnal changes of dermal oedema: evaluation by high-frequency ultrasound

Using high-frequency ultrasound, we measured the influence of gravitational stress on skin echogenicity in 22 young (age range 17-27; median 19) and 22 elderly (age range 75-100; median 87) healthy adults. B-mode ultrasound images were obtained from the medial malleolus, lateral calf, anterior thigh, volar forearm and the medial aspect of the arm three times daily: in the morning, immediately before rising, and 2 and 12 h later. The echogenicity was measured by counting the number of low echogenic pixels in the image. Pronounced changes of low echogenic pixel numbers were seen in the areas exposed to high gravitational stress, i.e. the ankle and calf. In the young age-group echogenicity of the skin increased steadily during the day, whereas in the elderly population echogenicity decreased 2 h after getting up in the morning, and subsequently returned to the baseline level. In a control group of 10 people (aged 17-83; median 18), who remained in the supine position throughout the day, the echogenicity of the skin remained unchanged. As the echogenicity of the dermis is inversely related to the amount of fluid it contains, our results indicate that young skin responds to gravitational stress by fluid depletion. In the skin of the elderly, the mechanism of fluid removal appears to be defective. The impaired protection against the development of intradermal oedema in the elderly may predispose to the development of lipodermatosclerosis and leg ulceration.

The use of cutaneous microdialysis to measure substance P-induced histamine release in intact human skin in vivo

BACKGROUND

The purpose of this study was to introduce a microdialysis technique, which makes it possible to measure the release of small inflammatory mediators into the extracellular water space in intact human skin in vivo. Using this technique, we have studied the histamine releasing properties of substance P, a putative skin mast cell releasing agent.

METHODS

Small hollow fibers were inserted into the upper dermis of nine healthy subjects. Each fiber was perfused with Kreb's Ringer bicarbonate buffer at a rate of 3.0 microliters/min. After establishment of a baseline, each fiber was challenged intracutaneously with substance P (0 to 4 mumol/L). Samples were collected at 2-minute intervals for 18 minutes. Histamine was measured by a fluorometric method, which correlated with an enzyme immunoassay (r = 0.96).

RESULTS

Baseline dialysate histamine concentration was 1.7 +/- 0.3 ng/ml. Peak histamine release after injection of vehicle, 0.5, 1, 2, and 4 mumol/L substance P was 0.0, 1.0, 6.0, 44.5, and 88.5 ng/ml, respectively (p = 0.00002). Statistically significant histamine release was demonstrated with 1.0 mumol/L substance P and greater. Most peak values were seen 2 to 4 minutes after injection. The histamine elimination showed a monoexponential decline; dialysate histamine half-life was 3.81 +/- 0.28 minutes.

CONCLUSIONS

This study showed that substance P releases histamine in a dose-dependent manner from intact human skin in normal subjects. We suggest that microdialysis may be a promising technique for the evaluation of mediator levels in intact human skin after intradermal injection of an inflammatory or allergenic stimulus.

Efficacy and safety of the 20-epi-vitamin D3 analogue KH 1060 in the topical therapy of psoriasis: results of a dose-ranging study

KH 1060 is a 20-epi-vitamin D3 analogue, structurally related to 1,25-dihydroxyvitamin D3 (1,25(OH)2D3). In vitro, KH 1060 is much more potent than 1,25(OH)2D3 in regulating cell growth and T lymphocyte mediated immune responses, despite a similar calcemic activity in vivo. Therefore, KH 1060 is of potential interest in the treatment of psoriasis and other diseases characterized by accelerated cell growth and T lymphocyte activation. In a multicenter, prospective, randomized, double-blind, vehicle-controlled right/left comparative study, patients with plaque-type psoriasis vulgaris were randomly assigned to one of the following treatment groups: (I) KH 1060 ointment 0.2 microgram/g versus placebo ointment, (II) KH 1060 ointment 0.2 microgram/g versus KH 1060 ointment 0.04 microgram/g, and (III) KH 1060 ointment 0.2 microgram/g versus KH 1060 ointment 1 microgram/g. All treatments were given twice daily for 6 weeks. Sixty-four of the 70 randomized patients completed the study. At the end of treatment, no difference was demonstrated between KH 1060 0.04 microgram/g and vehicle, whereas significantly increasing improvement was found for the doses KH 1060 0.2 microgram/g and KH 1060 1 microgram/g. According to the investigator's overall assessments at the end of treatment, KH 1060 1.0 microgram/g and KH 1060 0.2 microgram/g produced a marked or moderate improvement in most patients. Mild lesional irritation was observed after treatment with KH 1060 as well as with placebo. One patient was withdrawn because of an eczematous reaction, where KH 1060 1.0 microgram/g was applied.(ABSTRACT TRUNCATED AT 250 WORDS)

Impairment of the postural venoarteriolar reflex in aged individuals

The venoarteriolar vasoconstriction reflex plays a major role in the prevention of leg oedema in the upright position in man. We studied the venoarteriolar vasoconstriction reflex with laser Doppler flowmetry in young (21 subjects, age 17-27) and very old (20 subjects, age 75-100) healthy volunteers. In the group of young volunteers, after lowering of the lower extremity 50 cm below the heart level, cutaneous blood flux decreased to 16.6% of the baseline, whereas in the group of old persons the venoarteriolar reflex was impaired and the flux decreased only to 29.2%. The difference between the two groups was statistically significant (p < 0.001). These results may explain the increased prevalence of postural oedema in old people.

Microvascular reactions to postural changes in patients with sickle cell anaemia

Normal microcirculation of the lower extremity is characterized by the venoarteriolar vasoconstriction reflex and the disappearance of vasomotion in the dependent position. Patients with sickle cell disease are prone to develop ischemic leg ulcers at an early age. Dysfunction of the microcirculation might promote the development of leg ulcers in patients with sickle cell disease. Using laser Doppler equipment we have studied the changes of blood flux in the skin overlying the medial malleolus after leg lowering. Contrary to the normal physiological situation seen in our control persons, the venoarteriolar reflex was abolished and vasomotion preserved in the dependent position of the leg in both patients. We conclude that this may represent an adaptation to the dependent position in sickle cell disease.

Skin mechanical properties present adaptation to man's upright position. In vivo studies of young and aged individuals

In tall animals dependent tissues are stiffer to prevent oedema formation in the upright posture, but whether the same adaptation is operating in man is not known. Skin elasticity and distensibility were measured in vivo in 18 young and 15 aged individuals in the morning before getting up (baseline) and 12 h later. In young individuals skin was stiffer (less distensible) and less elastic in the acral parts of the extremities (ankle, forearm). In the evening distensibility and elasticity of the skin increased. In aged individuals skin was less elastic and no diurnal variability in elasticity and distensibility was detected. We propose that these unique mechanical properties of the acral skin reflect a major role of the integument in the protection against the gravitational stress and the development of the postural oedema. Altered skin mechanical properties may contribute to the poor compensation for gravitational stress in elderly.

[A short discharge letter with a copy to the patient--satisfactory for patients and practitioners]

This study evaluated the introduction of a new type of discharge letter (DL). The new DL is hand-written by the discharging doctor on a form, and a copy is both given to the patient and sent immediately to the general practitioner (GP). Questionnaires were sent both to the receiving patients and GPs. One hundred and thirty-four patients (55%) and 157 GPs (87%) replied to the questionnaires. Half of the responding patients stated that the DL had helped them to understand what had happened during their hospital stay, as well as future plans for treatment. A majority of the responding GPs found the hospital stay, the patient's status at discharge and the planned after treatment to be satisfactorily described in the new DLs. Almost all GPs (90%) were pleased with the promptness with which they received the new DL. Compared to the traditional DL, 40% of the responding GPs found the new DL to be better and 29% found it to be worse.

Ultrasound structure and digital image analysis of the subepidermal low echogenic band in aged human skin: diurnal changes and interindividual variability

Subepidermal low-echogenic band is a consistent echostructural finding in aged and photodamaged skin. The thickness of subepidermal low-echogenic band is considered to closely reflect the degree of cutaneous aging and its use for the monitoring of the severity of photoaging and the efficacy of drugs is rapidly expanding. We investigated subepidermal low-echogenic band structure in 23 old healthy volunteers (ages 75-100) with a high-frequency ultrasound scanner (B-mode, 20 MHz). Images were collected from the volar fore-arm twice daily: in the morning before getting up and 12 h later. To assess the severity of subepidermal low-echogenic band, echogenicity of the subepidermal region was determined by the image analysis and compared with visual scoring and subepidermal low-echogenic band thickness. All three methods gave consistent results, image analysis being the most sensitive, reliable, and bias-free. Significant interindividual variability of subepidermal low-echogenic band echostructure was revealed. Moreover, circadian variability of subepidermal low-echogenic band echogenicity was observed. These major interindividual and diurnal variations of subepidermal low-echogenic band suggest that this band does not only represent an irreversible structural change but also a redistribution of fluid in the aged dermis. Diurnal variations in the subepidermal low-echogenic band would limit the use of this parameter in studies of skin aging, photoaging, and efficiency of medication.

Polymorphonuclear neutrophil granulocyte chemotactic hyperresponsiveness in a case of canine acromegaly

Growth hormone (GH) has recently been shown to affect polymorphonuclear neutrophil granulocyte (PMN) function and to be secreted by mononuclear cells, indicating that the hormone may be active in an immunophysiologic network, acting as an endo- or paracrine priming agent. The purpose of the present study was to evaluate the chemotactic responsiveness of canine peripheral PMN in a dog with acromegaly, caused by spontaneous, progesterone-induced hypersecretion of GH and, secondary to this, a seven-fold increase in insulin-like growth factor I (IGF-I). The chemotactic responsiveness towards zymosan-activated serum (ZAS) and leukotriene B4 (LTB4) was evaluated at a time when the dog suffered from acromegaly and again 57 days after corrective surgery (ovariohysterectomy). The experiments showed that PMN from the patient exhibited enhanced chemotactic migration that appeared to be associated with the hypersomatotropic condition as judged from the reversibility of the phenomenon. The glucose intolerance and elevated serum alkaline phosphatase that were observed in the acromegalic dog were also shown to be reversible following surgery.

[Syphilis meets AIDS. Syphilis seen in relation to the AIDS epidemic--a review]

The incidence of syphilis in Denmark has changed within the last ten years. From being a relatively common disease at the end of the 1970's and beginning of the 1980's, the incidence has fallen considerably. It is assumed that the change is connected with the emergence of AIDS and the resulting increase in information and attention to sexually transmitted diseases. In the USA, after a fall in the beginning of the 1980's, the incidence of syphilis has risen markedly, particularly among heterosexual coloured people in large cities. Recently, there have been some reports claiming atypical syphilis in patients with HIV-infection. To date there are no controlled investigations to corroborate this notion. Seronegative syphilis or delayed seropositivity has been reported in certain immunosuppressed AIDS patients. Otherwise the syphilis serology of HIV-infected patients does not seem to differ essentially from HIV-negative patients. All patients with HIV infection should be counselled about syphilis and offered a test for syphilis, just as patients with syphilis should be encouraged to be tested for HIV antibody after informed consent.

[Contact tracing in HIV infection]

The results of contact tracing in two male and one female HIV antibody positive index cases are described. Altogether 19 sexual partners were reported, of whom 13 were traced. In one case previously unknown HIV infection was diagnosed. Contact tracing for HIV infection in Denmark depends solely upon the cooperation of the index case and upon the willingness of notified partners to appear for counselling and testing. The efficacy of partner notification for HIV infection in Denmark based on the current strategy should be further evaluated.

Histamine release in immediate-type hypersensitivity reactions in intact human skin measured by microdialysis. A preliminary study

The purpose of this study was to evaluate the application of a microdialysis technique for measurement of interstitial histamine levels in intact human skin. Three allergic subjects were investigated. Single dialysis fibers were glued to nylon tubings and inserted in forearm skin by means of a fine cannula. Dialysis fibers were inserted in triplicate and perfused with isotonic saline at a rate of 3 microliters/min. After a period of 2 h a 60-microliters base-line period was established. Then the patients were skin prick tested (SPT) with allergen in duplicate and a single saline control. Dialysate was collected in consecutive 30 microliters fractions. Histamine concentration in the dialysate was analyzed with a glass fiber fluorescence assay. Median base-line histamine level was 4 (range 4-7) ng/ml. Following allergen SPT, dialysate histamine concentration increased to 81 ng/ml (74-128), with maximum values 10-20 min after SPT. Intraindividual coefficient of variation on peak histamine levels was 18.9%. No histamine increase was seen following saline SPT. We consider microdialysis to be a valuable method for assessment of allergic mechanisms in intact human skin.

Ceftriaxone/metronidazole is more effective than ampicillin/netilmicin/metronidazole in the treatment of bacterial peritonitis

In a prospective, open, controlled clinical study, 190 consecutive patients who were thought to have bacterial peritonitis before operation, were randomised to antibiotic treatment during and after operation with either ceftriaxone 1 g plus metronidazole 1.5 g once daily (n = 94) or ampicillin 2 g plus netilmicin 150 mg twice daily plus metronidazole 1.5 g once daily (n = 96). Incisional and deep surgical wound infections, postoperative pneumonia and urinary tract infection as well as deaths caused by infection were recorded. Ceftriaxone-metronidazole was significantly more effective than ampicillin-netilmicin-metronidazole, 6/94 wound related infections (6%) compared to 18/96 (19%) (p = 0.02). In patients with peritonitis caused by a perforated colon or appendix the rates of clinical failure were 6% and 28%, respectively. We consider ceftriaxone plus metronidazole an efficient and easily administered antibiotic regimen in patients with bacterial peritonitis, and both the wide range of activity against Gram-negative aerobic rods and the long half life of ceftriaxone seem to be beneficial.

Leukotriene B4 in atopic dermatitis: increased skin levels and altered sensitivity of peripheral blood T-cells

Employing a radioimmunoassay, de-proteinated suction blister fluid from 12 patients with active atopic dermatitis appeared to contain higher levels of the pro-inflammatory and immunomodulatory mediator leukotriene B4 (LTB4) than suction blister fluid from 12 non-atopic individuals. Indirect support for the identity of the mediator was obtained by HPLC of pooled samples. Nylon wool enriched T cells from six patients with atopic dermatitis and six non-atopic people preincubated with LTB4 (10(-10) M - 10(-8) M) expressed no statistically significant suppression in co-culture with mitogen stimulated autologous mononuclear cells, and there was no difference between atopic and non-atopic T cells in this respect. In contrast, LTB4 induced a dose-dependent reduction in the percentage of phenotypic Leu 2a (suppressor) cells leading to an increased helper/suppressor ratio in five atopic patients that was not observed in five non-atopics. Elevated skin levels of LTB4 may initiate or amplify dermal inflammation, and abnormal T cell response to the mediator may account for the increased helper/suppressor ratio characteristic of patients with atopic dermatitis.

Reduced neutrophil production of leukotriene B4 associated with AIDS

Neutrophils from 10 homosexual men with evidence of HIV infection and 10 healthy controls were tested for their capacity to generate leukotriene B4. Neutrophils from patients with AIDS produced less leukotriene immunoreactivity when appropriately stimulated than neutrophils from healthy controls, whereas no significant difference could be detected between HIV-antibody-positive individuals without AIDS and healthy controls. This observation may be pertinent to the recurrence of some of the opportunistic infections associated with AIDS but more importantly, if reflecting a general defect in leukotriene production, it may provide further understanding of the mechanism which leads to reduced natural killer-cell activity, interleukin-2 and interferon-gamma production in AIDS.

AIDS related changes in pattern of sexually transmitted disease (STD) in an STD clinic in Copenhagen

Testing for antibodies against human immunodeficiency virus (HIV) was introduced in 1984 in this major sexually transmitted disease (STD) clinic in Copenhagen, which is attended by about 10,000 new patients each year. From 1984 to 1987 the proportion of patients examined for antibodies to HIV rose from 6% to 32%. The overall incidence of HIV antibody positivity decreased from 30% in 1984 to 3% in 1987, the combined result of decreased positivity in high risk patients tested and increased screening in low risk patients. HIV antibody positivity has been confined largely to homosexual men and drug addicts. Since 1985, however, 21 out of 2623 (0.8%) heterosexuals who were not drug addicts were found to be HIV antibody positive. During 1984-6 the incidence of STDs most often encountered in high risk groups (syphilis and gonorrhoea) decreased by 64% and 41% respectively, whereas the incidence of diseases most often diagnosed in low risk groups (condylomata acuminata and genital herpes) increased by 70% and 34% respectively in the same period. The addition of HIV infection to the list of STDs requires the allocation of more resources to the STD clinics to enable these clinics to handle this new problem. Screening for all patients attending an STD clinic for antibodies to HIV must be considered, and in our area it would be cost effective.

Lactoferrin, myeloperoxidase, lysozyme and eosinophil cationic protein in exudate in delayed type hypersensitivity

A skin window technique was used to study the morphology of leucocytes in upper dermis and exudate during nickel challenge in patients with contact allergy to nickel. Contact allergic patients and healthy volunteers tested with a skin widow without addition of nickel to the chamber medium served as controls. The morphology of the leucocytes in dermis was studied in biopsies taken 8, 24, or 48 h after skin window application, and in a parallel test the morphology of the exudate was examined by sequential collection of the chamber medium during a 48 h period. The infiltrate in dermis of contact allergic patients with nickel challenge in the chamber medium showed a time-dependent increase of mononuclear cells, eosinophils and basophils and a concomitant decrease of polymorphonuclear granulocytes, characteristic of a combined specific and unspecific inflammation. The morphology of the exudate in contact allergic patients exposed to nickel showed a dominance of polymorphonuclear granulocytes throughout the study period, while mononuclear cells, eosinophils and basophils were detected at a much lower quantity and with a considerable delay. Further, we studied the kinetics of the leucocyte granule proteins: lactoferrin, myeloperoxidase, lysozyme and eosinophil cationic protein in exudate fluid in a parallel test. A significant higher flux was found for all during the second day of allergen exposure compared to contact allergic patients without allergen challenge as well as normal volunteers. The increased protein fluxes were not accompanied by an increased flux of polymorphonuclear granulocytes in the exudate.(ABSTRACT TRUNCATED AT 250 WORDS)

Chemotactic activity of LTB4 in man

An improved skin window chamber technique has been developed and used for a quantitative study of the chemotactic effect of leukotriene B4 (LTB4). LTB4 (0.5 microM) was exposed to a skin window on the forearm of eight healthy volunteers, while phosphate buffered saline served as control in a skin window on the other forearm. Skin window exudates and samples of blood draining the skin window areas were collected after 1, 2, 4, 8, and 24 h. The samples were quantitated for the different types of leukocytes as well as the intra- and extracellular concentration of the eosinophilic cationic protein and lactoferrin as markers of eosinophil and neutrophil granulocytes. A significantly increased migration of neutrophil granulocytes into the skin window chamber containing LTB4 was found from the 2nd to the 8th hour after the initial LTB4 exposure. The eosinophils reached a significant peak at the 4th hour. The rise in the actual number of eosinophil cells did not reach significance, whereas measurements of the eosinophilic cationic protein in the cellular fraction of the exudate exhibited a significant increase as a reflection of the number of eosinophils. This highlights the potential clinical value of eosinophilic cationic protein measurements to reveal eosinophilia instead of the traditional eosinophil counts. Extracellular eosinophilic cationic protein and lactoferrin did not change significantly in the LTB4-exposed skin window, implying that LTB4 does not activate the eosinophils and neutrophils to exocytosis of their enzymes. The present in vivo results support the concept of LTB4 being a potent chemoattractant to neutrophil and less so to eosinophil granulocytes in humans, a chemoattractant that recruits the leukocytes but does not seem to activate them.

Eicosanoids in skin UV inflammation

Several studies have implicated the eicosanoids as mediator substances in different types of UV inflammation. In human UV erythema, various arachidonic acid metabolites--mainly cyclooxygenase products--have been detected, particularly in skin exudates. The concentration and the sequence of release of the various eicosanoids vary in relation to the time course and the various types of UV-induced erythema. UVB, UVC but not UVA erythema at its maximum was only to some extent inhibited by indomethacin despite almost complete inhibition of the synthesis of prostaglandins E2 and F2 alpha. A major issue cannot, as yet, be answered satisfactorily: are one or a number of eicosanoids per se causing the erythema or are they only passive bystanders released by damage to cellular structures? Until further evidence has been provided, the causative role of E and F prostaglandins in relation to development of UV erythema is doubtful. By contrast, PGI2 is a more likely candidate in this respect, being synthesized and released close to the events occurring in the vessel walls. The lipoxygenase pathway is still too unexplored for proper evaluation with regard to a role in the pathogenesis, but the pharmacological properties of leukotrienes and hydroxy-fatty acids may qualify them as potential candidates alone or in a concert of mediator events occurring during the developments of UV inflammation.

Refractory condylomata acuminata: a controlled clinical trial of carbon dioxide laser versus conventional surgical treatment

Uncontrolled trials indicate that treatment of condylomata acuminata with the carbon dioxide laser is effective and probably superior to conventional surgical treatment. We performed a controlled study of refractory condylomata acuminata to clarify whether this is the case. In this randomised trial 21 patients were treated with the carbon dioxide laser and 22 by conventional surgery after having been treated with podophyllin for an average of 33 and 35 weeks respectively. Five and seven patients respectively had previously required additional treatment, such as an operation. The treatment schedule was equally effective for both groups of patients. No difference between the two groups was seen in numbers of recurrences, postoperative pain, healing time, and rate of scar formation (p greater than 0.1-0.2). Treatment of recalcitrant condylomata acuminata with the carbon dioxide laser did not offer any advantages over traditional surgery, including electrocautery.