Conflict of interest: none declared. Haemorrhagic palmoplantar lesions are a recognised presentation of childhood dermatitis herpetiformis (DH), with a few reported adult cases.1, 2 We report two cases of palmar petechiae as a presenting feature of adult DH. Patient 1 was a 34‐year‐old woman, who presented with an 18‐year history of a rash affecting her fingertips and toes, most prominent on her dominant hand and preceded by an itchy sensation. On physical examination, multiple petechial lesions were seen on her fingertips and toes (Fig. 1a), together with a small tense blister filled with serosanguinous fluid on the right hand. Screening for anti‐mitochondrial, anti‐smooth muscle, anti‐parietal cell, anti‐liver kidney microsomal antibodies, cytoplasmic antinuclear cytoplasmic antibodies (ANCA) perinuclear ANCA, thrombophilia and porphyria was negative. She had a weakly positive antinuclear antibody titre with a nucleolar pattern. Histological examination of a petechial lesion found disruption of the keratin layer with haemorrhage, intracorneal vesicle formation and red cell extravasation in the dermis with moderate oedema. Histological examination of a biopsy taken from the blister on the right hand revealed a subepidermal split with abundant neutrophils, lymphocytes and histiocytes. Effacement of the dermal papillae was noted (Fig. 1b). Direct immunofluorescence of perilesional skin showed fibrillar deposits of IgA and fibrinogen within the dermal papillae (Fig. 1c). Anti‐endomysial IgA antibodies were negative on indirect immunofluorescence, but duodenal biopsies confirmed subtotal villous atrophy (Fig. 1d).

Precalcaneal congenital fibrolipomatous hamartoma (PCFH) is a condition that is seldom reported in the paediatric literature and rarely in the dermatological literature. It has other disparate and confusing names and as histology is rarely obtained, the condition may be under-reported. We describe this disorder in the male twin of a pair of nonidentical twins.

Low‐molecular‐weight heparins are used extensively in acute medicine. They are generally well tolerated but may cause a rare, eczema‐like type IV hypersensitivity reaction. We report 3 cases of this eruption and speculate that it may be significantly under‐reported due to misidentifying the causal drug, which may have serious consequences. We discuss treatment alternatives such as fondaparinux sodium, which may rarely cross‐react.

SIR, Imported superpotent topical steroids are sold for use as skin‐lightening agents at certain street markets in London. We describe a patient who developed striae and adrenal suppression following the purchase and inappropriate use of clobetasol propionate. A 46‐year‐old Afro‐Caribbean woman had a 3‐month history of a hyperpigmented patch on her left forearm, and was prescribed topical beclomethasone dipropionate (Propaderm®; Glaxo Wellcome, Uxbridge, U.K.) by her general practitioner for presumed eczema. As the hyperpigmentation did not resolve, she purchased an ointment called Movate® at a local market selling unlicensed products, seemingly imported from Italy. The tube was labelled as 0·05% clobetasol propionate and the cream was described as ‘anti‐inflammatory, antiallergic, antipruritic’ and particularly indicated in the ‘treatment of the most resistant dermatoses’. She was not taking any other medications at that time. The patient applied in total 30 g Movate ointment to the plaque, and began to notice the development of striae in the axillae and inner upper arms, which were progressive. At presentation to our clinic, the initial plaque had cleared but there was residual skin atrophy and telangiectasia at this site. She was otherwise well, blood pressure was normal and she did not demonstrate any symptoms or signs of adrenal dysfunction.

We describe two patients, who presented with erythematous facial plaques, in keeping with neutrophilic eccrine hidradenitis, during chemotherapy for acute myeloid leukaemia. Both patients were neutropaenic and febrile. Histology showed a dermal neutrophilic infiltrate around the eccrine glands with gland destruction. The importance of recognizing this disorder is to prevent the inappropriate use of antibiotics as it is self limiting.

Eosinophilic pustular folliculitis (EPF) of infancy is a rare disorder which may begin in the neonatal period and cause considerable parental anxiety. It must be distinguished from other causes of a pustular eruption in neonates, including infection and erythema toxicum neonatorum. and rare disorders such as transient neonatal pustular melanosis, infantile acropustulosis and Langerhans' cell histiocytosis. Skin smears and occasionally skin biopsy may be necessary to reach a diagnosis, We report a case of a Caucasian child with an unusually early onset of EPF in the first day of life. We wish to emphasize the importance of recognizing this self-limiting condition in order to prevent inappropriate antimicrobial treatment.

q 2000 British Association of Dermatologists, British Journal of Dermatology, 142, 812±851 with desmoglein 3 (Dsg3), index 7 ́98 (3 SD of normal range , 9 ́79) by enzyme-linked immunosorbent assays (Dsg1 and Dsg3 ELISA Kit, Medical and Biological Laboratories, Nagoya, Japan). Thus, the diagnosis of PF was made. His PF was treated initially with oral prednisolone 40 mg daily (0 ́8 mg kg daily) and azathioprine 100 mg daily (2 mg kg daily) from 28 September, but did not respond to therapy for 3 weeks. During the next 2 weeks, the exfoliative erythema changed into figurate erythema which resembled EGR (Fig. 1a,b), although lesions did not move centrifugally as quickly as in classical EGR. Skin biopsy showed superficial perivascular non-specific mononuclear cell infiltration (Fig. 1c). On 20 October, therapy for prostate cancer with LH-RH agonist was resumed after a suspension of 2 months, followed by significant improvement of not only the prostate cancer but also the figurate erythema. By 18 December, 2 months after resumption of LH-RH agonist treatment, the figurate erythema had totally disappeared. The prostate cancer reduced, with regression of invasion to the seminal vesicles and serum PSA below 0 ́1 mg L. Currently his PF and prostate cancer are controlled with oral prednisolone 25 mg daily and continuing hormone therapy with LH-RH agonist. The most recent titre of circulating antibodies against intercellular substances were at a titre of 1 : 160; the size of the prostate cancer has diminished with no signs of recurrence, and the figurate erythema has not recurred. There are two interesting features in the present case. First, PF did not respond to the initial therapy until the therapy for prostate cancer was resumed. Therefore, the PF in this case could have been triggered by prostate cancer, although pemphigus is rarely associated with prostate cancer; in 42 cases of pemphigus associated with non-thymic malignancy, none was prostate cancer. Secondly, figurate erythema developed when the therapy for prostate cancer was suspended, and disappeared after resumption of the therapy for the cancer. In the previous report of EGR associated with prostate cancer, the cancer was found 6 years after EGR started. In the present case, the cancer was diagnosed 3 months previously. Incomplete therapy for the cancer or prednisolone treatment for PF could have caused immunological alterations leading to development of figurate erythema in the present case. Immunological mechanisms are important in the aetiology of EGR. Antibody deposition at the BMZ was shown in some previously reported EGR cases: coarse granular deposits of IgG and C3 at the BMZ in both involved and uninvolved skin, mottled granular deposits of IgG and C3 in the upper dermis just beneath the dermal aspect of the lamina densa, and deposition of IgG C3, C4 in EGR coexisting with pemphigoid. Two immunological pathogenic mechanisms of EGR were proposed on the basis of these findings. (i) Antibodies against tumour antigens may cross-react with similar antigenic determinants in the patient's skin, and (ii) the tumour produces molecules which alter components of the BMZ, with subsequent induction of antibodies and their local deposition, which could cross-react with the BMZ of the patient's skin. As circulating antibodies against skin BMZ were not demonstrated by IIF in our case, the second hypothesis is more reasonable in explaining the features in our patient.

Objective To determine whether Chinese herbal creams used for the treatment of dermatological conditions contain steroids. Design 11 herbal creams obtained from patients attending general and EM Higgins pediatric dermatology outpatient clinics were analyzed with high resolution gas chromatography and mass spectrometry Setting Departments of dermatology and clinical biochemistry. Main outcome measure Presence of steroid. Results Eight creams contained dexamethasone at a mean concentration of 456 mu g/g (range 64 to 1500 mu g/g). All were applied to areas of sensitive skin such as face and flexures. Conclusion Greater regulation needs to be imposed on Chinese herbalists to prevent illegal and inappropriate prescribing of potent steroids.

BACKGROUND:Because prostaglandin (PG) E2 has been identified in the bone lesions of Langerhans cell histiocytosis (LCH), we speculated that indomethacin, a potent PG inhibitor, may be useful in patients with symptomatic LCH involving the bony skeleton.PROCEDURE:We used indomethacin to treat patients in whom we wanted to avoid steroids or chemotherapy, or in whom these treatments did not provide complete symptom relief. Ten children with bony LCH between 1984 and 1995 were treated; six had single-system bone disease and four had multisystem disease involving the bony skeleton and other organs.RESULTS:The dose of indomethacin ranged from 1 to 2.5 mg/kg/day (9-200 mg/day) in divided doses and was given for 1-16 weeks (mean, 6 weeks). Eight patients had a complete response to treatment, defined as complete resolution of symptoms for 4 weeks. One patient was withdrawn from treatment because of concern regarding the potential of indomethacin to induce seizures and a second patient, with suppurative skin lesions overlying a lytic skull defect, did not respond.CONCLUSIONS:Indomethacin is a useful therapy for LCH involving the bony skeleton and may have a role as first-line treatment in single-system bone disease. Whether it has a specific role in slowing disease progression or merely acts as an analgesic has not yet been established.

Recalcitrant viral warts are a troublesome therapeutic problem. Immunotherapy with the universal allergic contact sensitizer diphencyprone (DCP) has been used successfully in such cases. We have reviewed our experience of the use of DCP in the treatment of resistant hand and foot warts during an 8-year period. Sixty patients were sensitized to DCP during this time; the median duration of warts was 3 years. Twelve patients defaulted from treatment. Of the remaining 48 individuals, 42 (88%) cleared of all warts. The median number of treatments to clear was five (range one to 22) and the median time to clear was 5 months (range 0.5-14). Adverse effects occurred in 27 of 48 patients (56%), most commonly painful local blistering (n = 11), blistering at the sensitization site (n = 9), pompholyx-like reactions (n = 7) and eczematous eruptions (n = 4). Three of those who defaulted did so due to side-effects, one became pregnant and eight dropped out for unknown reasons. Three of the 48 patients who cleared or had at least six treatments also discontinued DCP therapy due to side-effects, but most tolerated treatment well. Twenty-five patients were followed up for periods of 1 month to 8 years (median 2 years) and none had a recurrence. DCP immunotherapy is an effective option for the treatment of recalcitrant viral warts but patients must be motivated to attend for sequential applications and must be warned about potential uncomfortable side-effects.

OBJECTIVETo determine whether Chinese herbal creams used for the treatment of dermatological conditions contain steroids.DESIGN11 herbal creams obtained from patients attending general and paediatric dermatology outpatient clinics were analysed with high resolution gas chromatography and mass spectrometry.SETTINGDepartments of dermatology and clinical biochemistry.MAIN OUTCOME MEASUREPresence of steroid.RESULTSEight creams contained dexamethasone at a mean concentration of 456 micrograms/g (range 64 to 1500 micrograms/g). All were applied to areas of sensitive skin such as face and flexures.CONCLUSIONGreater regulation needs to be imposed on Chinese herbalists to prevent illegal and inappropriate prescribing of potent steroids.

British Journal of DermatologyVolume 139, Issue 5 p. 924-925 Pyoderma gangrenosum and hepatitis C virus infection Keane, Keane Department of Dermatology, King's College Hospital, Denmark Hill, London SE5 9RS, U.K.Search for more papers by this author Macfarlane, Macfarlane Department of Dermatology, King's College Hospital, Denmark Hill, London SE5 9RS, U.K.Search for more papers by this author Munn, Munn Department of Dermatology, King's College Hospital, Denmark Hill, London SE5 9RS, U.K.Search for more papers by this author Higgins, Higgins Department of Dermatology, King's College Hospital, Denmark Hill, London SE5 9RS, U.K.Search for more papers by this author Keane, Keane Department of Dermatology, King's College Hospital, Denmark Hill, London SE5 9RS, U.K.Search for more papers by this author Macfarlane, Macfarlane Department of Dermatology, King's College Hospital, Denmark Hill, London SE5 9RS, U.K.Search for more papers by this author Munn, Munn Department of Dermatology, King's College Hospital, Denmark Hill, London SE5 9RS, U.K.Search for more papers by this author Higgins, Higgins Department of Dermatology, King's College Hospital, Denmark Hill, London SE5 9RS, U.K.Search for more papers by this author First published: 04 January 2002 https://doi.org/10.1046/j.1365-2133.1998.02531.xCitations: 22AboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article.Citing Literature Volume139, Issue5November 1998Pages 924-925 RelatedInformation

We report a florid case of incontinentia pigmenti in a neonate in which linear vesiculobullous, verrucous and pigmented lesions were present simultaneously at birth. Histology of a vesiculobullous lesion showed vesiculation with numerous eosinophils in the epidermis, and a sparse infiltrate in the dermis with pigmentary incontinence. The mother of our patient described a streaky linear rash on her legs during her own childhood which resolved spontaneously, in addition to partial anodontia, suggesting that she too has the disease, although previously undiagnosed. This emphasises the variable disease expression and the importance of recognising this condition so that patients can be followed up with regard to complications, and genetic counselling can be offered. The issue of prenatal diagnosis is discussed.

Dr. Stephanie Munn has a long-standing research interest in cutaneous mastocytosis. This article describes the various types of cutaneous mastocytosis and highlights therapeutic options. New forms of treatment which are currently undergoing assessment include the use of interferon alpha, interferon gamma, platelet activating factor antagonist and even laser therapy. Dr. Munn has provided a concise and up-to-date review which should be helpful to dermatology trainees and residents who have limited experience of the treatment of cutaneous mastocytosis.