Treatment of severe recalcitrant dermatoses of the palms and soles with PUVA-bath versus PUVA-cream therapy

PUVA-bath therapy developed into a first line topical PUVA therapy, and gel and cream preparations have been described as alternative modes of topical 8-MOP application. Because bath-PUVA can be difficult to manage, topical PUVA therapy using 8-MOP gel or cream preparations may become an important alternative when treating localised skin diseases. However, controlled comparisons of efficacy with this alternative topical PUVA therapy are lacking. We therefore compared the efficacy of PUVA-cream therapy with PUVA-bath therapy in 12 patients with recalcitrant dermatoses of the palms and soles using a left/right trial design. These patients responded well to both treatment modalities, meaning that both could be used successfully to treat recalcitrant dermatoses of the palms and soles.

[Pathogen spectrum of urethritis in the man]

545 male patients with a tentative diagnosis "urethritis" were examined between November 1984 and December 1994 in the Department of Dermatology and Venerology of the Military Hospital in Ulm. The patients, aged from 18 to 58 years (mean age 24.1 years), were examined according to a standardized diagnostic procedure: Smear preparations from the urethra with subsequent gram staining, bacterial cultures for aerobic bacteria, Neisseria gonorrhoeae (cultures and Phadebact gonococcus test), mycoplasma cultures (Mycoplasma hominis (M. hom.); Ureaplasma urealyticum (U. u), and Chlamydia trachomatis using several methods, primarily DIFT (Syva Micro-Trak). Trichomonas vaginalis counts in urine sediment 441 patients (81%) had 4 or more leukocytes per high-power (x1000) field in the gram stained specimens. In these 441 urethritis-patients the following germs could be detected: Trichomonas vagin 3 (1%), N. gonorrhoeae 80 (18%), Mycoplasma 94 (21%) [U. u. 59, M. hom. 24, both 11], C. trachomatis 114 (26%), other pathogenic bacteria 135 (31%). In 114 patients (26%) no bacteria could be identified. A single infection was diagnosed in a total of 242 patients (55%), a double infection was determined in 71 patients (16%) while a triple infection was found in 14 patients (3%). The spectrum determined in the single infection included the following: N. gonorrhoeae 41 (9%), Mycoplasma 45 (10%), C. trachomatis 67 (15%), other pathogenic bacteria 89 (20%) (most frequently found germs were Enterococcus, beta-hemolytic Streptococcus, Escherichia coli, Staph. aureus). In the double infections combinations with aerobic bacteria dominated. In triple infections, mycoplasma were most common. During the investigation period the number of patients with urethritis symptoms declined at a constant rate.

Nitric oxide inhibits tissue factor synthesis, expression and activity in human monocytes by prior formation of peroxynitrite

OBJECTIVE

Nitric oxide (NO) has antithrombotic properties by regulating platelet function, whereas direct effects on plasmatic coagulation are rarely described. In sepsis and inflammation, when synthesis of NO, oxygen radicals and toxic metabolites is crucial, the expression of tissue factor (TF) on monocytes stimulated by lipopolysaccharides (LPS) induces intravascular coagulation. This study was performed to examine the influence of NO and the NO-dependent metabolite peroxynitrite on LPS-induced TF expression and activity in human monocytes.

DESIGN

Experimental study.

SETTING

Laboratory for cell biology.

METHODS

Human peripheral blood mononuclear cells were isolated from buffy coats by gradient centrifugation. The NO-releasing compounds SIN1 and NOC18 were used under different conditions. TF antigen was assayed by flow cytometry, and its activity by a clotting assay. TF-mRNA was measured by reverse transcriptase polymerase chain reaction (RT-PCR-ELISA).

MEASUREMENTS AND RESULTS

Whereas NOC18, a pure NO donor, had no effect, SIN1, releasing both NO and superoxide (O2-), reduced TF expression and activity in a dose- and time-dependent manner; superoxide dismutase (SOD) reversed the SIN1-mediated effect. Adding the O2(-)-deliberating system hypoxanthin/xanthin oxidase (which had no significant effect per se) to NOC18, or using the NO and O2- reaction product peroxynitrite resulted in a reduction of TF expression. RT-PCR-ELISA indicated upregulation of TF-mRNA by SIN1 with a peak at 500 microM; higher doses had less effect.

CONCLUSION

These data demonstrate an influence of NO on LPS-induced TF expression in monocytes by prior formation of peroxynitrite; furthermore, the balance between NO and O2- seems to play a crucial role.

[Meningeal irritation--a complication of herpes zoster]

HISTORY AND CLINICAL FINDINGS

A previously healthy 26-year-old man complained of gradually increasing headache after an attack of flu. After 4 days an erythema with papules but no blisters was noted in the area of distribution of the left 10th thoracic nerve. As a child he had varicella (chickenpox) without complications.

INVESTIGATIONS

Lymphocytic pleocytosis and evidence of an abnormal blood-brain barrier were noted in cerebrospinal fluid (CSF). Serology for varicella zoster virus revealed an IgG titre of > 7400 IU/l in serum and 21 IU/l in CSF. The corresponding IgM titres were negative.

TREATMENT AND COURSE

The headaches and cutaneous changes regressed under i.v. treatment with acyclovir, 10 mg/kg body weight, 3 x daily for 10 days. Repeat CSF examination after 10 days showed merely minimal residual changes of inflammation.

CONCLUSION

This case illustrates the risk of severe neurological complications of herpes zoster infection. A seemingly minor rash with headache must be correctly diagnosed and immediate high-dosage acyclovir treatment instituted to prevent life-threatening and severe complications of herpes zoster meningitis or encephalitis.

Providing dermatological photographs using the multimedia extension of the international computer database for radiation accident case histories

The World Health Organisation (WHO) Radiation Emergency Medical Preparedness (REMPAN) centres have built up the International Computer Database for Radiation Accident Case Histories (ICDREC) to document the medical treatment of acute radiation syndrome (ARS) patients. Images play an increasing role as complementary information beside text and numerical data in medicine. In particular, retrieval and display of digitised skin photographs serve to improve patient care, medical education and scientific analysis concerning the cutaneous radiation syndrome (CRS). The ICDREC has been built up as a client/server system. Particular focus has been set on using commercial off-the-shelf software components. All the medical data including the multimedia data are stored in a relational database system. The database can be accessed by inexpensive personal computers in the physician's workplace. Retrieval of one photograph via local area network (LAN) requires approximately 3 s. Authorised institutions can access the database via the Internet. The current state of the ICDREC multimedia component is illustrated with the skin lesion treatment of a Chernobyl patient. An example is given on how the workflow in a dermatology department is supported by the ICDREC.

Dermatoscopy and high frequency sonography: two useful non-invasive methods to increase preoperative diagnostic accuracy in pigmented skin lesions

Dermatoscopy and high frequency sonography have recently been combined to increase diagnostic preoperative accuracy in the treatment of pigmented skin lesions. In this monocentric study 80 patients with pigmented skin lesions were evaluated clinically, by dermatoscopy, and 20 MHz-sonography followed by dermatohistopathological evaluation; 39 malignant melanomas, 37 common nevi, 3 dysplastic nevi, and 1 nevus Spitz were diagnosed histologically. In 72 of the 80 cases (91.3%) dermatoscopical diagnoses were confirmed by histopathology, compared to only 79% correct clinical diagnoses. For the mere clinical diagnosis of melanoma sensitivity was 79%, specificity was 78% and diagnostic accuracy was 65%. All diagnostic values increased by dermatoscopy: sensitivity reached 90%, specificity was 93%, and diagnostic accuracy was 83%. In order to determine tumor thickness preoperatively tumor thickness was measured by 20 MHz sonography. The correlation of tumor thickness between histometric and sonographic results was determined for nevi (r = 0.93) and melanoma (r = 0.95); 74.3% of melanomas were diagnosed correctly within an 0.2 mm range. Regarding the clinical important limit of 1 mm tumor thickness, 87.2% were diagnosed in accordance with histometric evaluation. An increase of 18% in diagnostic accuracy by dermatoscopy and 87.2% of correctly diagnosed cases of tumor thickness of malignant melanoma by high frequency sonography clearly demonstrate that these methods should be considered standard procedures in the diagnosis of pigmented skin lesions and will facilitate the decision on necessary surgical treatment.

[Suppurative acrodermatitis continua of Hallopeau. A differential diagnosis of paronychia]

HISTORY AND CLINICAL FINDINGS

A 39-year-old man was admitted for treatment of bilateral inflammatory-pustular skin changes in the area of the large toes and soles of the feet. Antibiotic treatment and an Emmert wedge resection had already been unsuccessfully performed at another hospital for what was diagnosed as paronychia. On admission there were inflammatory, in part erosive, red areas with yellow and partly confluent pustules on the distal phalanges of both great toes. The entire right nail-bed and left medial nail-bed were missing. In the area of the capillitium, both lower arms and the sulcus coronarius there were erythematous squamous plaques.

INVESTIGATIONS

Radiography of the great toes demonstrated dystrophic demineralisation, in part with subchondral cystic changes of the spongiosa. Histological examination of the nail-bed showed hyperplasia and papillomatosis, definite hyperkeratosis with a prominent granular layer, as well as ortho- and parahyperkeratosis. Laboratory tests for inflammatory disease were unremarkable and there was no association with HLA B27.

DIAGNOSIS, TREATMENT AND COURSE

Suppurative acrodermatitis continua of Hallopeau was diagnosed and immunosuppressive treatment with cyclosporin A given (initially 4.4 mg/kg. stepwise reduction to 2.5 mg/kg within 6 weeks, this dosage then continued for a further 10 weeks). Nearly complete healing was achieved, but the condition recurred in a mild form 2 weeks after the end of treatment.

CONCLUSION

Suppurative acrodermatitis continua of Hallopeau should be included in the differential diagnosis of inflammatory changes of the distal phalanges.

Transcriptional regulation of the human IL5 gene by ionizing radiation in Jurkat T cells: evidence for repression by an NF-AT-like element

Eosinophilia is often observed in patients with parasitic infections and atopic diseases like allergic asthma and atopic dermatitis. Additionally, it is a typical feature of the inflammatory reaction after therapeutic and accidental exposure to ionizing radiation. This uniquely specific phenomenon regulated by the cytokine interleukin 5 (IL-5) suggests specific control for IL5 gene expression. In this study, we generated promoter-CAT constructs containing different human IL-5 promoter regions spanning from positions -507 to +43. Transfection experiments in Jurkat T cells revealed that the promoter sequence from -57 to +43 was required for constitutive and inducible IL-5 promoter activity. Low baseline CAT activity could be enhanced by treatment with phenylmercuric acetate (PMA) or the combination of PMA and calcium ionophore. The promoter region between positions -97 and +43 showed responsiveness to low-dose X rays. Electrophoretic mobility shift assays demonstrated that the region from -117 to -97 was responsive to irradiation. Transcription factors specifically bound to this sequence showed a dose-dependent response to single doses of X rays between 1 and 8 Gy. Competition analysis indicated that the protein-DNA complexes at this region were related to the nuclear factor of activated T cells (NF-AT). Further confirmation was obtained by the addition of specific antibodies into protein-DNA reactions. For the first time, we have demonstrated that specific DNA binding of NF-ATp at the promoter region from -117 to -97 is involved in transcriptional regulation of the human IL5 gene in response to ionizing radiation.

[Anogenital condylomata acuminata, mucocutaneous candidiasis, vitiligo, keratopathy and primary hypoparathyroidism in an autoimmune polyglandular syndrome type 1]

HISTORY

6 months before admission a 21-year-old woman had developed anogenital condylomata acuminata (CA). Since early childhood she had been treated for primary hypoparathyroidism (PHPT) and recurrent mucocutaneous candidiasis. 5 years before admission corneal clouding had caused visual impairment. Recently, mainly truncal vitiligo with occipital poliosis had developed.

INVESTIGATIONS

PHPT was confirmed (parathormone level 7.7 mg/l). In addition, liver transaminases were raised (GOT 105.8 U/l, GPT 145.6 U/l, gamma-GT 56.8 U/l), pointing to noninfectious hepatitis. An ACTH stress test could not exclude manifest adrenocortical insufficiency, and thyroid function was also normal. The Merieux Multitest indicated an anergy.

DIAGNOSIS, TREATMENT AND COURSE

The constellation of test results suggested autoimmune polyglandular syndrome type I. The condylomata were treated by electrocautery and the intestinal candidiasis with amphotericin B suspension. Calcitriol capsules, 0.5 microgram, and calcium gluconate or lactate, 500 and 300 mg respectively, 3 times daily each, were given for the PHPT.

CONCLUSION

This case demonstrates a complex syndrome which can be recognized early by simple clinical tests. Early diagnosis prevents possible life-threatening complications.

Ionizing radiation induces, via generation of reactive oxygen intermediates, intercellular adhesion molecule-1 (ICAM-1) gene transcription and NF kappa B-like binding activity in the ICAM-1 transcriptional regulatory region

Ionizing radiation produces reactive oxygen intermediates in mammalian tissues and may serve as a model system for the investigation of the biologic effects of free radicals. We have previously shown that the adhesion molecule ICAM-1 is induced by ionizing radiation, and here we have investigated the molecular mechanisms responsible. ICAM-1 mRNA and cell surface expression was induced in HeLa and HaCaT cells after exposure to ionizing radiation. This induction was blocked by preincubation with the antioxidants PDTC and N-acetyl cysteine. ICAM-1 promoter activity was assessed by transiently transfecting HeLa cells with CAT-reporter gene constructs containing sequential ICAM-1 5' deletions. ICAM-1 5' fragments -1162/+1 (relative to the transcription start site) and -277/+1 displayed increased promoter activity when cells were exposed to ionizing radiation, but no induction was seen in a -182/+1 construct associating positions -277 to around -182 with inducibility by ionizing radiation. Nuclear extracts from HaCaT cells were tested in mobility shift assays using an NF kappa B-like binding site of the ICAM-1 5' region (positions -186/-177). There was marked enhancement of DNA-protein complex forming in extracts from irradiated versus untreated cells. Incubation of cells with antioxidants prior to irradiation prevented the radiation-dependent increase in complex formation. We conclude that reactive oxygen intermediates are involved in ICAM-1 induction by ionizing radiation. The ionizing radiation-induced, antioxidant-inhibitable binding at the ICAM-1 NF kappa B-like binding site is consistent with the view that NF kappa B is a pro-oxidant transcription factor.

Induction of interleukin 6 by ionizing radiation in a human epithelial cell line: control by corticosteroids

The cutaneous radiation syndrome after therapeutic or accidental exposure of human skin to ionizing radiation (IR) is accompanied by inflammatory processes which are controlled partly by proinflammatory cytokines. Besides tumour necrosis factor (TNF)-alpha and interleukin (IL)1, the pluripotent cytokine IL-6 belongs to the key mediators of inflammation. So far, there are no reports about the regulation of IL-6 by IR in epidermal cells. As an in vitro model to study the effects of IR on IL-6 gene expression, we treated the human epithelial HeLa cell line with different single X-ray doses between 1 and 20 Gy. Twenty-four hours after irradiation the IL-6 secretion was dose-dependently enhanced as measured by ELISA. At the transcriptional level, a slight increase of IL-6 transcripts was already detectable 1 h after irradiation, with maximum levels at 2 h, and a decline to baseline levels between 8 and 24 h. Addition of the transcriptional inhibitor actinomycin D inhibited the inducibility of IL-6 mRNA by TPA and IR. As the IL-6 promoter contains multiple binding sites for activated glucocorticoid receptors within the 5' regulatory region, the potential modulation of IL-6 expression by the corticosteroids hydrocortisone, dexamethasone and mometasone furoate was included in our study to modify the radiation-induced stress response. All corticosteroids applied could efficiently downregulate TPA- or radiation-induced IL-6 expression on both gene expression and protein levels. Mometasone furoate, followed by dexamethasone, was found to be most effective at low concentrations (1 nM), whereas hydrocortisone had to be applied at about 100-fold higher concentrations to achieve comparable inhibition. This experimental model is aimed at understanding the molecular circuits following IR, and thus to provide a basis for the treatment of radiation effects in skin.

[Bullous skin reactions after soft roentgen radiotherapy of HIV-associated Kaposi sarcomas]

Fractionated irradiation with X-rays or megavoltage is an important therapeutic option in the palliative treatment of Kaposi's sarcoma. We report on three HIV patients demonstrating bullous cutaneous eruptions in the irradiation field. Three homosexual men (age 45-60 y) stage of disease CDC 3C, were treated with fractionated soft X-rays with the scheme conventionally used by us (total dose 30 Gy, single doses 3 Gy). Immediately to three days after completion of treatment large blisters appeared within the irradiation field, resolving after 2-4 weeks, leaving post-inflammatory hyperpigmentation. The cause of this rare reaction to soft X-ray therapy, potentially suggesting an individually altered radiation sensitivity, is so far unknown. Controlled prospective studies applying different fractionation schemes will be necessary to better elucidate this issue.

Radiation lentigo. A distinct cutaneous lesion after accidental radiation exposure

BACKGROUND

Accidental exposure of skin to ionizing radiation leads to long-term alterations such as fibrosis, keratosis, and teleangiectasias. Also, noncharacteristic hyperpigmentation and hypopigmentation may be noted.

OBSERVATIONS

A distinct lesion is described on the calves of a white male survivor of the 1986 nuclear accident at Chernobyl, Ukraine. Several years after the accident at Chernobyl, characteristic pigmented macules developed in the areas of skin that had previously been exposed to ionizing radiation: there was a marked, sharply demarcated lentiginous hyperpigmentation of epidermal and basal keratinocytes and melanocytes, as well as an increase in the number of melanocytes. No cellular atypia was noted.

CONCLUSIONS

This case demonstrates the potential of high single doses of ionizing radiation to induce pigmented lesions with similar clinical and histological features as they have been described after exposure to natural UV radiation or radiation from a tanning bed or sunlamp or after therapy with oral psoralen with long-wave UV-A radiation (PUVA), described as solar, tanning bed, and PUVA lentigines. The absence of cellular atypia may account for a favorable prognosis and enables clear distinction from more serious diagnoses such as lentigo maligna melanoma.

Sonographic determination of cutaneous and subcutaneous fibrosis after accidental exposure to ionising radiation in the course of the Chernobyl nuclear power plant accident

Chronic cutaneous lesions in eight of 15 survivors of the Chernobyl nuclear energy plant accident presenting with clinical features of cutaneous radiation fibrosis were examined 6 years after exposure using high-frequency ultrasound. In all patients, lesional skin was examined using both the B- and A-modes. Similar phenomena were found in all patients. The corium was increased in thickness as well as density compared to normal skin. The increase in density was seen not only in the medium strata but also particularly at the border between corium and subcutaneous tissue. Within the subcutaneous tissue proper, isles of echo-rich spots were prominent. The number and width of echo signals in the subcutaneous tissue were increased, representing the sonographic correlate of subcutaneous fibrotic trabeculae. The thickness of epidermis plus corium was increased by more than 50% and was even doubled in some cases. According to the present findings obtained from patients with very severe exposure to ionising radiation, ultrasound analysis of cutaneous and subcutaneous radiation fibrosis shows a characteristic picture. Moreover, it was demonstrated that quantitative assessment of skin thickness is possible. As the method is simple and noninvasive, repeated examinations are possible. This provides the basis for monitoring possible treatment effects and efficient follow-up in these chronically progressive clinical conditions after exposure to ionising radiation.

[The treatment of cutaneous radiation-induced fibrosis with pentoxifylline and vitamin E. An empirical report]

BACKGROUND

Radiation fibrosis represents a severe complication of radiation therapy; standardized treatment protocols are lacking so far. Surgical excision rarely results in complete healing.

PATIENT AND METHODS

We report on a 58-year-old female patient who developed a squamous cell carcinoma within the fibrotic area of the irradiation field on the right chest, resulting from a radiotherapy following mastectomy for breast cancer 17 years ago. After surgical excision of the carcinoma a combined treatment with pentoxifylline tablets (3 x 400 mg/d p.o.) and vitamin-E capsules (1 x 400 mg/d p.o.) was initiated. Skin thickness was quantified by 20 MHz-ultrasound before and during treatment.

RESULTS

The patient noted an increasing improvement of the condition of the affected skin starting from 4 months. A continuing decrease of skin thickness as documented by 20 MHz-ultrasound could be demonstrated from the 6th month on. The treatment was tolerated well, no side effects were observed.

CONCLUSION

The data indicate a beneficial therapeutic effect of pentoxifylline and vitamin E on radiation-induced fibrosis. Little is known about the mechanism of action of this combined treatment protocol including pentoxifylline and vitamin E. Controlled clinical trials should be performed to confirm this observation.

Multiple superficial basal cell carcinomas (basalomatosis) following cobalt irradiation

Basalomatosis is an uncommon skin condition characterized by the occurrence of multiple basal cell carcinomas. Many cases reported in the literature have been attributed to arsenic treatment in psoriasis patients. We report a patient with basalomatosis caused by cobalt-60 (60Co) irradiation. A 55-year-old farmer developed 43 basal cell carcinomas 20 years after treatment of an immunoblastoma with 60Co irradiation. All the tumours were located within the radiation fields. Other possible causes of basalomatosis, such as arsenic intoxication and basal cell naevus syndrome, were excluded. The patient's multiple superficial basal cell carcinomas probably represent a late adverse effect of the 60Co irradiation.

Chromosome painting in highly irradiated Chernobyl victims: a follow-up study to evaluate the stability of symmetrical translocations and the influence of clonal aberrations for retrospective dose estimation

Follow-up fluorescence in situ hybridization (FISH) measurements of symmetrical translocations were performed in peripheral blood lymphocytes from 12 highly irradiated victims of the Chernobyl nuclear power plant accident biannually, between September 1991 and July 1994, to investigate the persistence of these aberration type with time post-exposure. Translocations were determined using biotin-labelled painting DNA probes for human chromosomes 1, 4 and 12 and a digoxigenin-labelled alpha-satellite pancentromeric DNA probe. In 11 of 12 cases the translocation frequencies remained fairly constant during the observation period, which allows to generate comparable dose estimates on the various sampling times. In one case (no. 9) the existence of a cell clone containing the consistent chromosome rearrangement t(1;13) (q25;q14) was identified using FISH in rehybridized slides with a digoxigenin-labelled painting DNA probe for chromosome 13 and a separate G-banding analysis. To obtain reliable dose estimates, total translocation frequency has to be corrected for the high contribution (16.5-23.5%) of this clonal translocation.

Human malignant melanoma. A genetic disease?

BACKGROUND

Human hereditary malignant melanoma, comprising 5% of all cases of malignant melanoma, occurs in association with other malignancies, predominantly in families with dysplastic nevus syndrome. Additionally, higher incidences of malignant melanoma have been reported in individuals with genetic disorders such as ataxia telangiectasia and xeroderma pigmentosum. The results and observations as reported in the literature on the involvement of oncogenes and chromosomal aberrations in the development of malignant melanoma are reviewed and compared with the authors' own experimental and clinical experience.

RESULTS

Numerous chromosomal regions, as on chromosomes 1 and 9, were altered. The long arm of chromosome 6 was affected in 60% of melanomas. Introduction of a normal copy of chromosome 6 resulted in loss of tumorigenicity in vitro. True melanoma genes were evident in two animal models: the Sinclair swine and the teleost fish Xiphophorus. In the Xiphophorus system, the crossing-conditioned elimination of a tumor suppressor gene led to the uncontrolled activity of a dominantly acting oncogene in certain hybrids. The causative oncogene, Xmrk, encodes a receptor tyrosine kinase closely related to human epidermal growth factor receptor (EGFR). Among the numerous studied human oncogenes, mutations in the extensively investigated ras family are the result rather than the cause of malignant transformation. High expression of nuclear oncogenes simply may be a common feature of rapidly dividing cells. The receptor tyrosine kinase EGFR may be involved in late stage melanoma; the human exon with homology to Xmrk shows elevated transcription levels in 80% of human melanoma metastases. Deletions of the tumor suppressor gene MTS 1 may be important for melanoma formation, whereas deletions of p53 appear to be of minor relevance.

CONCLUSION

Scientific progress in treating and diagnosing malignant melanoma will largely depend on experimental approaches to define relevant genetic changes by functional analysis rather than descriptive phenomenology and correlative observations.

Successful treatment and prophylaxis of scalp seborrhoeic dermatitis and dandruff with 2% ketoconazole shampoo: results of a multicentre, double-blind, placebo-controlled trial

Pityrosporum ovale appears to play an important role in the pathogenesis of seborrhoeic dermatitis. Ketoconazole is an antimycotic agent with a high in vitro and in vivo efficacy against P. ovale. We performed a multicentre study to investigate the efficacy of ketoconazole 2% shampoo in the treatment and prophylaxis of seborrhoeic dermatitis and dandruff. Five hundred and seventy-five patients presenting with moderate to severe seborrhoeic dermatitis and dandruff of the scalp were treated with 2% ketoconazole shampoo twice weekly for 2-4 weeks, producing an excellent response in 88%. Of those patients who responded, 312 were included in a prophylactic phase, lasting 6 months. These patients were treated with the active preparation (shampoo containing 2% ketoconazole) once-weekly, once every other week, alternating with placebo (shampoo without ketoconazole), or with placebo only once-weekly. Forty-eight (47%) patients in the placebo group experienced a relapse of seborrhoeic dermatitis, compared with 23 (19%) patients in the active treatment group, and 31 (31%) patients in the active/placebo group. The medication was well tolerated in all three groups. We conclude that ketoconazole 2% shampoo is highly effective, not only in clearing scalp seborrhoeic dermatitis and dandruff, but also in preventing relapse of the disease when used prophylactically once weekly.

Dicentric and translocation analysis for retrospective dose estimation in humans exposed to ionising radiation during the Chernobyl nuclear power plant accident

Chromosome analyses were carried out in peripheral blood lymphocytes obtained between September 1991 and March 1992 from 15 persons exposed to ionising radiation during the Chernobyl nuclear power plant accident. At present, all are being treated for symptoms of the delayed stage of the cutaneous radiation syndrome. Biological dose-equivalent estimates were determined, either by measuring the frequency of dicentric and ring chromosomes in first division unstable cells from conventional preparations (Qdr method), or by measuring the frequency of stable translocations using two-colour fluorescence in situ hybridisation (FISH) with composite whole chromosome-specific DNA libraries for human chromosomes 1, 4 and 12 (chromosome painting) and a degenerate alpha-satellite pancentromeric DNA probe. With both methods fairly comparable individual estimates between 1.1 and 5.8 Gy were obtained for 12 of 15 individuals. Three individuals exhibited no elevated aberration frequencies. Perspectives and limitations of chromosome painting for dose reconstruction of past radiation exposures are discussed.

Ionizing radiation induces human intercellular adhesion molecule-1 in vitro

Intercellular adhesion molecule-1 (ICAM-1) plays a central role in various inflammatory reactions and its expression is readily induced by inflammatory stimuli such as cytokines or ultraviolet irradiation. We have investigated the effect of ionizing radiation (IR) on human ICAM-1 expression in human cell lines and skin cultures. ICAM-1 mRNA levels in HL60, HaCaT, and HeLa cells were elevated at 3-6 h after irradiation and increased with doses from 10-40 Gy. The rapid induction of ICAM-1 occurred at the level of transcription, was independent of de novo protein synthesis, and did not involve autocrine stimuli including tumor necrosis factor-alpha and interleukin-1. IR also induced ICAM-1 cell surface expression within 24 h. Immunohistologic analysis of cultured human split skin revealed ICAM-1 upregulation on epidermal keratinocytes and dermal microvascular endothelial cells 24 h after exposure to 6 Gy. In conclusion, we propose ICAM-1 as an important radiation-induced enhancer of immunologic cell adhesion, which contributes to inflammatory reactions after local and total body irradiation.

Chronic cutaneous damage after accidental exposure to ionizing radiation: the Chernobyl experience

BACKGROUND

The hazards of acute radiation exposure are well known. Bone marrow failure from total body gamma or neutron irradiation is the most clinically relevant aspect of acute radiation disease. With nonhomogeneous exposure, as is characteristic in accidents, other organ systems, such as the skin, may be more important in determining clinical prognosis. This became obvious in the two worst radiation accidents since 1945, the Chernobyl accident in April 1986 and the Goiania accident in September 1987.

OBJECTIVE

Our purpose was to describe the characteristic chronic sequelae of accidental cutaneous radiation in a group of patients who survived the Chernobyl nuclear power plant accident.

METHODS

Fifteen patients with the delayed type of the cutaneous radiation syndrome were examined between September 1991 and January 1992. All patients had a history of acute radiation disease. The exposure pattern was characterized by partial body exposure with high doses of beta and gamma irradiation from radioactive water, steam, or dust.

RESULTS

Radiation-induced lesions were confined primarily to the legs and distal arms, but sometimes involved up to 50% of the total body surface. In addition to telangiectases, radiation keratoses, and radiation ulcers, hemangiomas, hematolymphangiomas, splinter hemorrhages in the distal nail bed, lentiginous hyperpigmentation, and severe subcutaneous fibrosis were noted. No malignant transformation could be detected. Associated diseases included cataracts, chronic hepatitis, and recalcitrant bacterial and herpesvirus infections.

CONCLUSION

After accidental partial body exposure to high doses of beta and gamma irradiation, the predominant involvement of the skin, described as the cutaneous radiation syndrome, can become the characteristic feature. This causes longlasting, serious diagnostic and therapeutic problems.

Increased expression of epidermal IL-8 receptor in psoriasis. Down-regulation by FK-506 in vitro

IL-8 is a chemotactic cytokine with proinflammatory and growth-promoting activities. Recently it has been shown to influence several functions of keratinocytes, including HLA-DR expression, chemotaxis, and proliferation by binding to a specific receptor. Because psoriasis vulgaris is characterized by epidermal hyperproliferation and infiltration of inflammatory cells, we investigated the expression of IL-8 and its receptor in normal and psoriatic epidermis using semiquantitative reverse-transcriptase-polymerase chain reaction. In addition the mRNA levels of the proto-oncogenes c-ras, c-raf, c-myc, and HER-2 were also investigated as potential growth-promoting stimuli in psoriatic epidermis. IL-8 mRNA was only detected in lesional psoriatic epidermis, and IL-8R-specific mRNA was found to be 10 times increased in lesional psoriatic epidermis. There was no significant difference in the protooncogene mRNA levels. In order to test the relevance of the massively increased IL-8R levels in psoriatic epidermis, we investigated the effect of the antipsoriatic drug FK-506 on specific IL-8 and IL-8R mRNA expression. FK-506 dose dependently inhibited IL-8R expression and function. Our data suggest that in psoriatic skin, elevated IL-8 levels and markedly increased IL-8R expression may act in concert to induce the cardinal signs of psoriasis--epidermal hyperproliferation and leukocyte infiltration. IL-8R may prove a molecular target for antipsoriatic drugs such as FK-506.

Increased expression of epidermal IL-8 receptor in psoriasis. Down-regulation by FK-506 in vitro

IL-8 is a chemotactic cytokine with proinflammatory and growth-promoting activities. Recently it has been shown to influence several functions of keratinocytes, including HLA-DR expression, chemotaxis, and proliferation by binding to a specific receptor. Because psoriasis vulgaris is characterized by epidermal hyperproliferation and infiltration of inflammatory cells, we investigated the expression of IL-8 and its receptor in normal and psoriatic epidermis using semiquantitative reverse-transcriptase-polymerase chain reaction. In addition the mRNA levels of the proto-oncogenes c-ras, c-raf, c-myc, and HER-2 were also investigated as potential growth-promoting stimuli in psoriatic epidermis. IL-8 mRNA was only detected in lesional psoriatic epidermis, and IL-8R-specific mRNA was found to be 10 times increased in lesional psoriatic epidermis. There was no significant difference in the protooncogene mRNA levels. In order to test the relevance of the massively increased IL-8R levels in psoriatic epidermis, we investigated the effect of the antipsoriatic drug FK-506 on specific IL-8 and IL-8R mRNA expression. FK-506 dose dependently inhibited IL-8R expression and function. Our data suggest that in psoriatic skin, elevated IL-8 levels and markedly increased IL-8R expression may act in concert to induce the cardinal signs of psoriasis--epidermal hyperproliferation and leukocyte infiltration. IL-8R may prove a molecular target for antipsoriatic drugs such as FK-506.

Increased expression of the epidermal growth factor receptor in human epidermal keratinocytes after exposure to ionizing radiation

The effect of exposure of human epidermal keratinocytes to ionizing radiation, both in vivo and in vitro, on the expression of the epidermal growth factor receptor (EGF-R) was studied on the protein, mRNA, and functional levels. Quantitative fluorometry of short-term organ cultures incubated with a monoclonal antibody against human EGF-R revealed a dose-dependent increase of EGF-R expression 24 h after irradiation with 4 and 6 Gy, with an additional increase after 48 h. In biopsy specimens from patients undergoing radiation therapy a markedly increased expression could be determined by quantitative fluorometry during radiation therapy which wa still considerably above the baseline level 4 weeks after termination of treatment. Radioligand binding assays demonstrated a 50% increase in 125I-EGF binding to primary keratinocytes and A431 cells, at doses of 1 Gy, with a further increase after 72 and 96 h. Northern blots were performed with total RNA from two human epidermal cell lines (SCLII and A431). In A431 cells, increased EGF-R transcript levels could be detected 48 h after irradiation. In cells of the SCLII cell line, EGF-R expression was not affected by irradiation. These results were confirmed by semiquantitative polymerase chain reaction of primary cultured keratinocytes, demonstrating an increase of transcripts of EGF-R 24 h after irradiation with single doses of 6 Gy. Thus exposure to ionizing radiation leads to an increased expression of functionally intact EGF-R in human keratinocytes, at the protein and mRNA levels, both in vitro and in vivo; we hypothesize that this effect is part of a stress program of epidermal cells in response to ionizing radiation, ensuring rapid repopulation of irradiated areas.

Analytic morphology in clinical and experimental dermatology

During the past several years, quantitative morphology has gained increasing attention in diagnostic pathology and in certain research applications. In the field of dermatopathology, quantitative morphology has been applied to numerous problems, ranging from the interactive measurement of nuclear contours to fully automated, high-resolution image analysis of ultrastructural micrographs. Dermatologic applications are reviewed, and potential developments in the future are briefly outlined.

Male reproductive system in patients exposed to ionizing irradiation in the Chernobyl accident

Twelve men with different forms and stages of chronic radiation dermatitis caused by accidental exposure to beta and gamma irradiation during and after the Chernobyl atomic power plant accident were examined. Two patients had impotentia coeundi, and the others reported various impairments of sexual function. One patient had aspermia, two patients had azoospermia, one had oligospermia, and four had normal sperm counts. In three samples abnormal forms of spermatozoa were increased. Sperm motility was decreased in 3 samples and was normal in another. Hormonal analyses demonstrated low testosterone plasma levels in two patients, an increase of follicle stimulating hormone (FSH) levels in six patients, and a decrease of luteinizing hormone (LH) in one patient. In one patient who showed an increase of plasma prolactin level, associated with low testosterone and LH, a microadenoma of the pituitary gland (prolactinoma) was detected. It would appear that there is an association between accidental exposure to ionizing radiation of varying severity and the impairment of exocrine and endocrine testicular function, sometimes resulting in long-lasting physiological and psychological problems.

[Incontinentia pigmenti in a male patient]

Incontinentia pigmenti (Bloch-Sulzberger syndrome) is a rare genetic disorder usually affecting females. Familial cases show an X-linked dominant inheritance with male lethality. The typical skin manifestations occur in several stages and can be associated with various extracutaneous anomalies. We report on a 10-month-old male patient with incontinentia pigmenti (IP) and a normal male karyotype. Besides the typical cutaneous lesions no other signs have been found so far. IP in male patients can be explained by the presence of Klinefelter syndrome, by the half-chromatid mutation model, or by an early somatic mutation. On the basis of this case report we discuss the clinical findings in and the genetics of IP.

Interleukin-8 receptors in normal and psoriatic polymorphonuclear leukocytes

Polymorphonuclear leukocyte (PMNL) infiltration is an important characteristic in psoriatic lesions. The proinflammatory 8-kD peptide interleukin-8 (IL-8) is present in psoriatic scales and possesses a high chemotactic activity on human neutrophils, which may relate to its role in psoriasis. Its chemotactic activity is mediated via specific receptors on PMNL. The goal of our work was to ascertain whether PMNL infiltration in psoriasis can be accounted for by functional abnormalities of the circulating PMNL due to alterations in the IL-8 receptor density or affinity (or both). Results of radioligand binding studies performed in 10 psoriatic patients, 10 patients with atopic eczema and 11 normal controls showed no difference in receptor affinity (Kd) between the groups. However, a slight but significant elevation in IL-8 receptor density was seen on PMNL from psoriatic individuals (31,230 +/- 3,237 binding sites per cell) compared to those from normal volunteers (24,152 +/- 2,643) and atopic eczema patients (24,092 +/- 2,743). Increased number of IL-8 receptors may, besides elevated cutaneous IL-8 concentrations, contribute to the intraepidermal accumulation of PMNL in psoriasis.

Therapeutic efficacy of oral low-dose cyclosporin A in severe psoriatic arthritis

Six male patients with severe psoriatic arthritis (PA) unresponsive to various topical and systemic therapies have been treated with oral cyclosporin A (CyA; Sandimmun) solution at daily doses ranging usually from 1.5 to 5.0 mg/kg. In 1 case the dose had to be increased to 7 mg/kg/day. At initiation of CyA therapy skin involvement was between 40 and 90% of total body surface. Initiation of CyA therapy resulted in marked improvement of skin lesions within 2-7 weeks accompanied by impressive relief from arthralgias and improvement of joint function. The requirement for nonsteroidal anti-inflammatory drugs was markedly reduced in all cases. All patients in whom CyA therapy was continued remained clinically stable for several months (follow-up period 2-7 months). Although mild to moderate relapses occurred, rebound phenomena were not observed after discontinuation of treatment. Side effects which comprised serum creatinine increases in 3 out of 6 cases were reversed by adjustment of CyA dosage.

[Cyclosporin A in the therapy of inflammatory dermatoses]

The experience reported in the literature with cyclosporin A (CyA) in the treatment of various inflammatory and autoimmune dermatological diseases is reviewed and compared with the authors' own experience of treating 36 patients presenting with psoriatic arthritis [8], generalized pustular psoriasis [2], palmoplantar pustular psoriasis [12], Behçet's disease [2], disseminated circumscribed scleroderma [2], acrodermatitis continua suppurativa [2], pemphigus vulgaris [1], lupus erythematosus [3], pyoderma gangrenosum [1], severe atopic eczema [2], and actinic reticuloid [1]. On the basis of the authors' own experience and the reported results, treatment with CyA appears to be primarily indicated in pyoderma gangrenosum, circumscribed scleroderma, psoriatic arthritis and acrodermatitis continua suppurativa. In diseases such as actinic reticuloid, Behçet's disease, localized and generalized pustular psoriasis, treatment with CyA leads to good results with an acceptable risk-benefit ratio. In our view, it is doubtful whether treatment with CyA alone is indicated in alopecia areata, lichen ruber, dermatomyositis, atopic eczema, systemic scleroderma, bullous diseases, and lupus erythematosus, and in the last two it should be given only in combination with systemic steroids. Literature reports provide no support for the use of CyA in ichthyosis vulgaris, pityriasis rubra pilaris, and cutaneous T-cell lymphomas. The risk-benefit ratio of CyA treatment should be carefully considered, especially in diseases that are not life-threatening.

[Extracutaneous malignant melanomas: clinical aspects and biology]

Approximately 5% of all malignant melanomas originate from primarily non-cutaneous sites. They are preferentially distributed along the choroid, the meninges, the subserous space of the oesophagus and the intestinal tract, at transitional areas of mucous membranes, and along organ capsules, the periadventitial tissues of major blood vessels, and, occasionally, muscle fasciae. Little is known about their biological behaviour; the prognosis, however, generally has to be considered less favourable than that of primary cutaneous malignant melanomas, probably at least in part because they are often not discovered until they are in advanced stages. There are no specific clinical signs suggestive for non-cutaneous malignant melanomas; symptoms vary with the site of manifestation of the tumours. Interpretation of these clinical data based on results from comparative anatomical studies leads to the conclusion that extracutaneous malignant melanomas in humans are residuals of phylogenetically old, extensive and well-developed non-cutaneous pigment cell patterns demonstrable in a variety of lower vertebrates, which result from interactions between organogenesis and pigment cell development during ontogeny. This demonstrates that consideration of fundamental principles of developmental biology can give diagnostic clues to the localizations at which primary non-cutaneous malignant melanomas may be suspected and can thus facilitate decisions about what diagnostic procedures are necessary.

Interleukin-8 receptor-mediated chemotaxis of normal human epidermal cells

Normal human keratinocytes show chemotactic behavior towards interleukin-8 (IL-8). Under physiological conditions this cytokine seems to be present in an equilibrium between monomeric and dimeric forms, as indicated by Western blotting data. Radioligand binding studies suggest that keratinocyte chemotaxis is mediated by receptors specific for IL-8 dimers. IL-8 receptor-specific mRNA can be detected in a keratinocyte cell line by polymerase chain reaction.

Prevalence of dysplastic nevi in healthy young men

Young white men (1176 men, mean age 20 years, age range from 18 to 26 years) were examined for dysplastic nevi. In 78 patients (6.63%), 107 clinically dysplastic nevi were observed, demonstrating all three NIH criteria (diameter greater than 5mm, irregularities of border, irregularities of color) suggestive for clinically dysplastic nevi. Of these, 71 nevi in 52 patients were excised and examined histologically, 46 nevi in 26 patients were not excised due to lack of patients' consent. Fifty-two of 78 (66.6%) patients with clinically dysplastic nevi agreed to excision. In these, seven nevi (13.5% of patients or 9.86% of all nevi excised) were confirmed by histology. According to these data, three additional patients with dysplastic nevi would have been expected among the 26 patients who refused surgery. Referring to the entire study group, the prevalence of dysplastic nevi in young white men is expected to be 0.85%.

[Two superficially spreading malignant melanomas on nevus spilus]

A case of a 49-year-old patient with two superficial spreading melanomas arising from a naevus spilus is presented. Although opinions differ on the potential for malignant transformation in naevi spili, they should be carefully watched, and if changes are found these lesions should be subjected to histopathologic examination.

Annular erythema associated with Sjögren's syndrome: a variant of systemic lupus erythematosus

We present a Burmese patient with widespread annular erythema associated with Sjögren's syndrome. Unlike previously described cases, the disease occurred in the setting of systemic lupus erythematosus. Photoprovocation testing revealed light sensitivity in the UVA range with elicitation of subacute cutaneous lupus erythematosus-like lesions. The presence of an erythema annulare centrifugum-like eruption should initiate the search for Sjögren's syndrome and systemic lupus erythematosus.

[Treatment of seborrhoeic eczema with ketoconazole in comparison with an active agent-free cream]

Both systemic and topical application of ketoconazole (CAS 65277-42-1) have been found effective in seborrhoeic dermatitis. The topical application of 2% ketoconazole in a cream base in particular has so far only once been compared to the application of the vehicle. Statistical analysis, however, has only been descriptive. In the present trial including 60 patients 2% ketoconazole cream (Nizoral) and a bland cream have been compared in a randomised, controlled fashion. Both erythema and scaling were found markedly more reduced in the verum group (p = 0.003 and p = 0.006, resp.). Hence the topical application of 2% ketoconazole cream can be considered as rational treatment of seborrhoeic dermatitis the more so as the application of the drug was well tolerated.

[Pigmented basalioma as pseudomelanoma of the breast]

We report on a patient with a pigmented basal cell carcinoma of the nipple. Despite its rarity, it is important to know about this tumour because it is so easy to confuse it with malignant melanoma.

Progressive growth of fish tumors after transplantation into thymus-aplastic (nu/nu) mice

The nude mouse does not reject xenografts of malignant and nonmalignant tissues of mammalian or avian origin, due to a deficiency of functional T-lymphocytes. In this study, tissue from a cold-blooded vertebrate, a teleost fish, was for the first time successfully transplanted to Swiss albino nu/nu mice. Malignant melanotic melanoma of Xiphophorus transplanted to nude mice showed progressive growth and could be serially passaged. In vitro culture experiments revealed that the fish tumor cells adapt to the physiological conditions of the mammalian host, most obviously to the body temperature. On the other hand, fish-specific morphological characters and biochemical features, e.g., expression of a melanoma-associated antigen, were retained. This experiment demonstrates the enormous capacity of the melanoma cells to adapt to severe changes in their environment, which even enables them to overcome the physiological barriers between such taxonomically distant vertebrate groups as fish and mammals.