544 Correspondence

In this study, we examined the patient serum using various IB methods. It was rather surprising that IIF showed positive reactivity with normal human skin, but not 1 mol L 1 NaClsplit skin, because IIF of 1 mol L 1 NaCl-split skin is usually more sensitive. It is possible that 1 mol L 1 NaCl treatment may mask or destroy the epitopes on the BP180 C-terminal domain or b4 integrin, which was specifically reacted to by the patient serum. It was also unknown why IgA antibodies were detected by IB but not by IIF. IB of the BP180 C-terminal domain recombinant protein may be more sensitive in detecting IgA antibodies than immunofluorescence, although the mechanism of this was not clear. The patient has a long-lasting and intractable disease course, which may be caused by the complex autoantibodies involved. It is possible that the two autoantibodies, which developed at variable intervals via the epitope spreading phenomenon, exerted a ‘sum effect’, leading to the lack of response to conventional immunosuppressive therapy. Recently, a combination therapy of rituximab and IVIg was proven to arrest disease progression and prevent total blindness in patients with recalcitrant ocular MMP.8 In our case, the patient refused to receive additional treatments. Patients with ocular MMP may have serious visual impairments, even blindness, and may need more aggressive treatments. Therefore, accurate and fast diagnosis should be made using various immunofluorescence and IB techniques.

Acknowledgments We are grateful for the technical assistance of Mr Carlos Aguilera and Ms Michiru Kubo, and for the secretarial work of Ms Mihoko Ikeda. 1

Department of Dermatology, Hospital Universitario de la Princesa, Madrid 28006, Spain 2 Department of Natural Science Informatics, School of Informatics and Science, Nagoya University, Nagoya, Aichi, Japan 3 Department of Dermatology, Kurume University School of Medicine, and Kurume University Institute of Cutaneous Cell Biology, Kurume, Fukuoka, Japan E-mail: [email protected]

G . S O L A N O - L O P E Z 1 M . J . C O N C H A - G A R Z O N 1 J . S AN C H E Z - P ER E Z 1 Y. HIRAKO2 X. LI3 N. ISHII3 T. HASHIMOTO3 E . D A U D EN 1

References 1 Chan LS, Ahmed AR, Anhalt GJ et al. The first international consensus on mucous membrane pemphigoid: definition, diagnostic criteria, pathogenic factors, medical treatment, and prognostic indicators. Arch Dermatol 2002; 138:370–9. 2 Foster CS. Cicatricial pemphigoid. Trans Am Ophthalmol Soc 1986; 84:527–663. 3 Hirako Y, Yonemoto Y, Yamauchi T et al. Isolation of a hemidesmosome-rich fraction from a human squamous cell carcinoma cell line. Exp Cell Res 2014; 324:172–82. British Journal of Dermatology (2015) 172, pp537–547

4 Nie Z, Hashimoto T. IgA antibodies of cicatricial pemphigoid sera specifically react with C-terminus of BP180. J Invest Dermatol 1999; 112:254–5. 5 Hisamatsu Y, Nishiyama T, Amano S et al. Usefulness of immunoblotting using purified laminin 5 in the diagnosis of anti-laminin 5 cicatricial pemphigoid. J Dermatol Sci 2003; 33:113–19. 6 Tyagi S, Bhol K, Natarajan K et al. Ocular cicatricial pemphigoid antigen: partial sequence and biochemical characterization. Proc Natl Acad Sci USA 1996; 93:14714–19. 7 Bhol KC, Dans MJ, Simmons RK et al. The autoantibodies to alpha 6 beta 4 integrin of patients affected by ocular cicatricial pemphigoid recognize predominantly epitopes within the large cytoplasmic domain of human beta 4. J Immunol 2000; 165:2824–9. 8 Foster CS, Chang PY, Ahmed AR. Combination of rituximab and intravenous immunoglobulin for recalcitrant ocular cicatricial pemphigoid: a preliminary report. Ophthalmology 2010; 117:861–9. Funding sources: none. Conflicts of interest: none declared.

The healing effect of over-the-counter wound healing agents applied under semiocclusive film dressing DOI: 10.1111/bjd.13289 DEAR EDITOR, Studies have demonstrated that topical over-thecounter (OTC) preparations are able to increase significantly the rate of epidermal migration in partial- and full-thickness wounds.1–3 One of the reasons for their ability to speed healing is the fact that these preparations provide a moist wound environment, which helps increase the rate of re-epithelialization.4,5 Semiocclusive dressings are the best documented method of enhancing healing via production of a moist wound environment, resulting in so-called moist wound healing. With the idea that we might improve upon the effect of semiocclusive film-induced moist wound healing, we examined the effects of three topical wound healing agents, each in combination with film semiocclusion. The OTC wound healing agents studied are either preparations or medical devices commonly available in Europe. An established porcine model that is particularly well suited to evaluating the healing of superficial partial-thickness wounds was used to determine potential differences in healing between treatments.6–8 Seven female specific pathogen-free animals were used for this study. Rectangular partial-thickness wounds measuring 10
0 mm 9 7
0 mm with a depth of 0
3 mm were created and divided into five groups. Each group was randomly assigned to one of the following agents or treatments: (i) dexpanthenol ointment in a paraffin-wax/petrolatum/lanolin– complex base (Bepanthenâ Wund- und Heilsalbe; Bayer Vital GmbH, Leverkusen, Germany); (ii) a hydroactive colloidal gel containing arginine, propylparaben, methlyparaben, branched-

© 2014 British Association of Dermatologists

Correspondence 545

*x†•

Fig 1. The percentage of complete re-epithelialization from all seven pigs combined against assessment days 4–10. The wounds began healing on day 4 and by day 10 all wounds were completely epithelialized. Statistical analysis was performed using the v2 test (2 9 2 contingency). 9 P < 0
001 compared to untreated; P < 0
005 compared to untreated; ♢P < 0
001 compared to dexpanthenol ointment and untreated; *P < 0
001 compared to dexpanthenol ointment and untreated, polyurethane film control and untreated; &P < 0
005 compared with hydroactive colloid gel; †P < 0
001 compared to treatment groups; ▲P < 0
05 compared to treatment groups.

chain fatty acids and purified water (Fenistilâ Wundheilgel; Novartis Consumer Health SA, Nyon, Switzerland); (iii) hydroactive acidic lipogel that contains trace elements (zinc and iron), nourishing oils and vitamin E (MediGelâ Schnelle Wundheilung; MEDICE Arzneimittel P€ utter GmbH & Co. KG, Iserlohn, Germany); (iv) semiocclusive polyurethane film dressing control that was also used to cover all agents (TegadermTM; 3M, Saint Paul, MN, U.S.A.); or (v) wounds left untreated and exposed to air. The latter group was included as a treatment, as various dressings alone can influence the rate of epithelialization. Wounds treated with one of the topical agents received approximately 200 mg agent once daily and were covered with a new film dressing. Beginning on the third day after the wounds were created, five wounds and the surrounding normal skin were excised and assessed using our technique to separate the dermis from the epidermis at the basement membrane.9 Epithelialization was considered complete (healed) if no defects were present in the epidermis of any of the wounds. On day 4, nearly 20% of the wounds treated with hydroactive acidic lipogel were completely healed (Fig. 1). On day 5, nearly 75% of the wounds treated with hydroactive acidic lipogel were completely healed, while approximately 30% of the wounds treated with polyurethane film alone or hydroactive colloid gel were completely healed. Wounds treated with the dexpanthenol ointment were only 14% re-epithelialized on this day. On day 6, the untreated, air-exposed wounds still had no re-epithelialization, while the hydroactive acidic lipogel-treated wounds reached 100% complete epithelialization, and all other treatment groups also showed a clear tendency towards healing. Most of the treated wounds were completely healed by day 7, at which time only 29% of the air-exposed wounds were completely healed. Ninety-one per cent of the © 2014 British Association of Dermatologists

air-exposed wounds were healed on day 9, and all were completely healed by day 10. This study compared polyurethane film occlusion with and without one of three OTC wound-healing agents using a porcine model known to highly correlate with healing in humans.10 Knowing that moist wound healing under dressings can accelerate healing, it is often speculated whether a wound-healing agent can improve upon the healing speed induced by occlusion. While the ability of semiocclusive film dressing and, in particular, the ability of the film dressing used in this study to speed healing is very well documented, this evaluation showed that not all OTC agents will improve upon the effects of a film dressing. One OTC product, the hydroactive acidic and trace element-containing lipogel was able to offer statistically significantly faster healing, as seen by the number of totally healed wounds in the early days (days 4–6) after wounding. Therefore, the hydroactive acidic lipogel with trace elements was able to speed up the healing of superficial wounds by nearly 1 day compared with the gold standard of semiocclusive film. The results of this study suggest that in acute wounds the rapid epithelialization that is associated with film semiocclusion can be improved upon. 1

University of Miami Miller School of Medicine, Miami, FL, U.S.A. 2 German Wound Academy DWA, Hamburg, Germany E-mail: [email protected]

S.C. DAVIS1 J. GIL1 R. TREU1 J. VALDES1 M. SOLIS1 T. EBERLEIN2 W.H. EAGLSTEIN1

British Journal of Dermatology (2015) 172, pp537–547

546 Correspondence

References 1 Lin TS, Latiff AA, Hamid NAA et al. Evaluation of topical tocopherol cream on cutaneous wound healing in streptozotocininduced diabetic rats. Evid Based Complement Alternat Med 2012; 2012:491027. 2 Geronemus RG, Mertz PM, Eaglstein WH. The effects of topical antimicrobial agents. Arch Dermatol 1979; 115:1311–14. 3 Malik KI, Malik MA-N, Aslam A. Honey compared with silver sulfadiazine in the treatment of superficial partial-thickness burns. Int Wound J 2010; 7:413–17. 4 Murphy PS, Evans GR. Advances in wound healing: a review of current wound healing products. Plast Surg Int 2012; DOI: 10.1155/2012/190436. 5 Korting HC, Schollmann C, White RJ. Management of minor acute cutaneous wounds: importance of wound healing in a moist environment. J Eur Acad Dermatol Venereol 2011; 25:130–7. 6 Eaglstein WH, Mertz PM. New method for assessing epidermal wound healing: the effect of triamcinolone acetonide and polyethylene film occlusion. J Invest Dermatol 1978; 71:382–4. 7 Sauder DN, Kilian PL, McLane JA et al. Interleukin–1 enhances epidermal wound healing. Lymphokine Res 1990; 9:465–73. 8 Davis SC, Mertz PM, Cazzaniga AL et al. The use of new antimicrobial gauze dressings: effects on the rate of epithelialization of partial-thickness wounds. Wounds 2002; 14:252–6. 9 Davis SC, Ricotti C, Zalesky P et al. Topical oxygen emulsion: a novel wound therapy. Arch Dermatol 2007; 143:1252–6. 10 Sullivan TP, Eaglstein WH, Davis SC, Mertz PM. The pig as a model for human wound healing. Wound Repair Regen 2001; 9:66–76.

Dermatological surgery is universally performed under local anaesthesia. An ‘awake’ patient may thus help the surgeon greatly by moving on request, intraoperatively, to prevent the surgeon adopting awkward body positions. For example, our own preference is to operate from the side ipsilateral to the patient’s defect; thus simply asking the patient to turn her head to the right would have prevented the strained body position adopted by the surgeon depicted in the article by Patel et al. Indeed, we have previously demonstrated in the BJD that asking a patient to move even a small degree during surgery can help facilitate otherwise difficult closures.4 A lack of an anaesthetist and anaesthetic equipment also creates more space in dermatology surgical theatres for the surgeon themselves to comfortably ambulate ‘around’ the patient if necessary to ensure they are in the optimum ‘stress-free’ position during surgery. Additionally, the use of automated, positionable operating couches should be seen as a mandatory requirement during dermatological surgery. Such couches ensure the patient moves into the position best suited for the surgeon rather than the surgeon having to ‘move’ into position to access the necessary surgical field. Many such couches are foot-pedal operated, enabling the surgeon to precisely manoeuvre the patient into the most comfortable operating position, thus obviating musculoskeletal strain.

Funding sources: This study was supported, in part, by funds from MEDICE Arzneimittel P€ utter GmbH & Co. KG, Iserlohn, Germany. Conflicts of interest: none declared.

Reducing the strain of dermatological surgery DOI: 10.1111/bjd.13212 DEAR EDITOR, We read with great interest the recent article by Patel et al.1 regarding ambidexterity in dermatological surgery. Although the acquisition of this skill to a high level is rare in our experience, the authors are to be commended on raising the important but often neglected problem of musculoskeletal problems that may occur during dermatological surgery. The authors refer to the results of a U.S. survey among members of the American College of Mohs Surgery.2 Similar findings were seen following a survey of members of the British Society for Dermatological Surgery,3 thus confirming the absolute importance of addressing this problem. While being truly ‘ambidextrous’ may indeed minimize the risk of adopting awkward body positions during surgery, we feel that the acquisition or development of this skill to enable a high degree of competency in delicate facial sites such as the periocular or perioral region may limit its usefulness in all but a few skilled individuals.

British Journal of Dermatology (2015) 172, pp537–547

Fig 1. Reducing the strain of dermatological surgery – a foot-pedal operated theatre couch enables the surgeon to come close to the operative field; the use of magnification loupes with a light source ensures a fixed operating distance occurs preventing the surgeon from bending forward awkwardly to visualize the required area. For the dermatological surgeon, the usual working distance of such loupes may vary between 25 cm and 60 cm depending on the surgeon’s individual preference, with the field of view also commonly ranging from 2 cm to 10 cm; the surgeon is also seated comfortably on a surgical stool with lumbar back support. © 2014 British Association of Dermatologists