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Mycosis fungoides, the most common type of cutaneous T-cell lymphoma, can manifest in a variety of clinical and histologic forms. Presentation with vesiculobullous lesions is extremely rare. We report the ninth documented case of mycosis fungoides bullosa in which other concomitant autoimmune blistering diseases were ruled out by negative immunofluorescence. All previously reported cases in the world literature since the first in 1887 are reviewed. We recommend the following defining criteria for the disease: (1) clinically apparent vesiculobullous lesions, with or without typical mycosis fungoides lesions (patches, plaques, tumors); (2) typical histologic features of mycosis fungoides (atypical lyphoid cells, epidermotropism, Pautrier's microabscesses) with intraepidermal or subepidermal blisters; (3) negative immunofluorescence (both direct and indirect, if possible) to rule out concomitant autoimmune bullous diseases; (4) negative evaluation for other possible causes of vesiculobullous lesions (eg, medications, bacterial or viral infection, porphyria, phototherapy).

Study Objective: To collect descriptive epidemiologic injury data on patients who suffered acute injuries after the April 19, 1995, Oklahoma City bombing and to describe the effect on metropolitan emergency departments., Methods: A retrospective review of the medical records of victims seen for injury or illness related to the bombing at 1 of the 13 study hospitals from 9:02 AM to midnight April 19, 1995. Rescue workers and nontransported fatalities were excluded., Results: Three hundred eighty-eight patients met inclusion criteria; 72 (18.6%) were admitted, 312 (80.4%) were treated and released, 3 (.7%) were dead on arrival, and 1 had undocumented disposition. Patients requiring admission took longer to arrive to EDs than patients treated and released (P =.0065). The EDs geographically closest to the blast site (1.5 radial miles) received significantly more victims than more distant EDs (P <.0001). Among the 90 patients with documented prehospital care, the most common interventions were spinal immobilization (964/90, 71.1%), field dressings (40/90, 44.4%), and intravenous fluids (32/90, 35.5%). No patients requiring prehospital CPR survived. Patients transported by EMS had higher admission rates than those arriving by any other mode (P <.0001). The most common procedures performed were wound care and intravenous infusion lines. The most common diagnoses were lacerations/contusion, fractures, strains, head injury, abrasions, and soft tissue foreign bodies. Tetanus toxoid, antibiotics, and analgesics were the most common pharmaceutical agents used. Plain radiology, computed tomographic radiology, and the hospital laboratory were the most significantly utilized ancillary services., Conclusion: EMS providers tended to transport the more seriously injured patients, who tended to arrive in a second wave at EDs. The closest hospitals received the greatest number of victims by all transport methods. The effects on pharmaceutical use and ancillary service were consistent with the care of penetrating and blunt trauma. The diagnoses in the ED support previous reports of the complex but often nonlethal nature of bombing injuries.

Background: Managed care in the American health care system may limit access to health care specialists., Objective: We assessed primary care providers' abilities at diagnosing and treating patients with a previously undiagnosed skin disorder., Methods: Patients with previously undiagnosed skin disorders were seen and examined sequentially by three groups of physicians: (1) internal medicine residents, (2) board-certified internal medicine attending physicians and (3) dermatology faculty. The internal medicine residents and attending physicians' diagnoses were compared with the dermatologists'. Appropriateness of therapy ordered by the internal medicine residents and attending physicians was assessed., Results: Medical residents' diagnoses were correct in 43% of the patients whereas the attending physicians diagnosed 52% of cases correctly. Attending physicians and residents frequently ordered therapy inappropriate for the patient's diagnosis. Internal medicine residents and attending physicians were more likely to order skin biopsies than dermatologists., Conclusions: Our results confirm earlier studies that nondermatologists perform poorly in the diagnosis and treatment of skin disease. Primary care providers should receive more training in dermatology, or dermatologists should be permitted to act as primary caregivers to patients with skin disease.

Background: Seabather's eruption (SE) is a highly pruritic eruption under swimwear that occurs after bathing in the ocean. Its cause has been unknown. Few data have been collected since the classic description by Sams in 1949., Objective: Our purpose was to describe the clinical and histopathologic findings in SE and to confirm the cause., Methods: Patients with a pruritic eruption that developed after swimming were seen within 1 week of onset. Skin biopsy specimens and sera were obtained in selected cases. Water samples taken from areas of active SE outbreaks were examined for a causative organism. Sera were tested by enzyme-linked immunosorbent assay for reactivity to this organism., Results: In southeast Florida, during a 4-month period, 70 patients with SE were seen. Inflammatory papules and pruritus were noted within hours of exposure. Eruptions were maximal in areas covered by a bathing suit. Children were more likely than adults to have systemic symptoms. The average duration of the eruption and pruritus was 12.5 days, with recurrences in 4.3% of patients. Histopathologic examination revealed a superficial and deep perivascular and interstitial infiltrate consisting of lymphocytes, neutrophils, and eosinophils. Water samples contained many cnidarian larvae, later grown to maturity and identified as Linuche unguiculata (thimble jellyfish). Enzyme-linked immunosorbent assay demonstrated in patients' sera high IgG levels specific for L. unguiculata., Conclusion: SE is a severely pruritic marine dermatosis that resolves spontaneously within 2 weeks. Therapy is symptomatic but often ineffective. Sera from affected persons showed specific reactivity to L. unguiculata.

Study Objective: To evaluate the efficacy, onset of action, duration of action, and side effects of 1% diphenhydramine compared with 1% lidocaine when used as a local anesthetic agent., Design: Prospective, double-blinded, cross-over study., Setting: Emergency medicine residency program, research section., Participants: Ten healthy male volunteers, aged 26 to 38 years old., Interventions: Baseline levels of sensation to pinprick (18-gauge needle) within a 2.4-cm-diameter midvolar forearm area and levels of sedation were recorded on 10.2-cm visual analog scales. Subjects then underwent subcutaneous infiltration of 20 mg (2 mL) of the study agent using a 27-gauge needle. Visual analog scale sensation and sedation scores were recorded at five, ten, and 15 minutes and then every 15 minutes until return to baseline. Subjects were studied one week later with the alternate agent. Nonparametric data were analyzed using the Mann-Whitney U test with significance at P < .05., Results: No significant differences in mean pinprick sensation were seen from baseline to 30 minutes. Significant differences were seen at 45 (P = .036) and 60 minutes (P = .036). The mean duration of effective anesthesia was significantly longer for lidocaine than diphenhydramine (81 versus 42 minutes, P = .028). No significant differences were seen in the sedation scores or in the frequencies of local reactions. One subject developed skin necrosis at the injection site with diphenhydramine., Conclusion: The duration of local anesthesia for 1% lidocaine was significantly longer and the depth of anesthesia after 30 minutes was significantly higher than that of 1% diphenhydramine. Diphenhydramine resulted in skin necrosis in one test subject.

Background: Actinic prurigo, an idiopathic familial photodermatosis, has been described in Amerindians in Manitoba, Canada, as well as in the United States, Mexico, and South America., Objective: Our purpose was to describe the clinical features and prognosis of actinic prurigo in Amerindians in Saskatchewan, Canada., Methods: Clinical examinations, questionnaires, phototesting, and laboratory tests were used., Results: We present a series of 93 Amerindian patients. The face is the most commonly involved area. A hereditary tendency, cheilitis, and pruritus are prominent features. One third of patients report some lesions, often minor, during the winter. The majority of patients phototested were sensitive to ultraviolet A light., Conclusion: We find the age of onset of actinic prurigo to be the most important feature in determining the type of eruption and the prognosis for the patient. In general the younger ages of onset (up to 20 years of age) are associated with cheilitis and more acute eruptions and are more likely to improve over 5 years. Those who develop actinic prurigo as adults (21 years of age and older) tend to have a milder and more persistent dermatosis.

Human leukocyte antigen typing of 41 white patients with polymorphous light eruption (limited concept) showed no significant differences when compared with the typing of 51 white control subjects. We previously found that actinic prurigo, an idiopathic photodermatosis particularly associated with Amerindians, has a positive association with antigens A24 and Cw4 and a negative association with A3. We suggest, on the basis of both laboratory and clinical findings, that polymorphous light eruption (limited concept) and actinic prurigo are two different and distinct diseases.

A 7-year-old girl had a 4 X 3 X 3 cm nodule on the left wrist with axillary lymphadenopathy. Acid-fast bacilli were seen on a smear from a biopsy specimen of this granulomatous skin lesion. A Rhodococcus species grew on culture. Skin infections caused by Rhodococcus may be more common than the few prior case reports suggest.

This article reviews the prognosis of contact dermatitis, particularly of occupational contact dermatitis. Most studies document a poor prognosis for occupational and nonoccupational contact dermatitis. The prognoses of occupational and nonoccupational contact dermatitis, irritant contact dermatitis, and allergic contact dermatitis are similar. Only a minority of studies on the prognosis of occupational contact dermatitis have found that a job change by the affected worker leads to clearing of the dermatitis. Dermatologic and nondermatologic factors associated with a poor prognosis are discussed.

Anaphylactic reactions to Crotalidae envenomation are extremely rare. The presentation of anaphylaxis after envenomation can be a confusing variable in the timely diagnosis of both problems. The therapy of this dual disorder involves combining treatment of the obvious shock from the allergic reaction with a standard approach to Crotalidae envenomation. We present the case of a 22-year-old man who presented to the emergency department with urticaria, hypotension, and bronchospasm that developed immediately after his second envenomation from a rattlesnake. His symptoms resolved after administration of 0.8 mg SQ epinephrine, 100 mg IV diphenhydramine, 2,000 mL normal saline IV, and 250 mg IV methylprednisolone. Only one previous case report of anaphylactic shock from a rattlesnake bite could be found in the medical literature.

Thirty-two actinic prurigo patients of Cree ancestry underwent human lymphocyte antigen (HLA) typing and were compared with 32 control subjects of Cree ancestry. We found a significantly increased frequency of HLA-A24 and Cw4 antigens and a significant decrease in the frequency of the A3 antigen in actinic prurigo patients. These HLA associations may be helpful in determining whether actinic prurigo is a distinct disease or a variant of polymorphous light eruption.

Transdermal drug delivery systems are marketed in the United States for four different drugs, and others are in various stages of development. Cutaneous side effects occur frequently with these systems and sometimes necessitate discontinuation of therapy. This article will review these adverse reactions.

A recent report documents three homosexual men with porphyria cutanea tarda associated with acquired immune deficiency syndrome (AIDS). We report two brothers with hemophilia and human immunodeficiency virus (HIV) exposure who developed porphyria cutanea tarda. These brothers are heterosexual, have familial porphyria cutanea tarda, and developed overt familial porphyria cutanea tarda in their early twenties. One brother's symptoms were provoked by attending an ultraviolet A suntanning parlor. Our two patients, unlike the previously reported three patients, have not developed AIDS, though one patient has evidence of defective cell-mediated immunity. Three of the five cases of porphyria cutanea tarda associated with HIV infection involved familial porphyria cutanea tarda. It now may be advisable to order HIV serology tests in patients who have porphyria cutanea tarda. We recommend that HIV-positive individuals avoid ultraviolet A radiation because of its immunosuppressive effects in persons already at risk of immunosuppression. Such exposure is further contraindicated in those individuals with porphyria cutanea tarda.

Lichenoid stomatitis has been reported in the use of a number of drugs. This is a case report of lichenoid stomatitis associated with lithium carbonate. The association between lichenoid stomatitis and lithium carbonate was confirmed by rechallenge in this patient. A number of cutaneous reactions have been reported as adverse effects of lithium therapy. Lichenoid reactions are characterized by an infiltrate of T cells. Lithium has been reported to alter T cell function in vitro.