the thalamus, the mamillary bodies, and the cerebellar vermis. They tend to correlate with symptoms-thus diencephalic lesions are associated with amnesia. The severity of these changes also explains the very limited response of the Korsakoff state to thiamine, whereas Wemicke’s symptoms readily resolve with such therapy. Jacobson and Lishman’ have now compared clinical and computed tomographic brain scan variables in chronic alcoholics, Korsakoff patients, and normal controls. The Korsakoff group had a significantly longer drinking history, more frequent hallucinatory states (and delirium tremens) and larger brain ventricles than the other groups. Frontal brain shrinkage was especially pronounced, as other studies have shown,s,6 leading the researchers to suggest a dual aetiology-thiamine deficiency plus alcohol neurotoxicity. Whilst alcoholism in the families was common, there was no family history of Korsakoffs state; selection problems and small numbers may diminish the value of these observations. The notion of an inherited vulnerability due to an enzyme defect remains appealing, especially in view of the syndrome’s rarity amid the stampede of alcoholic candidates for its label. With respect to treatment, Australian workers8 have called for the fortification of beer with thiamine, and for supplementary educational programmes. Methylphenidate9 and fluvoxamine1o have been advocated as a result of small uncontrolled studies, but the early use of thiamine, for any confused alcoholic, remains the priority. Even when a Korsakoffstate is evident, some 25% of patients make a complete recovery1 and 50% a partial recovery.

and reliable means of palliation for isolated oral lesions have been hard to find.1 Differentiation of LP from other oral conditions, especially discoid lupus erythematosus and keratoses (leucoplakias), may require biopsy. After any known causal agents such as drugs have been eliminated, symptomatic oral LP is generally controlled with corticosteroids applied

topically or, occasionally, injected intralesionally.1-1 Hydrocortisone, triamcinolone, fluocinonide, betamethasone, or prednisolone preparations have all been shown to be beneficial,4-8 and even some of the more potent and more effective of these agents (eg, fluocinonide) are unlikely to suppress adrenocortical function substantially over periods of 3 weeks or SO.9 Nevertheless, adrenal suppression remains a concern, since oral LP may require treatment for many months. Systemic corticosteroids or azathioprine are very occasionally indicated for severe erosive LP.10,11 Retinoids have also been tried. The systemic agents (tretinoin, etretinate, or isotretinoin) may be associated with adverse effects on liver function, cheilitis, and teratogenicity, and topical retinoids such as isotretinoin have therefore been introduced.lz-’4 Topical isotretinoin gel improves oral LP significantly, with a transient burning sensation on application and virtually no systemic absorption.14 Bollag and Ott,15 as a result of an open study, reported complete or very great improvement in eight of nine patients with oral LP treated systemically with temarotene, a new retinoid with no adverse effects other than slight increases in liver enzymes in some cases. These results need to be

confirmed. 1. Victor M, Adams RD, Collins GH. The Wernicke-Korsakoff syndrome. Philadelphia: FA Davis, 1971. 2. Diagnostic and Statistical Manual of Mental Disorders, 3rd ed. Washington, DC: American Psychiatric Association, 1980. 3. Kopelman MD. Two types of confabulation. J Neurol Neurosurg Psychiatry, 1987; 50: 1482-87. 4. Jacobson RR, Lishman WA. Cortical and diencephalic lesions in

Korsakoff’s syndrome: a clinical and CT scan study. Psychol Med 1990; 20: 63-75. 5. Mayes AR, Meudell PR, Mann D, Pickering A. Location of lesions in Korsakoff’s syndrome: neuropsychological and neuropathological data on two patients. Cortex 1988; 24: 367-88. 6. Shimamura AP, Jemigan TL, Squire LR. Korsakoff’s syndrome: radiological (CT) findings and neuropsychological correlates.

J Neuroscience 1988; 11: 4400-10. JP, Gibson GE. Abnormality of a thiamine-requiring enzyme in patients with Wernicke-Korsakoff syndrome. N Engl J Med 1977; 297:

7. Blass

1367-70. 8. Price J, Kerr R, Hicks

M, Nixon PF. The Wernicke-Korsakoff syndrome: a reappraisal in Queensland with special reference to prevention. Med J Aust 1987; 147: 561-65. 9. O’Donnell VM, Pitts WM, Fann WE. Noradrenergic and cholinergic agents in Korsakoff’s syndrome. Clin Neuropharmacol 1986; 9:

65-70. 10 Martin PR, Adinoff B, Eckardt MJ, et al. Effective pharmacotherapy of alcoholic amnestic disorder with fluvoxamine. Arch Gen Psychiatry

1989; 46: 617-21.


systemically is effective in controlling LP, but the adverse effects and the


severe cutaneous

chronicity of oral lesions have dissuaded clinicians from prescribing systemic treatment for oral LP. Results from two groups, including one double-blind study, suggest that a topical cyclosporin rinse produces significant improvement in oral LP, with no systemic adverse effects and little absorption over an 8-week period; some patients experienced burning on use.16,17 Most patients improved within 1-6 weeks of treatment; two-thirds of responders remainded disease free for at least another 12 weeks and one-third for more than 6 monthsY Topical cyclosporin now needs to be compared with topical corticosteroids. Other agents have been less thoroughly evaluated. Thus griseofulvin was tried but a beneficial effect was by no means invariable and some researchers found it to be valueless.18 Dapsone is occasionally helpful19 (patients with desquamative gingivitis may respond), but adverse effects such as haemolysis, nausea, and headaches may outweigh any likely moderate benefit. Ronbeck et al20 have suggested that systemic doxycycline may improve desquamative gingivitis in oral LP. Since none of these treatments has been shown to offer any significant advantage over corticosteroids, therapy of oral LP is likely to be with topical corticosteroids until well-controlled double-blind comparisons have been

completed. TREATMENT OF ORAL LICHEN PLANUS Oral lichen planus (LP) affects up to 1 % of the population. Some patients present with symptomless white lesions, with without involvement of other squamous epithelia; in others, the lesions are painful, especially with the atrophic and erosive forms or when there is desquamative gingivitis.1 L’nlike cutaneous LP, the oral disease tends to be chronic,2


Scully C, El-Kom M. Lichen planus: review and update on pathogenesis. J Oral Pathol 1985; 14: 431-58. 2. Thorn JJ, Holmstrup P, Rindum J, Pindborg JJ. Course of various clinical forms of oral lichen planus: a prospective follow-up study of 611 patients. J Oral Pathol 1988; 17: 213-18. 3. Conklin RJ, Blasberg B. Oral lichen planus. Dermatol Clin 1987; 5: 1.




Zegarelli EV, Kutscher AH, Silvers HF, et al. Triamcinolone acetonide

in the treatment of acute and chronic lesions of the oral mucous membranes. Preliminary report. Oral Surg Oral Med Oral Pathol 1960; 13: 170-75. 5. Cawson RA. Treatment of oral lichen planus with betamethasone. Br Med J 1968; i: 86-89. 6. Sleeper HR. Intralesional and sublesional injection of triamcinolone acetonide for oral lichen planus. Yale J Biol Med 1967; 40: 164. 7. Tyldesley WR, Harding SM. Betamethasone valerate aerosol in the treatment of oral lichen planus. Br J Dermatol 1977; 96: 659-62. 8. Lozada F, Silverman S. Topically applied fluocinonide in an adhesive base in the treatment of oral vesiculoerosive diseases. Arch Dermatol 1980; 116: 898-901. 9. Plemons JM, Rees TD, Zachariah NY. Absorption of a topical steroid and evaluation of adrenal suppression in patients with erosive lichen planus. Oral Surg 1990; 69: 688-93. 10. Silverman S, Lozada-Nur F, Magliorati C. Clinical efficacy of prednisone in the treatment of patients with oral inflammatory ulcerative diseases. A study of 55 patients. Oral Surg 1985; 59: 360-63. 11. Lozada F. Prednisone and azathioprine in the treatment of patients with vesiculoerosive oral diseases. Oral Surg 1981; 52: 257. 12. Sloberg K, Hersle K, Mobacken H, et al. Topical tretinoin therapy and oral lichen planus. Arch Dermatol 1979; 115: 716-18. 13. Camisa C, Allen CM. Treatment of oral erosive lichen planus with systemic isotretinoin. Oral Surg Oral Med Oral Pathol 1986; 62: 393-96. 14. Giustina TA, Stewart JCB, Ellis CN, et al. Topical application of isotretinoin gel improves oral lichen planus. Arch Dermatol 1986; 122: 534-36. 15. Bollag W, Ott F. Treatment of lichen planus with temarotene. Lancet 1989 ii: 974. 16. Frances C, Boisnic S, Etienne S, Szpirglas H. Effect of the local application of cyclosporine A on chronic erosive lichen planus of the oral cavity. Dermatologica 1988; 177: 194-95. 17. Eisen D, Ellis CN, Duell EA, Griffiths CEM, Voorhees JJ. Effect of topical cyclosporine rinse on oral lichen planus. N Engl J Med 1990; 323: 290-94. 18. Bagan JV, Silvestre FJ, Mestro S, Gisbert C, Bermejo A, Agramunt J. Treatment of lichen planus with griseofulvin. Oral Surg Oral Med Oral Pathol 1985; 60: 608-10. 19. Matthews RW, Pinkney RC, Scully C. The management of intransigent desquamative gingivitis with dapsone. Ann Dent 1989; 48: 41-43. 20. Ronbeck BA, Lind PO, Thrane PS. Desquamative gingivitis: preliminary observations with tetracycline treatment. Oral Surg 1990; 69: 694-97.


Towards the end of the 19th century shrewd Scottish industrialists discovered that Caledonia could boast natural products other than coal and the raw ingredients of uisgebeatha (the water of life). Amidst the "tangle of the Isles" were certain types of brown seaweed from which algin, a viscous gum, could be extracted. Many commercial applications were investigated,l including thickening of soups, making of jujubes, and stiffening of Nottingham lace. Yet the ancient mariners’ empirical use of seaweed as a dressing for cuts and bruises seems to have been largely ignored for another 50 years until alginates were advocated in otorhinolaryngology,2 dentistry,3 and neurosurgery4 as a haemostatic material that could be packed into bleeding crevices. It was non-antigenic, sterilisable, and absorbable to varying degrees. New variants are still in use.5 The chemical extract in question is alginic acid, an acid of a natural polysaccharide whose sodium salt has the remarkable property of forming an instant clot or gel when combined with a suitable calcium salt. Of great practical importance is the reversibility of the reaction-washing with a sodium-containing solution will dissolve the gel. Modem manufacturing methods, including advanced fibre-spinning technology, have led to the wide availability of calcium-sodium alginate wound dressings licensed for the management of chronic and bleeding wounds, including skin graft donor sites.6 On contact with blood or exudate, the

calcium ions in the fibre exchange with sodium ions to forrn a hydrophilic viscous gel. The released calcium ions catalyse the clotting cascade and the fibre matrix provides a large surface area for contact activation of the coagulation mechanism. Of greater clinical and economic relevance is the potential use of alginate fabric as a cheaper and more effective replacement for the traditional surgical swab. Blair and his colleagues report a prospective randomised study of normal surgical gauze or calcium alginate swabs (BritCair, Aldershot, UK) in 100 patients undergoing cholecystectomy, simple mastectomy, or inguinal hernia repair. There was a significant reduction in blood loss and, more surprisingly, in operating time in the alginate group. The researchers noted that the test swabs were strong enough for most surgical manoeuvres, non-adherent to fresh coagulum, and four times more absorbent per unit weight than traditional gauze. The handling characteristics of alginate swabs differ from those of gauze and surgeons would need to modify some of their techniques. Small airborne filaments readily separate from the dry material, but presumably would not cause harm in the operating field since they are haemostatic and totally absorbed; the radiolucent swab, although biodegradable, tends to coalesce with time into a gelatinous blob and could be lost in a large body cavity. Whilst it is not recommended that the swabs be left in the abdomen or chest, the haemostatic film remaining after swab removal is probably beneficial. A balanced view at this stage of development would be that individual surgical procedures could be adapted to accommodate the new swab technology. Gauze would still be required for "grab and dab" manoeuvres, but the alginate material could be placed under skin flaps, and would also be useful during retroperitoneal dissections and the separation of vascular adhesions to control and reduce the continuing ooze of blood. More controlled studies are required in a wider range of surgical procedures with bigger potential blood loss. The possibility that embossing of the material improves handling is being investigated by the manufacturers. Small variations in the ratio of calcium to sodium alginate will presumably produce subtle changes in the gelling and absorbency characteristics of the material, and this aspect of production would need close scrutiny. Seaweed could well be harvested in bulk more cheaply than cotton, and if alginate swabs led to a reduction in blood transfusion requirements they might replace traditional gauze in large areas of surgical practice. Would hospital quality control officers then be charged with regular inspection of the aquatic vegetation around the Scottish and Scandinavian archipelagos?

1. Stanford ECC. On algin. J Soc Chem Ind 1884: 297-303. 2. Garnett Passe ER, Blaine G. Alginates in endaural wound dressing Lancet 1948; ii: 651. 3. Rumble JFS. Twenty-five dental cases treated with absorbable alginate wool. Br Dent J 1949; 86: 203-05. 4. Oliver LC, Blaine G. Haemostasis with absorbable alginates in neurosurgical practice. Br J Plast Surg 1950; 37: 307-10. 5. Milford CA, Sudderick RM, Bleach NR, O’Flynn PE, Muglison TA. Hadley J. The influence of calcium alginate haemostatic swabs upon operative blood loss in adenotonsillectomy. Clin Otolaryngol 1990; 15: 303-06. 6. Attwood AI. Calcium alginate dressing accelerates split skin graft donor site healing. Br J Plast Surg 1989; 43: 373-79. 7. Blair SD, Jarvis P, Salmon M, McCollum C. Clinical trial of calcium alginate haemostatic swabs. Br J Surg 1990; 77: 568-70.

Treatment of oral lichen planus.

913 the thalamus, the mamillary bodies, and the cerebellar vermis. They tend to correlate with symptoms-thus diencephalic lesions are associated with...
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