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Systemic corticosteroids are of value in severe lichen planus which interferes with the patient's life or is ulcerative or where there is nail destruction. Azathioprine has been shown to be effective steroid sparing treatment for generalized lichen planus. We report two patients with severe lichen planus who responded to azathioprine alone and suggest it may be an alternative therapy, especially when there are risk factors against corticosteroid use. Lichen planus accounts for approximately 1% of new presentations to a dermatology unit. It can affect all body areas and markedly interfere with a patient's life. Mucous membrane lesions are common (30-70%) but ulcerative lesions in the mouth are uncommon. Lichen planus seems to be immunologically mediated with evidence favouring a lymphocytotoxic process described in the literature. Treatment is mainly symptomatic and can be difficult. Systemic corticosteroids are of value in treating severe cases where the disease is interfering with a patient's life or when ulcerative mucous membrane lesions have occurred or if there is severe nail destruction. Relapse can occur on cessation of steroids. Azathioprine has been shown to be effective steroid sparing therapy for generalized lichen planus. However, the use of azathioprine alone has not been described. We report two cases of generalized, erosive lichen planus that responded well to azathioprine alone.

Erythema elevatum diutinum is a syndrome of vasculitis in which lesions, typically over the extensor surfaces, showed a mixed inflammatory infiltrate on biopsy. We describe a series of 13 patients. The most common association in our series was with hypergammaglobulinemia; both mono and polyclonal. Chronic infection, not streptococcal, was a less frequent finding although two of three patients had a positive reaction to the intradermal injection of streptococcal antigen. Dapsone remains the initial treatment of choice.

Fourteen patients with large cell lymphocytoma were studied. They presented with solitary or small numbers of grouped nodules on the trunk or head and neck region, which histologically consisted of diffuse and nodular dermal aggregates of lymphoid cells. A proportion of these cells were large with clear cytoplasm and a varying degree of nuclear atypia. An infiltrate of small mature lymphocytes surrounded and extended between the zones of larger cells. Mitotic figures and pleomorphic cells were frequent and, on the basis of this histopathology, an initial diagnosis of cutaneous lymphoma had frequently been made. There were eight male and six female patients with a mean age at presentation of 40 years (range 14-71) who were followed up for a period of between 4 and 31 years (mean = 14.6). Thirteen of the 14 are alive and well, and there has been no evidence of systemic involvement in any of the patients; one patient died of chronic renal failure and pneumonia. Monoclonal antibody studies on paraffin sections showed the presence of lymphoid cells of B and T cell lineage in large cell lymphocytoma. We believe that these patients have a variety of cutaneous lymphocytic infiltrate, large cell lymphocytoma, which has characteristic clinical and histological features and is important to recognize because of its benign course. Large cell lymphocytoma has been used to describe a nodular lymphoid infiltrate of the skin composed principally of large follicular centre cells. Often these lesions had been diagnosed as reticulum cell sarcoma but, on follow-up, all the patients were alive and well.(ABSTRACT TRUNCATED AT 250 WORDS)

A total of 97 out-patients with steroid responsive dermatoses (63 eczema, 34 psoriasis) were recruited from two centres. They were randomly allocated in a double-blind manner to receive either betamethasone dipropionate cream twice daily or betamethasone dipropionate cream in the morning and base cream in the evening. The treatment period was 3 weeks. Eighty-five patients completed the study. There were no statistical differences between once daily application and twice daily for all of the parameters studied in both the eczema and psoriasis patients. Analysis of the diary card records, however, showed that symptomatic relief occurred more quickly in eczema patients receiving twice daily application of betamethasone dipropionate cream (P = 0.03). The use of betamethasone dipropionate cream once daily in conjunction with an emollient provides a regime which is as effective as a twice daily application of betamethasone dipropionate.