Human papillomavirus DNA and TP53 mutations in lung cancers from butchers

To investigate whether the high frequency of human papillomavirus infection in butchers may be linked to their higher than average incidence of lung cancer, we have examined lung cancers from 40 butchers and 26 controls for the presence of DNA from both HPV type 7, which is found almost uniquely in hand warts from butchers and fishermen, and for those HPV types associated with laryngeal and genital cancers. No HPV 7, and only a low frequency of HPV DNA was found, suggesting that HPV infection does not make an important contribution to the elevated levels of lung cancer in meat handlers. In addition, the frequency of p53 mutation was shown to be slightly lower than previously reported in lung cancers.

Self screening for risk of melanoma: validity of self mole counting by patients in a single general practice

OBJECTIVE

To validate self screening by patients of high mole counts, assess the within family association of sun protection behaviour and mole counts, and estimate prevalence of risk factors for melanoma.

SETTING AND SUBJECTS

Systematic sample of families from a single affluent general practice population in Wessex.

DESIGN

Subjects completed a questionnaire about risk factors for melanoma and counted their moles. Subsequently a mole count was done by a general practitioner trained at dermatology clinics.

MAIN OUTCOME MEASURES

Validation of self counts by observer's count. Within family association of sun protection behaviour and mole counts; self reported risk factors.

RESULTS

199/237 subjects (84%) returned the questionnaire; 212/237 (89%) were examined. High counts by patients on the front of the trunk (> 7 moles of > or = 2 mm) were reasonably sensitive (79%), predictive (75%), and specific (97%) of the observer's mole counts (kappa = 0.74), unlike arm or total body counts. Sun protection behaviour correlated between individuals and other family members (Spearman's coefficient r = 0.50, P < 0.01). In the past three months 15/114 adults (13.2%, 95% confidence interval 7.0% to 19.4%) reported any change in a mole and 6/114 (5.3%, 2.0% to 11.1%) "major" changes; 6/109 adults (5.5%, 2.1% to 11.6%) had both high mole counts and freckling.

CONCLUSIONS

Asking patients to count trunk moles could be a feasible way of identifying patients at high risk of melanoma. Concentrating on reported major changes in moles should avoid considerable workload in general practice. The generalisability of these findings and the adverse effects, net benefit in earlier diagnosis and prevention, and workload implications of such self screening need further research.

Cutaneous necrosis in pregnancy secondary to activated protein C resistance in hereditary angioedema

A 26-year-old woman with hereditary angineurotic oedema (HAE) presented at 22 weeks gestation with severe cutaneous necrosis similar to that seen in coumarin skin necrosis. Protein S deficiency secondary to HAE and pregnancy was postulated. Treatment with heparin, C1-inhibitor concentrates, systemic steroids and surgical debridement resulted in a successful outcome for both mother and child. Subsequent investigations revealed normal levels of protein C, antithrombin III, total protein S, free protein S but reduced function protein S activity with evidence of activated protein C resistance. Cutaneous necrosis has not been reported in associated with activated protein C resistance previously and the possible mechanisms are discussed.

Butchers' warts: no evidence for person to person transmission of HPV7

The distribution of warts due to HPV7 in workers in six abattoirs and 103 retail and wholesale butcheries has been studied to determine whether the high prevalence of HPV7 in the meat trade is the result of enhanced person to person transmission, or whether it is a ubiquitous virus which is activated by an unknown factor in meat. Warts were detected in 164 of 486 men. Scrapings were taken from 156 men, and HPV DNA was found in 112 samples, 74 of which contained HPV7. HPV7 was found in 36 workplaces, and there was no evidence of clustering of cases, as would be expected if person to person transmission was occurring in the workplace. This suggests that HPV7 is widely distributed in the community, but only causes clinical disease under specific conditions. We suggest that some unknown factor in meat enhances viral replication.

Cutaneous warts in butchers

Several studies have indicated a high prevalence of hand warts in meat handlers, although the reasons for this are not clear. The high prevalence may be partly due to HPV7, a virus found almost exclusively in meat handlers, but the source of HPV7 is not known. We have carried out a cross-sectional survey of hand warts in male meat workers and controls from other occupational groups, to investigate the reasons for the high prevalence of warts, and particularly of HPV7, in butchers. We studied 240 abattoir workers, 246 retail and wholesale butchers, 308 engineering fitters and 292 office workers. Each subject was interviewed using a standard questionnaire, and his hands were examined by a dermatologist. Scrapings from the warts were tested for HPV1, HPV2 and HPV7 by a polymerase chain reaction method. The prevalence of hand warts was 33.3% in the abattoir workers, 34.1% in the butchers, 19.5% in the engineers and 14.7% in the office workers. Scrapings were taken from 247 of 267 subjects with warts, and HPV DNA was detected in 151 samples. The most common viruses were HPV2 (94 men) and HPV7 (76 men). The excess of warts in meat workers was largely due to HPV7, which was found in only two of the office workers, and was not found in any of the engineers. Logistic regression analysis showed no association between the prevalence of hand warts (or HPV2 and HPV7 specifically) and hand trauma, cold and wet working conditions, smoking, atopy, or handling any particular kind of meat. We suggest that some constituent of animal flesh predisposes to replication of HPV7 in keratinized epithelium.

Successful treatment of steatocystoma multiplex by simple surgery

Steatocystoma multiplex is usually a minor cosmetic problem but rarely can be extremely disfiguring. Unfortunately, the very patients who would benefit most from treatment are usually regarded as having too may cysts for surgery. We report a case of extensive steatocystoma multiplex which was treated by a simple surgical technique under general anaesthetic.

Hailey-Hailey disease--exacerbation by herpes simplex virus and patch tests

Benign familial chronic pemphigus, or Hailey-Hailey disease, is a rare hereditary condition characterized by development of blisters at sites of friction such as the neck, axillae and groin. Contact sensitivity to topical medications is reported to be common and routine patch testing has been strongly advocated. We report a case of Hailey-Hailey disease in a 43-year-old veterinary surgeon who presented with an acute exacerbation of his disease caused by herpes simplex virus type 1 (HSV). Patch testing was carried out to exclude a coexistent contact dermatitis and was complicated by severe local blistering. We are reporting this case to remind clinicians that HSV is a recognized cause of exacerbations of this disease and to warn that patch testing is not without hazard.

Shape analysis for classification of malignant melanoma

Melanoma is a malignant skin tumour. If detected and surgically removed early whilst residing in the superficial part of the skin the prognosis is excellent. A seven-point check-list of signs and symptoms has been adopted by the Cancer Research Campaign to help non-dermatologists distinguish benign pigmented lesions from melanoma. The presence of irregularity in shape or outline of a mole is one of these important signs. However, it has recently been shown that not only patients, but also clinicians have difficulty in agreeing upon whether a mole exhibits irregularity or not. Computer image analysis methods have been developed to derive quantitative measures of those shape parameters which dermatologists appear to use in their assessment of shape irregularity. The overall shape of the lesion is expressed by the 'bulkiness' measure. Irregularity of the border is expressed by two fractal dimension measures, one for the 'structural' aspect of the shape and the other for the 'textural' aspect. These measures were used in combination to classify melanomas in the study containing silhouettes of 43 melanomas and 45 benign lesions producing correct classification with 91% sensitivity and 69% specificity. This paper describes computer image analysis aspects of the study.

Bowen's disease arising in a scar--a case report and review of the relationship between trauma and malignancy

A 55-year-old female presented with a 1-year history of Bowen's disease on the leg at the site of a scar from an injury that occurred at 5 years-of-age. The clinical features in this case suggest a causal relationship, although trauma may have been acting as a co-carcinogenic factor to an unknown primary-cause. The relationship between trauma and malignancy is reviewed and proposals for further investigation are discussed.

The relationship between risk of death from clinical stage 1 cutaneous melanoma and thickness of primary tumour: no evidence for steps in risk. Scottish Melanoma Group

Previous reports have suggested that the relationship between survival and thickness of primary cutaneous malignant melanoma is not linear, but that there are natural breakpoints at which survival worsens in a step fashion. Nine hundred and ninety-seven cases of primary cutaneous malignant melanoma less than 9.75 mm thick, excised in Scotland between 1979 and 1983 inclusive, were examined to see if this could be confirmed. An adjusted Cox's regression analysis showed that age, sex, site and thickness were all significant predictors of survival. Thickness was grouped either empirically or by the breakpoints reported by other authors. It was then entered into a model either as a regressor or as a factored variable. The ranges 0-9.75 mm and 0-2 mm were studied separately. In the 0-9.75 mm range the factored variable was a statistically significant better fit than the regressor for each set of breakpoints, including an empirical analysis with eight groups. This suggests that there is no single best fit and that a step-effect is unlikely. Across the 0-2 mm range there was no significant improvement in the fit if thickness was entered as a factored variable, again indicating that a step effect is unlikely. We argue that there is no biological or statistical evidence to support the existence of natural breakpoints.

Papuloerythroderma. Another case of a new disease

We describe a case of papuloerythroderma. This is a distinctive clinical entity characterized by pruritus, red-brown flat-topped papules exhibiting the "deck-chair" sign, eosinophilia, and lymphopenia. We propose that the Langerhans cell may have a central role in the pathogenesis of papuloerthroderma and we describe an excellent response to photochemotherapy.

Cryotherapy of hand warts--a questionnaire survey of 'consumers'

One-hundred and thirty (82%) of 159 patients who had been treated with cryotherapy for warts on the hands replied to a postal questionnaire. Most patients had wanted treatment for cosmetic reasons, although 35% also wanted treatment because of pain. Only 34% had used a wart paint for more than 6 weeks before referral. The long-term results of cryotherapy were poor, although 83% of patients thought they had been cured in the short-term; only 57% of patients were clear of warts after a median of 19 months' follow-up. Seventy-one per cent had defaulted from follow-up. In some cases this may have been encouraged by the dermatologists, but other reasons were pain, cost and perceived failure of treatment. Nearly 90% tolerated cryotherapy well and for 76% this was the preferred method of treatment. Fifty-nine per cent would have preferred to be treated in their local health centre and 85% would have been willing to be treated by a nurse. The results are discussed and we conclude that cryotherapy should be offered as a treatment for hand warts in most general practices.

A study of the value of the seven-point checklist in distinguishing benign pigmented lesions from melanoma

A seven-point scoring system has been adopted by the Cancer Research Campaign to help non-dermatologists recognize melanoma (MM). Its value is reviewed in the light of increasing referrals of pigmented lesions. One-hundred and ninety-five patients (M:F, 43:152; mean age = 43 years, s.d. = 19) were asked whether their lesions possessed the seven points before diagnosis. The dermatologist assessed the signs. Six patients were unable to comply and some had multiple lesions; thus, 216 lesions were fully assessed by patient and dermatologist, and six by the dermatologist alone. Histology was obtained where appropriate. There were eight MMs, 95 naevi, 80 seborrhoeic warts, three dysplastic naevi, and 36 other lesions. Seven of the eight MMs were diagnosed clinically; the other was biopsied because of suspicious features and was a nodular MM. Four lesions suspected to be MMs proved benign. The predictive value (PV) of a clinical diagnosis of MM was 64% and of non-MM was 99%. Using accepted cutpoints for the seven-point system (refer if score greater than or equal to 3) patients' scores gave a PV for MM of 7% and for non-MM of 99%. Two MMs scored less than three. Dermatologists' scores gave a PV for MM of 8% and for non-MM of 99%. One MM scored less than 3. Univariate analyses showed that enlargement (P less than 0.05), dermatologists' assessments of an irregular margin (P less than 0.001), size (P less than 0.05) and pigmentary irregularity (P less than 0.05), and patients' assessments of size (P less than 0.05) were statistically significant.(ABSTRACT TRUNCATED AT 250 WORDS)

Erysipelas complicating chronic discoid lupus erythematosus of the face--a case report and review of erysipelas

We present a case of erysipelas which complicated chronic discoid lupus erythematosus (CDLE) of the face. The diagnosis and implications for management are discussed. The changing epidemiology and clinical spectrum of erysipelas are reviewed.

Acute pancreatitis: a fatal complication of treatment of bullous pemphigoid with systemic corticosteroids

Acute pancreatitis may be a rare complication of systemic corticosteroids, although this is disputed. We describe a patient with bullous pemphigoid whose treatment was complicated by fatal acute pancreatitis. The question of a cause and effect relationship is discussed with reference to the literature. We emphasise the way that corticosteroids modified the presentation of acute pancreatitis in this case.

An audit of wart treatment in a Scottish dermatology department

We measured a dermatology department's workload from wart treatment in terms of time and numbers, and we studied the use made of routine treatments according to the site of the warts and the age of the patient. Twenty-one per cent of new referrals were for warts and 19% of clinic time was used for wart treatment, 9% of clinic time was for plantar warts alone and 29.5% of new patients failed to attend. Overall cryotherapy was the commonest treatment, particularly for warts on the hands and face, 73.2% of patients treated for hand warts defaulted from follow-up and 11.3% were referred back for further treatment. The implications of the results are discussed and we argue that hospital budget holders should fund community-based wart treatment facilities.

Routine treatment of cutaneous warts: a questionnaire survey of general practitioners

A postal questionnaire was sent to 185 general practitioners to assess their approach to cutaneous warts and their views on the future development of the routine wart treatment service; 159 (85.9%) replied. A wide range of treatments were offered and most patients were given some treatment. The main reasons respondents gave for referring patients to hospital were failure of wart paints (73.6%) and lack of availability of liquid nitrogen (70.4%). Most general practitioners (74.2%) believed that dermatologists should spend less than 5% of their time treating warts. Many general practitioners (61.6%) wanted a practice-based wart clinic offering cryotherapy and 30.8% would like to refer directly to a hospital clinic run by a nurse. A practice clinic was more popular with general practitioners who have a treatment room nurse (P less than 0.01). Most seemed to appreciate the need for training to use liquid nitrogen. We conclude that general practitioners are keen to use cryotherapy and we argue that hospital management should provide the necessary resources for running a community-based service.