Anogenital Lichen Sclerosus in Women

A study of 350 women with lichen sclerosus, originally made to elucidate the relationship between lichen sclerosus and autoimmunity, led to the amassing of a considerable amount of clinical material. Our review is confined to those with anogenital lesions (342), supplemented by some new cases (15), giving a total of 357 women with biopsy proven lichen sclerosus. It demonstrates the wide age range of the condition, the association with morphoea and lichen planus and the occurrence of squamous cell carcinoma in some cases. It also shows that inappropriate surgery has continued to be carried out for benign disease.

Management of Lichen Sclerosus and Intraepithelial Neoplasia of the Vulva in the UK

Women with vulval intraepithelial neoplasia (VIN), lichen sclerosus (LS) and Paget's disease are referred either to gynaecologists or to dermatologists. We have ascertained the caseloads, referral patterns and treatment modalities used in the two specialties.

A postal questionnaire was sent to 540 consultant gynaecologists and 225 consultant and senior registrar members of the British Association of Dermatologists. 350 gynaecologists and 161 dermatologists returned completed questionnaires. The workload of LS and Paget's disease was evenly distributed, with 54% of dermatologists and 58% of gynaecologists seeing more than six cases of LS per annum and less than 1% seeing more than five cases of Paget's disease. 92% of responding gynaecologists saw at least one case of VIN per year whereas 43% of dermatologists saw no cases. Patients with VIN and Paget's were referred to gynaecologists for treatment by 66% of dermatologists. Both groups are equally prepared to treat LS. Indications for treatment of VIN and LS were suspicion of invasion and symptoms. Local excision of VIN is the treatment of choice by both gynaecologists and dermatologists. LS is predominantly treated with topical steroids but gynaecologists also use topical oestrogen and testosterone.

The great majority of responders favoured establishing a national register to study the outcome of vulval lesions.

Baseline and storm event monitoring of Bacteroidales marker concentrations and enteric pathogen presence in a rural Canadian watershed

Bacteroidales 16S rRNA gene markers were evaluated for their use as a microbial source tracking tool in a well characterized 750 ha agricultural watershed in Nova Scotia, Canada. Water quality monitoring was conducted following the validation of host-specific and universal Bacteroidales (AllBac) markers for their proficiency in this particular geographic region, which provided further evidence that these markers are geographically stable. Increasing Escherichia coli concentrations were positively correlated (p < 0.01) with concentrations of the AllBac marker in water samples, suggesting that this universal marker is more suited as a positive DNA control rather than as an indicator of recent fecal contamination. Ruminant (BacR) and bovine (CowM2) specific marker detection was associated with increased runoff due to precipitation in sub-watersheds putatively impacted by cattle farming, demonstrating that the BacR and CowM2 markers can be used to detect the recent introduction of fecal matter from cattle farming activities during rainfall events. However, the human associated marker (BacH) was only detected once in spite of numerous on-site residential wastewater treatment systems in the watershed, suggesting that this assay is not sensitive enough to detect this type of human sewage source. E. coli O157:H7 and Salmonella spp. DNA was not detected in any of the 149 watershed samples; however, 114 (76.5%) of those samples tested positive for Campylobacter spp. No significant correlation (p > 0.05) was found between Campylobacter spp. presence and either E. coli or AllBac marker levels. Further studies should be conducted to assess the origins of Campylobacter spp. in these types of watersheds, and to quantify pathogen cell numbers to allow for a human health risk assessment.

β-Glucosidase 2 (GBA2) activity and imino sugar pharmacology

β-Glucosidase 2 (GBA2) is an enzyme that cleaves the membrane lipid glucosylceramide into glucose and ceramide. The GBA2 gene is mutated in genetic neurological diseases (hereditary spastic paraplegia and cerebellar ataxia). Pharmacologically, GBA2 is reversibly inhibited by alkylated imino sugars that are in clinical use or are being developed for this purpose. We have addressed the ambiguity surrounding one of the defining characteristics of GBA2, which is its sensitivity to inhibition by conduritol B epoxide (CBE). We found that CBE inhibited GBA2, in vitro and in live cells, in a time-dependent fashion, which is typical for mechanism-based enzyme inactivators. Compared with the well characterized impact of CBE on the lysosomal glucosylceramide-degrading enzyme (glucocerebrosidase, GBA), CBE inactivated GBA2 less efficiently, due to a lower affinity for this enzyme (higher KI) and a lower rate of enzyme inactivation (k(inact)). In contrast to CBE, N-butyldeoxygalactonojirimycin exclusively inhibited GBA2. Accordingly, we propose to redefine GBA2 activity as the β-glucosidase that is sensitive to inhibition by N-butyldeoxygalactonojirimycin. Revised as such, GBA2 activity 1) was optimal at pH 5.5-6.0; 2) accounted for a much higher proportion of detergent-independent membrane-associated β-glucosidase activity; 3) was more variable among mouse tissues and neuroblastoma and monocyte cell lines; and 4) was more sensitive to inhibition by N-butyldeoxynojirimycin (miglustat, Zavesca®), in comparison with earlier studies. Our evaluation of GBA2 makes it possible to assess its activity more accurately, which will be helpful in analyzing its physiological roles and involvement in disease and in the pharmacological profiling of monosaccharide mimetics.

The zebrafish embryo as a tool for screening and characterizing pleurocidin host-defense peptides as anti-cancer agents

The emergence of multidrug-resistant cancers and the lack of targeted therapies for many cancers underscore an unmet need for new therapeutics with novel modes of action towards cancer cells. Host-defense peptides often exhibit selective cytotoxicity towards cancer cells and show potential as anti-cancer therapeutics. Here, we screen 26 naturally occurring variants of the peptide pleurocidin for cytotoxic and anti-cancer activities, and investigate the underlying mechanism of action. Cytotoxicities were assessed in vitro using cell-based assays and in vivo using zebrafish embryos. Morphological changes were assessed by both transmission and scanning electron microscopy, and functional assays were performed on zebrafish embryos to investigate the mechanism of cell death. A total of 14 peptides were virtually inactive against HL60 human leukemia cells, whereas 12 caused >50% death at ≤32 μg/ml. Morphological changes characteristic of oncosis were evident by electron microscopy after only 1 minute of treatment with 32 μg/ml of variant NRC-03. Only two peptides were hemolytic. Four peptides showed no toxicity towards zebrafish embryos at the highest concentration tested (25 μM; ∼64 μg/ml) and one peptide was highly toxic, killing 4-hour-post-fertilization (hpf) embryos immediately after exposure to 1 μM peptide. Four other peptides killed embryos after 24 hours of exposure at 1 μM. Most peptides caused mortality at one or more developmental stages only after continuous exposure (24 hours) with higher lethal doses (≥5 μM). Pleurocidin NRC-03 bound to embryos and induced the release of superoxide, caused an increase in the number of TUNEL-positive nuclei, and caused membrane damage and the loss of embryonic epithelial integrity, marked by the exclusion of cells from the outer epithelium and the appearance of F-actin within the circumferential cells of the repair site. Our results indicate that specific pleurocidin variants are attractive cancer-selective agents that selectively induce cell death in target cells but leave non-target cells such as erythrocytes and non-transformed cells unaffected.

Management of anogenital lichen sclerosus

Lichen sclerosus (LS) is a skin condition that affects genital and extra genital epithelia in both males and females of all ages and it may occur in association with other autoimmune disease. Currently, the first line effective treatment is an ultra-potent topical corticosteroid. The long-term sequelae of LS include scarring, malignancy, which is rare, and psychosexual disfunction, which is common.

A clinical study of 23 cases of female anogenital carcinoma

BACKGROUND

Vulval carcinoma is a relatively rare disorder that may have various aetiologies. Objectives To document the features and outcome in a series of patients with this disorder.

METHODS

Retrospective analysis of patients presenting to a vulval clinic over a 5-year period.

RESULTS

Twenty-one women presented with a squamous cell carcinoma (SCC) and two with a verrucous carcinoma (VC). The age range was 43-83 years. Twenty-one had well-established (1-30 years) vulval symptoms prior to developing their tumour. Specific tumour-related symptoms ranged from 3 weeks to 11 months. Eight had had a prior diagnosis of lichen sclerosus (LS) or lichen planus (LP), only two of whom were on regular treatment and follow-up. At presentation, 12 patients had clinical signs of LS, three of LP, and five had some changes of both LS and LP. Two patients had multifocal vulval intraepithelial neoplasia (VIN3). Only one had no evidence of any background vulval skin disease. The commonest histological changes noted in the epithelium either adjacent to or distant from the SCC were those of atrophic LS (n = 8), LS with squamous cell hyperplasia (n = 3), LS with hyperplastic foci and lichenoid infiltrate (n = 4), and LS with differentiated VIN3 (n = 1). Four cases demonstrated the changes of LP, and three showed VIN3. All patients were treated surgically and, in those who had lymphadenectomy, four had positive nodes. There have been two deaths due to metastatic disease, and one further patient has developed a second primary SCC at a different site.

CONCLUSIONS

An underlying skin disorder prior to the development of their carcinoma was found in 22 of 23 patients with vulval SCC and is therefore an important risk factor.

Vulvodynia. Theory and management

Vulvodynia, defined as vulval pain, soreness or burning as opposed to itching or pruritus, is a common and important problem. Although not a sexually transmitted disease, it often presents to physicians working in that field. The main groups of vulvodynia are those where the symptoms are the consequence of an active dermatosis or infection, and those where it is not attributable to such conditions. In the latter group, the patients fall into two main categories: those of dysesthetic vulvidynia, with constant unprovoked pain, and vulval vestibulitis, with pain provoked by attempted vaginal entry. The recent realization that dysesthetic vulvodynia and vulval vestibulitis may be regarded as pain syndromes is proving a fruitful concept as regards both theory and management of these troublesome conditions.

Genital lichen sclerosus (lichen sclerosus et atrophicus) in childhood and adolescence

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Lichen sclerosus

Lichen sclerosus is a skin condition affecting all areas of the body at all ages and in both sexes. It appears to be a histologic and clinical entity, although in very many respects it is close to lichen planus and morphea. Its cause and pathogenesis are not established, but a link with autoimmune disease is recognized. Its predilection for the anogenital area in women has led to an unfortunate dichotomy between dermatologists and gynecologists. This was a potent source of confusion for many years but has now been resolved with a the recent formulation of a classification acceptable to the ISSVD (representing gynecologists, dermatologists, and pathologists) and the ISGyP (see Appendices). It is hoped that management will now be more logical, with the mainstay being emollients and topical corticosteroids, and that the vulvectomies sometimes performed for benign disease have become a thing of the past. There is almost certainly an increased risk of malignancy in lichen sclerosus, albeit at present an unquantifiable one, and for that reason patients should be kept under review.

Chronic erosive vulval disease

The clinical features and differential diagnosis of chronic erosive vulval disease are described. Many cases are examples of erosive lichen planus but a similar picture is sometimes associated with cicatricial pemphigoid, lichen sclerosus et atrophicus, vulval intra-epithelial neoplasia, and vestibulitis, while a few examples still defy categorization.

Dermatological conditions of the vulva

Management of vulval conditions in the elderly will present no special problems if the following points are borne in mind: 1. The patient's condition will often be multifactorial; the components should be unravelled and the patient followed until the picture is clear. 2. Point 1 is particularly important because infections and neoplasia can easily go unrecognized. 3. Biopsy will often be needed. 4. Management of chronic dermatological conditions (especially where systemic treatment is indicated) is usually best carried out by the dermatologist. 5. It is vital to consider the area as one would any other as regards diagnosis of cutaneous and mucosal lesions. With this approach the vast majority of lesions can be accurately named and reasonable treatment given. To this end the naked-eye morphology, and the histopathological evidence which will sometimes be a necessary supplement, must be accurately described and understood. 6. The study of vulval conditions is interdisciplinary. 7. Much old and contentious terminology is now obsolete. The new classification is simple and should be universally applied by gynaecologists, dermatologists and pathologists so that other involved clinicians are helped rather than confused.

Lichen sclerosus et atrophicus and autoimmunity--a study of 350 women

A study of autoimmune related phenomena in 350 women with histologically confirmed lichen sclerosus et atrophicus revealed that 21.5% had one or more autoimmune related diseases, 21% had one or more first degree relatives with an autoimmune-related disease, 42% had an autoantibody at a titre greater than 1:20, and 59.5% had one or more of these autoimmune-related phenomena. No statistically significant differences in the natural history of lichen sclerosus et atrophicus were demonstrated between those patients with autoimmune-related phenomena and those without.

Lichen sclerosus et atrophicus

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The acute exanthem associated with seroconversion to human T-cell lymphotropic virus III in a homosexual man

An illness characterised by fever, arthralgia, myalgia, a macular erythematous rash, a sore throat and the appearance of atypical lymphocytes in the blood film is described in a 27-year-old homosexual man. There was serological evidence that this illness was due to the human T-cell lymphotropic virus Type III.