How Many GP Referrals to Dermatology Outpatients are Really Necessary?

In a survey of patients referred to the dermatology outpatients department of a British teaching hospital, 26% of referrals were considered unnecessary by a senior house officer with three months practical dermatological experience. We conclude that better undergraduate and postgraduate education in dermatology is essential. A period spent in dermatology should be included in all vocational training schemes for general practice.

Treatment of Basal Cell Carcinoma with Intralesional Interferon Alpha-2b

We report a series of 11 basal cell carcinomas of various types treated with nine intra-lesional injections of 1.5 million units of interferon alpha-2b. The diagnosis was confirmed histologically in each case.

After 3 months' follow-up six tumours had resolved both clinically and histologically. In three cases the tumour size was reduced. One tumour grew larger. Side effects were well tolerated except by one subject who was withdrawn. Those cases which responded have now been followed-up for between 12 and 26 months with no clinical or histological evidence of tumour recurrence.

This is the longest period of follow-up so far reported for this novel treatment. The results are encouraging and, if maintained in future series, may indicate a useful role for interferon alpha in the management of this common cutaneous malignancy.

Pimecrolimus: a review of pre-clinical and clinical data

Pimecrolimus (Elidel) is a novel cell-selective inhibitor of inflammatory cytokines that has specifically been developed for the treatment of inflammatory skin diseases due to its favourable skin selective pharmacological profile. Therapeutic efficacy and safety of pimecrolimus cream 1% has been established in the short-term treatment and the long-term management of atopic eczema in clinical studies in adults, children and infants. It rapidly relieves pruritus, and redness and swelling disappear or are only mild in up to 70% of pimecrolimus treated patients during the first three weeks. When applied at the first signs and symptoms of atopic eczema, pimecrolimus has proven to prevent flare progression and to provide superior long-term disease control compared with a conventional treatment, based on reactive use of corticosteroids. Pimecrolimus cream 1% is well tolerated, even on sensitive areas such as the face and neck. Blood concentrations remain low, even when extensive body areas are treated and no clinically significant systemic effects have been observed during short- or long-term clinical studies with pimecrolimus.

Cyclosporin for severe childhood atopic dermatitis: short course versus continuous therapy

Cyclosporin (CyA) has been shown to be highly effective and well tolerated in the short-term treatment of severe childhood atopic dermatitis; however, there is limited experience in its longer-term use. The aim of this study was to compare multiple short courses of CyA with continuous therapy for 1 year, with respect to efficacy, safety, tolerability and quality of life. Children aged 2-16 years, with a diagnosis of severe atopic dermatitis refractory to topical steroid therapy, were randomly assigned to receive short course therapy (multiple courses of 12 weeks) or continuous therapy. The starting dose and maximum dose for all patients was 5 mg/kg per day. Disease activity was monitored using the Six Area Six Sign Atopic Dermatitis score and the 'Rule of Nines' area score. Pruritus, sleep disturbance and irritability were measured using visual analogue scales, and topical therapy was monitored. Safety measurements included monitoring of serum creatinine, blood pressure and adverse events. Forty patients were included in the efficacy analysis, 21 of whom were randomized to the short course group (of whom six were withdrawn) and 19 to the continuous group (of whom five were withdrawn). Significant improvements were seen in all efficacy parameters at every time-point. There were no significant differences between groups, although the improvement was more consistent in the continuous arm. In the short course arm, 7 out of 21 patients could be managed by at least two short courses. The remaining 14 patients includes 12 who could not be controlled by at least two short courses, one patient who failed to return after week 12 and another patient who was withdrawn at week 4 due to an adverse event. Quality of life improved for both the children and their families. Tolerability was considered good or very good in at least 80% of the patients at week 12 and at the end of the study. No clinically significant change was seen in mean serum creatinine and no change was seen in mean blood pressure in either group. CyA is effective in controlling severe atopic dermatitis in children over a 1-year period and is well tolerated. More consistent control is achieved with continuous treatment; however, short course therapy was adequate for some patients, indicating that treatment should be tailored to the individual patient's needs. Short course treatment may produce prolonged remission in some cases and reduce the cumulative exposure to the drug.

False negative clinical diagnoses of malignant melanoma

The false negative rate for the clinical diagnosis (FNR) for malignant melanoma is reported to be of the order of 20-50%. The aim of this study was to investigate possible predictor variables for FNR, with particular reference to the features and score of the seven-point check-list within the total population (778) of histologically proved malignant melanomas presenting in Leicestershire between 1982 and 1996. The FNR was 18.5%. The check-list would have failed as a referral indication in only 0.8-1. 1% of the lesions. The major check-list features occurred more commonly than the minor features, excepting size >/= 7 mm, confirming the diagnostic importance of the major criteria. The FNR was unaffected by age or sex. More rarely involved sites had higher rates (31-42%), and the face was a particularly difficult diagnostic site. Clinical features of lesions associated with a higher FNR were lack of irregular pigmentation and shape, altered sensation, the presence of inflammation and size < 7 mm. The FNR was inversely related to the total score and major feature score, but directly related to the minor score. The minor features, in addition to the major features, are potentially valuable in avoiding false negative diagnoses and we suggest their retention as part of the check-list. There was only one patient, in whom the diagnosis of melanoma was initially missed and who was not biopsied on presentation to hospital, who re-presented after 1 year. However, the study illustrates the importance of avoiding a false negative diagnosis as there was marked delay in the excision of such lesions.

The value of an aide memoire in the dermatology clinic

A randomized study was undertaken to investigate the effectiveness of a chart as an aid to memory illustrating the topical medication most frequently prescribed both in the dermatology clinic, and in general practice. One hundred subjects, half new referrals and half follow-ups, were recruited and asked to recall all of the topical preparations that had previously been prescribed for this condition. They were then asked to consult the chart, and any additional medication recognized at this time was noted, along with any clarification of formulation and strength where possible. Despite some limitations, our chart proved to be of considerable value. Thirty-eight patients could identify between three and eight additional preparations. Overall, the mean number of additional preparations recalled per patient was two. Clarification of strength and formulation was achieved by 21 patients. Eight charts were used, and provided additional information at consultation in 87% of subjects interviewed.

The effect of the introduction of a pigmented lesion clinic on the interval between referral by family practitioner and attendance at hospital

The value of pigmented lesion clinics (PLCs) for the early detection and treatment of malignant melanoma has been questioned. We have examined the effect of the introduction of a PLC on the referral interval between patients with melanoma presenting to their general practitioner (GP) and their attendance at hospital. The case notes of all patients presenting with melanoma in Leicestershire between 1984 and 1994 were reviewed. There was a significant initial reduction in the mean referral interval following the introduction of the PLC from 27.9 days (SEM = 6.6) in 1984 to 11.3 (2.3) days in 1987 (P < 0.01). However, the referral interval gradually rose over the following 7 years to a mean of 20.4 (4.4) days in 1994, which was not significantly better than the 1985/86 level. The increase in the referral interval was due to a greater percentage of melanomas being referred to clinics other than the PLC. Only 48% of melanomas were referred to the PLC in 1994 compared with 70% in 1987. We also reviewed the referral letters for those patients presenting in 1991 and 1994, and decided, on the basis of the content of the letter, whether the GP had suspected the diagnosis of melanoma. More than 50% of the melanomas were correctly diagnosed by the GP, but only half of these were then appropriately referred to the PLC. We believe that PLCs are of value in the early diagnosis and treatment of melanoma, but only if they are appropriately utilized by GPs.

Sweet's syndrome and malignancy in the U.K

Acute febrile neutrophilic dermatosis (Sweet's syndrome) is reported to be a marker for underlying malignancy. Much of the evidence for this is based on case reports, small series of cases and reviews of the literature. In order to clarify the association with malignancy and determine the common clinical features of Sweet's syndrome, we reviewed the case notes of patients presenting to six dermatology units in the U.K. Eighty-seven cases of histologically proven Sweet's syndrome were reviewed. Fourteen patients (16%) developed associated malignancy, predominantly haematological, two patients (2%) had a history of previous malignancy and four patients (5%) had premalignant conditions (monoclonal gammopathy, two: myelodysplasia, two). Malignancy developed up to a year after presentation with Sweet's syndrome. Patients with associated malignancy were more likely to be anaemic (P < 0.01) at presentation, had a lower mean platelet count (207 x 10(9)/L vs. 332 x 10(9)/L; P < 0.003) and were, on average, older (59 years vs. 49 years; P = 0.002). Contrary to previous reports, a greater percentage of females developed malignancy than males.

Treatment of psoriasis with intermittent short course cyclosporin (Neoral). A multicentre study

A 1 year, prospective multicentre study was performed to investigate the efficacy and safety of intermittent treatment with cyclosporin in psoriasis vulgaris. Subjects received cyclosporin (Neoral) 5 mg/kg per day until achieving 90% reduction in area affected, or for a maximum of 12 weeks. Those failing to demonstrate a satisfactory response were withdrawn. When further treatment was required, cyclosporin was recommenced. This cycle was repeated up to three times. Psoriasis activity was recorded using the area affected and sign scores for erythema, scaling and infiltration. Overall assessments of response and tolerability were recorded. Forty-one subjects, mean age 36, mean PASI 12.8, entered the first treatment period. Thirty-three received a second period of treatment and 16 a third. Eighteen failed to complete the study as planned: five were withdrawn due to adverse events, four due to treatment failure and nine due to protocol violations. At the end of each treatment period, significant improvements were seen in all efficacy parameters. Overall response was graded as 'considerable improvement' or 'minimal or no symptoms', by over 80% of subjects and investigators. Median intervals to relapse for subjects remaining in the study were 72 days (range 28-329) and 53 days (range 14-141) after periods 1 and 2, respectively. There were significant increases in mean serum creatinine and blood pressure during each treatment period. However, there were no significant differences in either parameter between baseline and the final follow-up visit. At the end of each treatment period, overall tolerability of the treatment was considered 'good' or 'very good' by over 80% of subjects and investigators.

A possible explanation for the increased referral of atopic dermatitis from the Asian community in Leicester

The population of the city of Leicester contains, in addition to the 'native' population, a large immigrant 'Asian' community originating from the Indian subcontinent. Among referrals to our department, atopic dermatitis (AD) was 3,3 times more common in Asians. We therefore performed a study based on a cohort of consecutive births in Leicester hospitals to investigate the possible ethnic difference in prevalence and to examine possible reasons for an ethnic difference in referral pattern. Parents of 1,800 children were asked at the time of the birth to allow their child to be entered on a register. A year later, parents of a sample of 499 of these children, 158 Asian and 341 non-Asian, were invited for interview and for examination of the children. A total of 413 children were examined. The overall point prevalence of AD was 10.7% (95% confidence interval, 7.7%-13.7%). There was no significant ethnic difference. However, a history of eczema in a first degree relative was found in 14.2% of Asian subjects and 35.1% of non-Asians (P < 0.0001, chi-square test). The data suggest the increased referrals to our clinic from the Asian community may result from a lower level of familiarity with AD.

Predictors of atopic dermatitis in Leicester children

There is little contemporary data available on the prevalence of atopic dermatitis (AD) or the risk factors associated with this disease. We therefore performed a prospective study of 1-year-old children based on a cohort of consecutive births in Leicester hospitals. Parents of 1800 children born between March and May 1992 were asked at the time of the birth to allow their child to be entered on a register. A sample of 499 of these children were invited for interview and examination at 1 year of age. Data were collected on gestational maturity, birth weight, feeding pattern, family history of eczema and atopy, social class and other parameters. Four hundred and thirteen of the 499 children were examined (83%). The overall point prevalence of AD was 10.7% (95% confidence interval, 7.7%-13.7%). The most significant risk factor for a child developing AD was a parental history of eczema.

Etretinate may work where acitretin fails

Acitretin (Ro 10-1670, Neotigason), a second-generation monoaromatic retinoid, is the main acid derivative and active metabolite of etretinate (Ro 10-9359, Tigason). Three patients who were unresponsive to treatment with acitretin but who responded to etretinate are reported. Twenty-nine patients in the U.K. are currently receiving etretinate on a named-patient basis. Possible explanations for the functional discrepancy between the two drugs are discussed.

Long-term efficacy and safety of cyclosporin in severe adult atopic dermatitis

A prospective, open, multicentre study was performed to investigate the efficacy and safety of long-term treatment with cyclosporin in adults with severe atopic dermatitis. Subjects were treated for a maximum of 48 weeks. For the first 8 weeks, cyclosporin was administered at 2.5 mg/kg per day. The dose was then adjusted according to response. Disease activity was monitored using the six-area, six-sign score and the proportion of skin involved. Pruritus and sleep disturbance were assessed using four-point scales. Response was further evaluated on a five-point scale. Adverse events, blood pressure and serum biochemistry were monitored. Tolerability was assessed on a five-point scale. One hundred subjects were enrolled and 65 completed 48 weeks of treatment. Withdrawals occurred due to remission (three), inadequate response (seven), protocol violations (11) and adverse events (14, of which seven were probably treatment related). Cyclosporin produced rapid and highly significant improvements in all indices of disease activity. Sixty-five subjects considered that they had shown a considerable improvement or complete clearance of disease. Most patients relapsed after cessation of treatment, but neither signs nor symptoms had returned to baseline severity 8 weeks later. Blood pressure and serum creatinine levels increased slightly, and in one subject renal impairment was a major factor contributing to withdrawal of the drug. Overall, 85 subjects rated the tolerability of cyclosporin as good or very good. The results indicate that cyclosporin has a place in the long-term treatment of severe atopic dermatitis provided that appropriate patients are selected and careful monitoring is performed.

Cyclosporine in severe childhood atopic dermatitis: a multicenter study

BACKGROUND

Severe atopic dermatitis (AD) remains difficult to treat. Cyclosporine is effective in adults but has not previously been investigated in children with AD.

OBJECTIVE

The aims were to investigate the efficacy, safety, and tolerability of cyclosporine in severe refractory childhood AD.

METHODS

Subjects 2 to 16 years of age were treated for 6 weeks with cyclosporine, 5 mg/kg per day, in an open study. Disease activity was monitored every 2 weeks by means of sign scores, visual analogue scales for symptoms, and quality-of-life questionnaires. Adverse events were monitored. Efficacy and tolerability were assessed with five-point scales.

RESULTS

Twenty-seven children were treated. Significant improvements were seen in all measures of disease activity. Twenty-two showed marked improvement or total clearing. Quality of life improved for both the children and their families. Tolerability was considered good or very good in 25 subjects.

CONCLUSION

Cyclosporine may offer an effective, safe, and well-tolerated short-term treatment option for children with severe AD.

A new microemulsion formulation of cyclosporin (Neoral) is effective in the treatment of cyclosporin-resistant dermatoses

Cyclosporin is a highly effective treatment for severe psoriasis and atopic dermatitis. However, both inter- and intrapatient gastrointestinal absorption of the conventional formulation of cyclosporin (Sandimmun) are very variable, ranging from 20 to 50%. Variations in bioavailability may explain isolated resistance to therapy. Neoral is a novel microemulsion formulation of cyclosporin which has been developed to enhance and standardize its absorption. We report the first experience with Neoral in patients with psoriasis and atopic dermatitis refractory to Sandimmun.

An immunohistochemical study of the dermal infiltrate and epidermal staining for interleukin 1 in 12 cases of Sweet's syndrome

Interleukin 1 (IL-1) has been proposed as a possible mediator in Sweet's syndrome. We examined all cases of Sweet's syndrome (n = 12) presenting to the department over a 10-year period, from 1982 to 1992, for the presence of IL-1 and also assessed the nature of the dermal inflammatory infiltrate in those cases. Staining for IL-1 alpha and IL-1 beta was stronger in control tissues than in Sweet's syndrome. This may possibly be explained by the release of IL-1 alpha and IL-1 beta into the dermis in Sweet's syndrome. Contrary to recent reports, we found that neutrophils predominated in all cases examined, although histiocytes were present in increased numbers indicating their possible role in the pathophysiology of Sweet's syndrome.

Pyoderma gangrenosum complicating hysterectomy for fibroids

Pyoderma gangrenosum is a destructive, non-infective ulceration of the skin. The case presented illustrates a rare but important presentation in a patient following a total abdominal hysterectomy and bilaterial salpingo-oophorectomy (TAH and BSO).

Protection of children against sunburn: a survey of parental practice in Leicester

The incidence of melanoma in the U.K. is increasing more rapidly than that of most other malignant tumours. Sunburn in childhood increases the risk of malignant melanoma in later life and it is therefore essential that protection of children is improved if primary prevention of melanoma is to be effective. We asked 238 parents in Leicester how they protected their children against sunburn, how often their children suffered sunburn, and whether they had heard of malignant melanoma. Although most (80%) had heard of melanoma, 47% did not regularly ensure that their children used a sunblock lotion, and only 34% regularly protected them from the midday sun. Forty-eight per cent of parents stated that their children burned at least once a year. New approaches to public education about melanoma may be needed to improve the protection of children against sunburn.

Nodular prurigo responds to cyclosporin

Nodular prurigo is a distressing disease which is difficult to treat. Two patients with severe nodular prurigo were treated with cyclosporin for periods of 36 and 24 weeks, respectively, using doses of 3-4.5 mg/kg per day. In both cases there was a reduction in the severity of pruritus after 2 weeks of treatment. In one patient there was a considerable, although incomplete response, and in the other almost complete resolution of the disease was achieved. The improvement was maintained throughout the treatment period, and the drug was generally well tolerated, although in one patient there was a rise in serum creatinine during treatment, which later returned to normal.

Prevalence of atopic dermatitis in Leicester: a study of methodology and examination of possible ethnic variation

A study was undertaken to investigate and compare various methods of estimating the prevalence of atopic dermatitis (AD), and to investigate a possible ethnic difference in our local community. Preschool children attending routine child health surveillance clinics and Social Services day nurseries were examined by a trained observer, and their parents were interviewed. In addition, general practice records from a health centre were scrutinized. Three hundred and twenty-two children aged 1-4 years were examined, and the point prevalence of AD was 14% [95% confidence interval (CI) 10-18]. There was no apparent ethnic difference in prevalence. Twenty-seven per cent (95% CI 22-32) of parents reported that their children had suffered from 'eczema' at some time. General practitioners' records contained a diagnosis of 'eczema' in 32% (95% CI 28-36) of 446 children aged 1-4 years. It is clear that methodology must be carefully standardized if comparisons are to be made between different studies. Accurate estimations of the prevalence of AD can probably only be obtained by examination of a population sample by a trained observer. However, the estimates obtained in this study are high, and would tend to support existing evidence that the prevalence of AD is rising.

Melanoma awareness and sun exposure in Leicester

The city of Leicester, in conjunction with other centres throughout the U.K., was targeted for publicity about melanoma over a 3-year period from 1987 to 1989. We report the results of a survey to assess the level of awareness of melanoma, and to document current sunbathing practices subsequent to that period. The general level of awareness of melanoma in the community was good (74%). People who knew about melanoma were more likely to use a sunscreen at home and abroad (odds ratios 1.63, 95% CI 1.19-2.24 and 1.39, 95% CI 1.03-1.86), but paradoxically more likely to sunbathe than those who had never heard of melanoma (odds ratio 1.33, 95% CI 1.03-1.72). Females were more knowledgeable than males (odds ratio 1.74, 95% CI 1.26-2.22), but continued to sunbathe. Teenagers and young adults tended to be relatively ignorant of melanoma, and were less likely to protect themselves against sunburn while sunbathing than other age groups. Teenagers, young adults, and males need to be targeted more effectively in future publicity campaigns. Furthermore, many people who know about melanoma continue to put themselves at risk by sunbathing. New strategies need to be developed to influence behaviour as well as increasing awareness.

Benign familial chronic pemphigus (Hailey-Hailey disease) responds to cyclosporin

A patient with benign familial chronic pemphigus was treated with cyclosporin at a dose ranging from 2.8 to 3.4 mg/kg per day. There was a clear improvement in the area of skin affected and in exudation and soreness. The response was maintained for 24 weeks but there was a gradual deterioration after treatment was stopped.

The U.K. Working Party's Diagnostic Criteria for Atopic Dermatitis. I. Derivation of a minimum set of discriminators for atopic dermatitis

A working party of 13 dermatologists, two family practitioners and a paediatrician was assembled, with the aim of developing a minimum list of reliable discriminators for atopic dermatitis. Each physician was asked to select 10 consecutive new cases of unequivocal mild to moderate atopic dermatitis and 10 controls with other inflammatory dermatoses. Each subject was examined by two independent observers, who were blind to the clinical diagnosis and study aim, with regard to 31 clinically useful diagnostic features for atopic dermatitis. Two hundred and twenty-four patients were studied (120 cases and 102 controls). Using the key physician's clinical diagnosis as a gold standard, the sensitivity and specificity of each of the 31 diagnostic criteria were tested. Using multiple logistic regression techniques, a minimum set of diagnostic criteria for atopic dermatitis was derived. These were: history of flexural involvement, history of a dry skin, onset under the age of 2, personal history of asthma, history of a pruritic skin condition, and visible flexural dermatitis. Adjustment for age, sex, region, social class and ethnic group did not alter the choice of final criteria. The discriminatory value of these criteria was also satisfactory when tested against a further sample of 150 patients drawn from the community, who did not have skin disease.

Dermatology examination performance: wide variation between different teaching centres

Three hundred and one clinical medical students in four universities took the same 50 question MCQ dermatology examination after their dermatology teaching. In one centre, half the students had had additional teaching; these students performed better (mean score 47.5%, n = 29) than those who had no extra teaching (mean score 40.9%, n = 29). In another centre, the students' mean score improved from 24.1 (SD = 6.7) before to 41.6 (SD = 7) (n = 46, P < 0.001) after their dermatology teaching. The different subject areas covered by the examination were analysed separately. In the lowest scoring centre (mean score 34.0, SD = 9.4) the students scored lowest in 9 of the 14 subject areas. In the highest scoring centre (mean score 47.5, SD = 9.9) students scored highest in 7 of these 14 subject areas. This study enabled questions of high discriminatory value to be identified for future use. The use of the same examination in different centres provides feedback for the centres concerning strengths and weaknesses of their teaching.

Partial unilateral lentiginosis associated with blue naevi

We report a patient with unilateral lentiginosis and blue naevi. This association has not been reported previously. Additional clinical features included right bundle branch block and lateral popliteal nerve palsy.

An evaluation of the revised seven-point checklist for the early diagnosis of cutaneous malignant melanoma

The seven-point checklist has been widely advocated as a sensitive screening test for malignant melanoma. A number of groups have questioned the sensitivity of this system, especially in the detection of early lesions. We have assessed the sensitivity and specificity of the revised seven-point checklist when applied to lesions seen in our department over a 26-month period and compared it with the American ABCDE evaluation system. All melanomas (n = 65) were detected using the revised seven-point checklist and all were found to have at least one of the three major criteria defined by that system. Five (7.7%) melanomas were not picked up by the ABCDE checklist. Of 100 randomly selected patients who attended the clinic during the same period, with clinically diagnosed benign pigmented lesions, 63 had at least one major feature of the revised seven-point checklist. Forty (62%) of the melanomas, compared with only (4%) of the benign lesions, had more than one major feature. This study confirms the sensitivity of the revised seven-point checklist in the diagnosis of cutaneous malignant melanoma.

Cyclosporin greatly improves the quality of life of adults with severe atopic dermatitis. A randomized, double-blind, placebo-controlled trial

A multicentre, randomized, double-blind, controlled crossover clinical trial was conducted on 33 patients with severe refractory atopic dermatitis, to determine the effects of cyclosporin (5 mg/kg/day) on their health-related quality of life. Treatments were administered for 8-week periods. One group (n = 16) received placebo followed by cyclosporin, and the other (n = 17) received cyclosporin and then placebo. Health-related quality of life was assessed at 0, 8 and 16 weeks using a general measure, the United Kingdom Sickness Impact Profile (UKSIP), an eczema-specific measure, the Eczema Disability Index (EDI), and a global 5-point rating scale of overall health (very good to very poor). In addition, clinical assessments (i.e. extent and activity of disease) were made by the investigators. UKSIP and EDI scores indicated significant improvement in quality of life (P < 0.05-P < 0.01) of patients with atopic dermatitis after treatment with cyclosporin. Although no patient required withdrawal from the study, 20 patients receiving cyclosporin reported adverse events, compared with eight taking placebo. There was a close correlation (P < 0.05-P < 0.01) between the UKSIP and EDI scores. In contrast, there was either no correlation, or only a very poor correlation, between the quality of life parameters and clinical measures of extent and activity of eczema. When cyclosporin was stopped, relapse was rapid, but the mean scores for disease activity and extent of disease were less than their baseline values (i.e. an improvement of greater than 25% was maintained in 11 patients at week 4).(ABSTRACT TRUNCATED AT 250 WORDS)

Further experience of public education for the early diagnosis of malignant melanoma in Leicestershire

Publicity campaigns alerting the public to the need for early attention to malignant melanoma (MM) were conducted in Leicestershire, England during the summers of 1987, 1988 and 1989. There was a marked, and statistically significant, rise in the number of referrals with good prognosis MMs in the period immediately after the first campaign. In the 2 subsequent years, despite further publicity campaigns, the number of MMs diagnosed per week remained lower than the postpublicity peak of 1986/87. The postpublicity rise was less marked in 1987/88 and 1988/89. In the next year (1989/90), in which there was no publicity campaign, the total number of MMs seen was higher than in 1988/89. Numbers of MMs seen per week remained relatively steady throughout the year. There was again no publicity in 1990/91, and the total number of MMs diagnosed was about the same as in the previous year. There was a rise in the number of MMs seen per week in what would have been the postpublicity period of this year. The initial results would be consistent with the initial postpublicity rise in numbers of MMs seen being made up of lesions seen 'early', that is, in 1986/87 and 1987/88. Since these lesions were seen earlier than they would have been had there been no publicity, the number of MMs seen in 1988/89 was lower than it would otherwise have been and the publicity effort appeared to have less effect. By 1989/90 and 1990/91 this effect seems to have been wearing off. It may be that, at least in low MM incidence areas like the UK, it is better to pulse public education for the early diagnosis of melanoma rather than to use annual or continuous campaigns. However, longer-term experience, and the pooling of data between centres will be necessary to test this conclusion.

Placebo-controlled trial of essential fatty acid supplementation in atopic dermatitis

Treatment of atopic dermatitis with essential fatty acids remains controversial. A double-blind, placebo-controlled, parallel-group study was done to investigate the response of patients with atopic dermatitis to essential fatty acid supplements. Patients with atopic dermatitis were randomised to receive evening primrose oil, evening primrose oil and fish oil, or placebo for 16 weeks. Disease activity was monitored by clinical severity scores recorded by the investigator, topical steroid requirement, and symptom scores recorded by subjects. Of 123 subjects recruited, 102 completed the treatment period. No improvement with active treatment was demonstrated. Our study, which avoided the methodological and analytical problems of previous studies, found no effect of essential fatty acid supplementation in atopic dermatitis.

Sweet's syndrome responding to cyclosporin

We report a case of Sweet's syndrome which responded to treatment with cyclosporin 4 mg/kg/day. Cyclosporin is effective in the treatment of many dermatoses, and although the immunosuppressive effects of cyclosporin are mainly attributed to inhibition of T-lymphocyte proliferation, it has also been shown to affect the functions of both neutrophils and monocytes. Possible mechanisms of action of cyclosporin in Sweet's syndrome are discussed.

Ethnic differences in the pattern of skin disease seen in a dermatology department--atopic dermatitis is more common among Asian referrals in Leicestershire

The Leicester Royal Infirmary serves a large immigrant community from the Indian subcontinent. We surveyed referrals to the Dermatology Department over the months of November 1986 and September 1987. In both surveys atopic dermatitis (AD) was significantly more common among the Asian patients.

Double-blind, controlled, crossover study of cyclosporin in adults with severe refractory atopic dermatitis

A few patients remain severely affected by atopic dermatitis into adult life despite treatment with systemic steroids, azathioprine, and photochemotherapy. 33 patients took part in a double-blind, placebo-controlled, crossover study to assess the efficacy and safety of cyclosporin (5 mg/kg per day) in adults with severe refractory atopic dermatitis. Treatments were given for eight weeks each with one group (n = 16) receiving placebo followed by cyclosporin and another (n = 17) receiving cyclosporin and then placebo. Disease activity, extent of disease, sleep and itch, topical steroid use, and adverse events were assessed every two weeks. Both extent and activity of dermatitis were significantly improved (p less than 0.001) as were subjective measures of disease. 20 patients receiving cyclosporin reported adverse events compared with 8 taking placebo, although no patient required withdrawal from the study. Cyclosporin therapy led to an increase in the mean serum urea, creatinine, and bilirubin concentrations, although only the rise in bilirubin was significant (p = 0.001). Our results confirm that cyclosporin is a safe and effective short-term treatment for severe, refractory atopic dermatitis.

Juvenile spring eruption of the ears: a probable variant of polymorphic light eruption

We report 18 cases in which a pruritic, erythematous, papular and vesicular eruption developed on the ears following sun exposure. Four of these patients had, on other occasions, suffered from typical polymorphic light eruption. The clinical features, histological changes, and results of phototesting suggest that juvenile spring eruption of the ears is a localized form of polymorphic light eruption.

Lichen sclerosus et atrophicus--a review of 15 cases in young girls

We report a series of 15 girls who developed lichen sclerosus between the ages of 18 months and 9 years. Only five of these were initially referred to a dermatologist and the diagnosis was made promptly in these cases on the first visit to the clinic. The diagnosis was usually delayed under disciplines less familiar with the disease. We encountered a high level of parental anxiety regarding the possibility of misdiagnosis of lichen sclerosus as childhood sexual abuse. Dysuria and pain on defaecation were common and prominent symptoms which have not previously been stressed adequately. The clinical features were diagnostic in all our cases, although three had undergone vulval biopsy under general anaesthesia prior to being seen by a dermatologist. There was a trend towards improvement with increasing age.