CORRESPONDENCE
2 Lurtt R]. Fridmanis M. MIsiunas AL et al. Association of melasma with thyruUl autoimniunity and other thyroidal abnormalities and their relationship to the origin of ihe melanasma. / Gin Endariiwl Metab 1 9 8 5 : 6 1 : 2 8 - 3 1 . 3 Taleisnik S. Orias R. An MSH-rcleasing factor in hypothalaraus extracts. Am I Phusiot 1965; 208: 293-6. ADONIS OOO7U96391OO198C
t'oam cells after treatmenl wilh hydrocolloid dressings SIR. Hydrocolloid dressings are commonly used in the treatment of ulcerations of the skin and provide many advantages.' However, in a recent paper Reuterving et air noted biochemical and histological changes in the granulation tissue of rats after treatment with a hydrocolioid dressing (Granuflex®. Squibb). Macropbages underwent morphological alterations resembling those of foam cells and these were found in all wounds treated with the hydrocolloid dressing.- The hydrocolloid dressing used is composed of polyisobutylene (a hydrophobic synthetic polymer) and three types of hydrophilic particles: carboxymethylcellulose sodium, pectin and gelatin. It was suggested that one or more of the hydrophilic particles were phagocytosed by the macrophages resulting in these changes.To study the composite eftect of the hydrophilic particles on wound healing, the breaking strength' of incisional wounds was examined on the tenth post-operative day. A total of 200 mg carboxymethylceliulose sodium, pectin and gelatin in equal proportions was introduced into one of two parallel 6cm-long dorsal skin incisions on each of eight male SpragueDawley rats: the contralateral incision received no treatment (control). No significant difference (piiired Mest, n = 8) in breaking strength was found between experimental wounds (26 3 ± 2 S g/O- 5 cm: mean ±SEM) and control wounds (2S7±25). However, no foam cells were found in the experimental wounds on light microscopy. We therefore carried out a study to find out which of the substance(s) in the hydrocolloid dressings was responsible lor the presence of foam cells. Excisinnal full-thickness skin wounds on rats were treated for 10 days with either a single application of a complete bydrocolloid dressing, with only the hydrophilic particles or with the polyisobutylene alone. The hydrocolloid dressing or the hydrophilic particles alone disintegrated or dissolved in the wounds, whereas the polyisobutylene alone was unaffected tnacroscopicaliy after treatment. Histological examination revealed granulation tissue abundant in foam cells but only in wounds treated with the hydrocolloid dressing. Foam cells were also absent if the wounds were treated with a polyurethane membrane (OpSite®. S&N). Thus, It appears that the appearance of foam ceils after hydrocolloid wound treatment In rats is due to the combination of one or more of the hydrophilic particles and the polyisobutylene and not to a single component of hydrocolloid dressings. It is possible that swelling of the hydrophilic particles in contact with wound exudate makes the polyisobutylene more available for phagocytosis by macrophages. The clinical implications of our finding are not clear. It may be that
193
macrophages, cells that are essential for wound healing, are adversely affected by phagocytosis of the dressing material. However, wounds in both rats- and humans' treated with hydrocolloid dressings heal more rapidly than conventionally treated wounds. Department of Pathology. Faciikii of Health Sciences,
M.S.AGREN* L.FBANZ(?;N
Linkbping. Sweden *Presetit address: iJepartment of Dermalohay and Cutaneous Surficrn. Universitij of Miami School of Medicine. P.O. Box 0162 SO IR-2S0). Miami. FL 33101. U.S.A. References 1 Falanga V, Ocdusive wound dressings. Why. when, which.' Arch Dernujto! 198H: 124: 872-7. 2 Reuterving C-0, Agren MS, Soderberg TA et al The effects of OLclusive dressings on inflammation and gratiuiation tissue formation in excised wounds in rats. Scand / P/asI ReconstrSurg 1989:23: 89-96. 3 Agren MS. Franzen L. Influence of zinc deficiency on breaking strength of 3-week-old skin incisions in the rat. Acta Chir Scand 1990; 156:667-70. ADONIS 00O7O963910OI99T
No association between cicatricial pemphigoid and malisnant disease SIR. A recent study of host factors involved in the metastatic potential of cutaneous squamous cell carcinomas identified patients with cicatricial pemphigoid (CP) as being at high risk.' It was unclear in this report whether the increased frequency of malignancy associated with CP is intrinsic to the condition or related to the immunosuppressive therapy for the disease. Over the years, there have been sporadic reports of CP associated with malignant disease.-" Among the neoplasms recorded are a variety of carcinomas. leiomyosarcoma of the small bowel and abdomen and chronic lyniphocytic leukaemia. We have investigated as to whether patients with CP have an excess prevalence of malignant disease. Thirty-four patients with CP were investigated. All cutaneous and internal malignant diseases occurring in the patients were ascertained by questionnaire and case note review in a retrospective manner. Kach patient was matched with two controls (from biopsy clinics) and the prevalence of internal malignancy in the two groups compared. The controls were of the same sex and of an age within (S months of the patient and none were known to have any dermatological conditions associated with internal malignancy. Two out of 34 patients (5-8%) had malignant disease compared to three out of 68 controls (4'4%). Using Fisher's exact test, this difference is not statistically significant {P = O-79S). The two patients were both female who developed adenocarcinoma of the breast at the age of 56 and 69. respectively. Their neoplasms occurred 5 years after the onset of CP and did not run a parallel course to it. Neither patient had received oral corticosteroids or any other
194
CORRESPONDENCE
immunosuppressive therapy known to predispose to neoplasia during the course of their follow-up. One patient died from widespread metastasis 2 years after the diagnosis of cancer while the other continues to he well a year after simple mastectomy and is on tamoxifen. None of the CP patients had cutaneous malignancies. Breast cancer is common in elderly females and its occurence in two of our patients is not unexpected. These observations are in accordance with Hardy et aiJ who concluded that theincreasedfrequencyof malignancy in 12 out of S] patients in their series was attributable to tbe advanced age of these patients. It is not surprising for some CP patients to subsequently develop malignancy as both are diseases that are more common in the elderly. Few cases of a strictly concurrent course between CP and tumour have been documented in the literature and this makes the association even more doubtful. Therefore, patients with CP do not appear to have a higher risk of developing systemic or cutaneous cancers. Further studies on larger series of CP patients will clarify the link between CP and malignancy. Department of Dermatology. The Stade ilospita!. Headington Oxford, U.K.
MALUKA NAYAH FENELM WOJNAROWSKA
References 1 Dinehart SM. Chu DZl. Maners AM et al. Immunosuppression in patients with metastatic squamoiis cell carcinoma from the skin, / Denmto! Siirfi Oncot 1990: 16: 271-4. 2 Hardy KM. Perry HU. Pingree GC. Kirby TJ, Benign niucnus membrane pemphigoid. Arch Dermalol 1971: 104: 4h7-75. J Pdlliack A, Benign muL-ous membrane pemphigoid with kiryngeal stenosis in a patient with thyroid carcinoma. Arch Ptithol 196S; 86: 48-51. 4 David M. Oren N, Feverman EF. Occurrence of cicatricial pemphigoid and leiomyosarcoma in a psoriatic patient. Dermaloiogka 1962; 170:256-9. 5 Chadiield HW, Kanagasundaram CR. Carcinoma in benign mucous membrane pempblgoid (ocular pemphigus). B} Dermatol 1962; 74: 458-fit. 6 Greer KE. Beat-ham BE, Askew FC. Benign mucous membrane pemphigoid in association with internal malignancy, Cutis 1980: 25: 183-5, 7 Kllby PE. Carcinoma of the pancreas presenting witb benign mucous membrane pemphigoid. Cancer 1965; 18: 847-50,
Figure 1. Marked onchodystrophy with tiiinning of the nails and distal splitting.
A 62-year-old female was referred to our department in 1989 with an onychodystrophy that affected the finj^ernails which were thinned with longitudinal ridging, splitting, distal notching and onycholysis (Fig. 1 (. Her toenails were normal. She was in good health and there were no other abnormalities. The patient h;ul noted that the changes in the nail tirst occurred 1 5 years ago with spontaneous improvement and relapses. A longitudinal nail biopsy was performed on her left thumb and the histology showed a dense infiltrate in the superficial dermis of the proximal nail matrix. Tbis hnnd-like infiltrate consisted of lymphocytes, a large number of bistiocytes and numerous multinucleate giant cells. The basal layer showed moderate hydropic changes but there was no hyperkeratosis. hypergranulosis or acanthosis of the epidermis (Fig. 2).
ADONIS 0007096391002008
Lichen planus of the nails with giant cells: lichen nitidus? SIR. Nail changes may be the only manifestation of several dermatological disorders and although a biopsyofthe nail may make it possible to correlate tbe pathology with a specific disease, sometimes this is not possible. We report a 62-year-old patient with a long-standing onychodystrophy with the pathological features that resembled both lichen planus and lichen nitidus.
Figure 2. tX'nse iichcnoid intiiiratc involving superticial liermis ol tbe proximal nail matrix (haematoxylin and eosin, x I2S).
Sbe was treated witb intramuscular slow-release triamcinolone in a dosage of 40 mg ever/ 2 weeks for 4 months. There was no improvement of her nails at 6 months follow-up. Inilammatory dermatoses may show unusual pathological
2 Lurtt R]. Fridmanis M. MIsiunas AL et al. Association of melasma with thyruUl autoimniunity and other thyroidal abnormalities and their relationship to the origin of ihe melanasma. / Gin Endariiwl Metab 1 9 8 5 : 6 1 : 2 8 - 3 1 . 3 Taleisnik S. Orias R. An MSH-rcleasing factor in hypothalaraus extracts. Am I Phusiot 1965; 208: 293-6. ADONIS OOO7U96391OO198C
t'oam cells after treatmenl wilh hydrocolloid dressings SIR. Hydrocolloid dressings are commonly used in the treatment of ulcerations of the skin and provide many advantages.' However, in a recent paper Reuterving et air noted biochemical and histological changes in the granulation tissue of rats after treatment with a hydrocolioid dressing (Granuflex®. Squibb). Macropbages underwent morphological alterations resembling those of foam cells and these were found in all wounds treated with the hydrocolloid dressing.- The hydrocolloid dressing used is composed of polyisobutylene (a hydrophobic synthetic polymer) and three types of hydrophilic particles: carboxymethylcellulose sodium, pectin and gelatin. It was suggested that one or more of the hydrophilic particles were phagocytosed by the macrophages resulting in these changes.To study the composite eftect of the hydrophilic particles on wound healing, the breaking strength' of incisional wounds was examined on the tenth post-operative day. A total of 200 mg carboxymethylceliulose sodium, pectin and gelatin in equal proportions was introduced into one of two parallel 6cm-long dorsal skin incisions on each of eight male SpragueDawley rats: the contralateral incision received no treatment (control). No significant difference (piiired Mest, n = 8) in breaking strength was found between experimental wounds (26 3 ± 2 S g/O- 5 cm: mean ±SEM) and control wounds (2S7±25). However, no foam cells were found in the experimental wounds on light microscopy. We therefore carried out a study to find out which of the substance(s) in the hydrocolloid dressings was responsible lor the presence of foam cells. Excisinnal full-thickness skin wounds on rats were treated for 10 days with either a single application of a complete bydrocolloid dressing, with only the hydrophilic particles or with the polyisobutylene alone. The hydrocolloid dressing or the hydrophilic particles alone disintegrated or dissolved in the wounds, whereas the polyisobutylene alone was unaffected tnacroscopicaliy after treatment. Histological examination revealed granulation tissue abundant in foam cells but only in wounds treated with the hydrocolloid dressing. Foam cells were also absent if the wounds were treated with a polyurethane membrane (OpSite®. S&N). Thus, It appears that the appearance of foam ceils after hydrocolloid wound treatment In rats is due to the combination of one or more of the hydrophilic particles and the polyisobutylene and not to a single component of hydrocolloid dressings. It is possible that swelling of the hydrophilic particles in contact with wound exudate makes the polyisobutylene more available for phagocytosis by macrophages. The clinical implications of our finding are not clear. It may be that
193
macrophages, cells that are essential for wound healing, are adversely affected by phagocytosis of the dressing material. However, wounds in both rats- and humans' treated with hydrocolloid dressings heal more rapidly than conventionally treated wounds. Department of Pathology. Faciikii of Health Sciences,
M.S.AGREN* L.FBANZ(?;N
Linkbping. Sweden *Presetit address: iJepartment of Dermalohay and Cutaneous Surficrn. Universitij of Miami School of Medicine. P.O. Box 0162 SO IR-2S0). Miami. FL 33101. U.S.A. References 1 Falanga V, Ocdusive wound dressings. Why. when, which.' Arch Dernujto! 198H: 124: 872-7. 2 Reuterving C-0, Agren MS, Soderberg TA et al The effects of OLclusive dressings on inflammation and gratiuiation tissue formation in excised wounds in rats. Scand / P/asI ReconstrSurg 1989:23: 89-96. 3 Agren MS. Franzen L. Influence of zinc deficiency on breaking strength of 3-week-old skin incisions in the rat. Acta Chir Scand 1990; 156:667-70. ADONIS 00O7O963910OI99T
No association between cicatricial pemphigoid and malisnant disease SIR. A recent study of host factors involved in the metastatic potential of cutaneous squamous cell carcinomas identified patients with cicatricial pemphigoid (CP) as being at high risk.' It was unclear in this report whether the increased frequency of malignancy associated with CP is intrinsic to the condition or related to the immunosuppressive therapy for the disease. Over the years, there have been sporadic reports of CP associated with malignant disease.-" Among the neoplasms recorded are a variety of carcinomas. leiomyosarcoma of the small bowel and abdomen and chronic lyniphocytic leukaemia. We have investigated as to whether patients with CP have an excess prevalence of malignant disease. Thirty-four patients with CP were investigated. All cutaneous and internal malignant diseases occurring in the patients were ascertained by questionnaire and case note review in a retrospective manner. Kach patient was matched with two controls (from biopsy clinics) and the prevalence of internal malignancy in the two groups compared. The controls were of the same sex and of an age within (S months of the patient and none were known to have any dermatological conditions associated with internal malignancy. Two out of 34 patients (5-8%) had malignant disease compared to three out of 68 controls (4'4%). Using Fisher's exact test, this difference is not statistically significant {P = O-79S). The two patients were both female who developed adenocarcinoma of the breast at the age of 56 and 69. respectively. Their neoplasms occurred 5 years after the onset of CP and did not run a parallel course to it. Neither patient had received oral corticosteroids or any other
194
CORRESPONDENCE
immunosuppressive therapy known to predispose to neoplasia during the course of their follow-up. One patient died from widespread metastasis 2 years after the diagnosis of cancer while the other continues to he well a year after simple mastectomy and is on tamoxifen. None of the CP patients had cutaneous malignancies. Breast cancer is common in elderly females and its occurence in two of our patients is not unexpected. These observations are in accordance with Hardy et aiJ who concluded that theincreasedfrequencyof malignancy in 12 out of S] patients in their series was attributable to tbe advanced age of these patients. It is not surprising for some CP patients to subsequently develop malignancy as both are diseases that are more common in the elderly. Few cases of a strictly concurrent course between CP and tumour have been documented in the literature and this makes the association even more doubtful. Therefore, patients with CP do not appear to have a higher risk of developing systemic or cutaneous cancers. Further studies on larger series of CP patients will clarify the link between CP and malignancy. Department of Dermatology. The Stade ilospita!. Headington Oxford, U.K.
MALUKA NAYAH FENELM WOJNAROWSKA
References 1 Dinehart SM. Chu DZl. Maners AM et al. Immunosuppression in patients with metastatic squamoiis cell carcinoma from the skin, / Denmto! Siirfi Oncot 1990: 16: 271-4. 2 Hardy KM. Perry HU. Pingree GC. Kirby TJ, Benign niucnus membrane pemphigoid. Arch Dermalol 1971: 104: 4h7-75. J Pdlliack A, Benign muL-ous membrane pemphigoid with kiryngeal stenosis in a patient with thyroid carcinoma. Arch Ptithol 196S; 86: 48-51. 4 David M. Oren N, Feverman EF. Occurrence of cicatricial pemphigoid and leiomyosarcoma in a psoriatic patient. Dermaloiogka 1962; 170:256-9. 5 Chadiield HW, Kanagasundaram CR. Carcinoma in benign mucous membrane pempblgoid (ocular pemphigus). B} Dermatol 1962; 74: 458-fit. 6 Greer KE. Beat-ham BE, Askew FC. Benign mucous membrane pemphigoid in association with internal malignancy, Cutis 1980: 25: 183-5, 7 Kllby PE. Carcinoma of the pancreas presenting witb benign mucous membrane pemphigoid. Cancer 1965; 18: 847-50,
Figure 1. Marked onchodystrophy with tiiinning of the nails and distal splitting.
A 62-year-old female was referred to our department in 1989 with an onychodystrophy that affected the finj^ernails which were thinned with longitudinal ridging, splitting, distal notching and onycholysis (Fig. 1 (. Her toenails were normal. She was in good health and there were no other abnormalities. The patient h;ul noted that the changes in the nail tirst occurred 1 5 years ago with spontaneous improvement and relapses. A longitudinal nail biopsy was performed on her left thumb and the histology showed a dense infiltrate in the superficial dermis of the proximal nail matrix. Tbis hnnd-like infiltrate consisted of lymphocytes, a large number of bistiocytes and numerous multinucleate giant cells. The basal layer showed moderate hydropic changes but there was no hyperkeratosis. hypergranulosis or acanthosis of the epidermis (Fig. 2).
ADONIS 0007096391002008
Lichen planus of the nails with giant cells: lichen nitidus? SIR. Nail changes may be the only manifestation of several dermatological disorders and although a biopsyofthe nail may make it possible to correlate tbe pathology with a specific disease, sometimes this is not possible. We report a 62-year-old patient with a long-standing onychodystrophy with the pathological features that resembled both lichen planus and lichen nitidus.
Figure 2. tX'nse iichcnoid intiiiratc involving superticial liermis ol tbe proximal nail matrix (haematoxylin and eosin, x I2S).
Sbe was treated witb intramuscular slow-release triamcinolone in a dosage of 40 mg ever/ 2 weeks for 4 months. There was no improvement of her nails at 6 months follow-up. Inilammatory dermatoses may show unusual pathological
