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Bullous pemphigoid (BP) is an uncommon autoimmune bullous disorder, with significant morbidity and mortality. Mortality may be as high as 23.5% in the first year after diagnosis. Clear epidemiologic data across Australasia are lacking.A retrospective, multi-centred cohort study was designed to determine the incidence and mortality of bullous pemphigoid in New Zealand. Data from all histopathologically diagnosed patients with bullous pemphigoid between 2009 and 2015 from the Auckland region were obtained. Demographics, clinical characteristics and outcome 3 years from diagnosis (until 31 December 2018) were collected. Demographic data were compared against a denominator year-matched New Zealand Census population.One hundred sixty-one patients had confirmed bullous pemphigoid, with an incidence rate of 3.03/100 000 person-years [95% CI 2.58-3.54]; 70% were of European ethnicity; 12.4% were Pacific peoples; 11.2% were Asian; and 6.8% were Māori. 45.3% had associated cognitive impairment and/or stroke. In the 3-year follow-up, 25% had treatment complications mostly from prednisone therapy. The mortality rate was 40%, highest in the first year of diagnosis, with age at diagnosis a predictor.The incidence and mortality rates are comparable to the UK/Northern Europe. Knowledge of the epidemiology of bullous pemphigoid in New Zealand and within an international settling informs the provision of future care and treatments.

BACKGROUND Patch testing is the gold standard diagnostic test for allergic contact dermatitis and needs to be relevant to the region and the population being tested. The aim of this study was to develop a specific New Zealand baseline series (NZBS). METHOD We performed a retrospective case note review of patients attending four regional patch test centres between 2008 and 2020. Demographic and diagnostic information was collected for each patient along with results of patch testing. Using the results of this review, a group of 11 dermatologists with an interest in contact dermatitis agreed on a core group of allergens for inclusion in an NZBS, based on the frequency of positive reactions and allergens of interest. The remaining potential allergens were ranked by each dermatologist using an online questionnaire, with inclusion in the final NZBS by consensus. RESULTS Results from 2402 patients (67% female, mean age 44 years) from Auckland, Wellington, Palmerston North and Christchurch were collated. The 10 most frequent positive (relevant and non-relevant) allergens were nickel sulfate (22.0%), fragrance mix I (8.6%), cobalt chloride (7.3%), Myroxylon pereirae (5.6%), colophonium (5.1%), p-phenylenediamine (4.9%), methylisothiazolinone/methylchloroisothiazolinone (4.1%), fragrance mix II (3.9%), potassium dichromate (3.5%) and methylisothiazolinone (3.4%). Based on these results, a core series of 30 allergens was developed, with an additional 30 allergens added to form the extended series (total 60 allergens). CONCLUSION The baseline series of patch test allergens for routine use in New Zealand (NZBS) is based on national patch test data and expert consensus.

Since it was first approved for use in 1982, isotretinoin has revolutionized the management of acne vulgaris. Despite almost four decades of widespread use, uncertainty still exists regarding the manner in which it is best prescribed. In this review, we provide an update on the pharmacokinetics, mechanism of action, contraindications, interactions, and appropriate dosing schedule of isotretinoin in the treatment of acne. We also discuss the safety of performing concurrent dermatological procedures in patients taking isotretinoin.

Background The COVID‐19 pandemic has disrupted the practice of medicine. Dermatologic laser and energy‐based device (EBD) treatments carry a potential risk for the transmission of SARS‐CoV‐2 both for the patient and the practitioner. These risks include close practitioner to patient proximity, the treatment of higher viral load areas such as the face, the potential for infective bioparticles being carried by generated plumes and aerosols, and the direct contact between device, practitioner and patient. Objectives SARS‐CoV‐2 is a highly infective respiratory pathogen transmitted by respiratory droplets, respiratory/mucosal secretions, medically generated aerosols and via its transfer from contaminated fomites. This requires a review of the appropriateness of infection control protocols in regard to dermatologic laser and energy‐based device treatments. Methods A critical evaluation of patient skin preparation including skin asepsis, device disinfection, laser and electrosurgical plume management and PPE in regard to SARS‐CoV‐2 was performed. Results The adherence to a high standard of skin preparation and asepsis, device disinfection, laser and electrosurgical plume and aerosol management and appropriate PPE should help mitigate or reduce some of the inherent treatment risks. Head and neck treatments along with aerosol and laser plume generating treatments likely carry greater risk. Conclusions COVID‐19 needs to be considered in the clinic set‐up along with the planning, treatment and post‐treatment care of patients utilising EBD procedures. Some of these treatment precautions are COVID‐19 specific; however, most represent adherence to good infectious disease and established laser and EBD safety precautions.

The Virtual Lesion Clinic (VLC) of Waitematā District Health Board (WDHB) improves melanoma assessment and treatment using teledermatology. The VLC is reserved for pigmented lesions referred as suspected melanoma from primary care but indeterminate at the initial triage.To assess the efficacy of the VLC diagnosis of melanoma.A retrospective audit of suspected melanoma referrals (1 January 2012 to 31 December 2016) was conducted. Lesions were referred to the VLC if diagnostic uncertainty remained at the initial triage. VLC patients attended MoleMap imaging centres, a dermatologist reviewed history and images remotely and suggested a diagnosis and management plan. Post VLC provisional diagnosis of melanoma, all lesions subsequently excised were reviewed. A positive predictive value (PPV) was calculated using concordance between VLC diagnosis of melanoma and histopathological diagnosis of melanoma. Number needed to excise (NNE) for melanoma was derived, as well as an invasive to in-situ melanoma ratio (IM:MIS) and false negative rate (FNR).The VLC received 1874 referrals for 3546 lesions during the 5-year study period. Six hundred and seventy-nine lesions were recommended excision/biopsy or specialist face-to-face assessment, and 504 lesions were subsequently excised. The PPV was 62%, NNE 1.62 and IM:MIS 0.76 for lesions suspected to be melanoma at VLC assessment. The VLC had a melanoma-specific FNR of 7%.The VLC is effective in early diagnosis of melanoma with a high positive predictive value, low number needed to excise and low false negative rate amongst lesions referred as suspected melanoma.

Coronavirus disease 2019 (COVID-19) is the disease caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), as named by the International Committee on Taxonomy of Viruses (ICTV). There is very limited evidence base to formulate specific advice for dermatology patients on immunomodulators with regards to COVID-19. The following is based on expert opinion, taking into account known risks of influenza (a negative sense single-stranded RNA virus) and other, positive-sense single-stranded, RNA virus infections (such as SARS, MERS, and the common cold). An Australia/New Zealand consensus document is in development.

The Australasian Psoriasis Collaboration has developed a clinical practice narrative with respect to the relationship between psoriasis, its treatment and infection. The cutaneous microbiome of patients with psoriasis is different to those without psoriasis, although the significance of this is unclear. Whilst a wide range of microorganisms has been associated with psoriasis (including β-haemolytic streptococci, Staphylococcus aureus, Porphyromonas gingivalis, Candida albicans, Chlamydia psittaci, human immunodeficiency virus and hepatitis C virus), there is limited evidence that antimicrobial therapy is of direct benefit in preventing flares of psoriasis. Psoriasis is independently associated with an increased risk of serious infection, but the absolute risk is low. The risk of serious infections is further increased with immune-modulatory treatments. The decision whether to, and when to, stop or resume immune-modulatory treatment after a serious infection has occurred depends on risk assessment for that patient, taking into account the infection being treated, the risk of recurrent infection, any interventions that can modify the risk and the need for psoriasis control. Live vaccines (e.g. MMR, varicella, zoster and yellow fever) are generally contraindicated in patients with psoriasis on immune-modulatory agents, but this depends on the degree of immune suppression and individual risk factors. Wound healing in psoriasis is normal. Treatment with infliximab, adalimumab, etanercept, methotrexate and ciclosporin can safely be continued through low-risk surgical procedures. For moderate- and high-risk surgeries, a case-by-case approach should be taken based on the patient's individual risk factors and comorbidities.

Background Few population-based studies assess both invasive and in situ melanoma. We document all patients with a first biopsied melanoma in a general population in New Zealand (NZ). Methods All residents in a defined area of New Zealand with a biopsy showing a new primary invasive or in situ melanoma from 2010 to 2012 were identified, 974 patients; analysis used multivariate methods. Results Age-standardised incidence rates were 34.3 in females (F) and 41.4 in males (M) for invasive, 20.9 F and 27.6 M for in situ, and 55.2 F and 69.0 M for total melanoma. More in situ melanoma occurred in older patients and on the head and neck. Geometric mean Breslow thickness for invasive was 0.78 mm F and 0.85 mm M, with thicker lesions at ages over 60 and on the lower limb; there was no significant relationship with sex, distance from care or social deprivation assessed from residential address. Nodular melanomas (15%) were more frequent in older and male patients, and on the limbs, and were thicker. The estimated cumulative risk for melanoma is 4.4% F and 4.6% M by age 70. The body site distribution and sex differences were consistent with sun exposure patterns. Estimated incidence of melanoma in New Zealand in 2018 is 2500 invasive and 1700 in situ cases. Conclusions Assessing both in situ and invasive melanoma expands the clinical picture, better estimating health care demand and costs. Results suggest that in situ disease is a more slowly growing lesion than the early phase of invasive disease. The features of thicker or nodular melanoma show priorities for prevention and early detection.

Background/objective To describe the dermoscopic features of melanoma in situ using the Chaos and Clues method. Method Histologically proven primary melanoma in situ (MIS) diagnosed through a specialist teledermoscopy clinic were reviewed by three dermatologists. By consensus they agreed on the global dermoscopic pattern, colours, presence of chaos (asymmetry of colour and structure and more than one pattern), and each of the nine clues described for malignancy. Results One hundred MIS in 92 patients of European ethnicity (45 males) were assessed. Mean age was 67.3 years (range 20-95). The mean dimensions of the lesions were 11.1 × 12.0 mm (range 2.5-31.3 × 2.3-32.3 mm). Using pattern analysis, 82% of the lesions had three or more patterns (multicomponent) and the rest had 2 patterns. Colours included light brown (100%), dark brown (98%) and grey (75%). All MIS demonstrated chaos. The most prevalent clues were thick lines (88%), eccentric structureless areas (88%), and grey or blue structures (75%). Conclusion Dermoscopy can be very helpful in the early diagnosis of melanoma and MIS. The Chaos and Clues method is simple to use. Its unambiguous descriptors can be successfully used to describe MIS. The presence of chaos and clues to malignancy (including thick lines, eccentric structureless areas, and blue/grey structures) should raise a red flag and lead to referral or excision.

The Australasian Psoriasis Collaboration has reviewed the evidence for managing moderate to severe psoriasis in those who are pregnant or are breast-feeding, or planning a family. The severity of the psoriasis, associated comorbidities and specific anti-psoriasis treatment, along with other exposures, can have a deleterious effect on pregnancy outcomes. Psoriasis itself increases the risk of preterm and low birthweight babies, along with spontaneous and induced abortions, but no specific birth defects have been otherwise demonstrated. The baseline risk for a live born baby to have a major birth defect is 3%, and significant neuro-developmental problem is 5%. In Australia, pregnant women with psoriasis are more likely to be overweight or obese, depressed, or smoke in their first trimester, and are also less likely to take prenatal vitamins or supplements. Preconception counselling to improve maternal, pregnancy and baby health is therefore strongly encouraged. The topical and systemic therapies commonly used in psoriasis are each discussed separately, with regards to pregnancy exposure, breast-feeding and effects on male fertility and mutagenicity. The systemic therapies included are acitretin, adalimumab, apremilast, certolizumab, ciclosporin, etanercept, infliximab, ixekizumab, methotrexate, NBUVB, prednisone, PUVA, secukinumab and ustekinumab. The topical therapies include dithranol (anthralin), calcipotriol, coal tar, corticosteroids (weak, potent and super-potent), moisturisers, salicylic acid, tacrolimus, and tazarotene. As a general recommendation, effective drugs that have been widely used for years are preferable to newer alternatives with less foetal safety data. It is equally important to evaluate the risks of not treating, as severe untreated disease may negatively impact both mother and the foetus.

Background/Objectives Rosacea is a chronic inflammatory disorder that affects up to 10% of the population. Standard treatments include topical azelaic acid and metronidazole or systemic tetracyclines. Isotretinoin has generally been restricted to severe disease, often at a dose of 0.5–1.0 mg/kg/day. Method Retrospective review of open-label isotretinoin (initial dose 20 mg/day, with dose adjustments according to response), in patients with mild to moderate papulopustular rosacea. Results Altogether 52 patients (33 women), mean age 48 years (range 18–86) were treated with isotretinoin over a 5-year period. All patients were commenced on 20-mg isotretinoin/day which was reduced to 10–20 mg once to five times a week (equivalent to 5 mg/day) in 67%, but increased in 15% (who all had additional acne) to 30–40 mg/day. In terms of dose/kg/day, 29% received ≤ 0.1 mg/kg/day, 46% received 0.11–0.25 mg/kg/day and 10% received > 0.5 mg/kg/day. Treatment was continued for 57 weeks (range 9–223). Six patients (12%) did not attend follow up. Of the remainder, in 91% (42/46) the rosacea had cleared or was excellent. One patient stopped isotretinoin because of its adverse effects. Two-fifths (44%) suffered no adverse effect. The most common side-effect was cheilitis in half (52%), which was mild in all but one patient. Conclusion Very low-dose isotretinoin (e.g., 10–20 mg once to five times a week, equivalent to 5 mg/day) is an effective treatment for mild to moderate papulopustular rosacea and is well tolerated.

The Australasian Psoriasis Collaboration reviewed methotrexate (MTX) in the management of psoriasis in the Australian and New Zealand setting. The following comments are based on expert opinion and a literature review. Low-dose MTX (

Background/Objectives The prevalence of melanocytic naevi falls with age. It has been postulated that this could be due to spontaneous involution (fading). Our objective was to provide dermatoscopic evidence of fading naevi and to describe the patterns of fading observed. Methods Serial dermatoscopic images of naevi demonstrating fading were collected from a set of 25 000 images. Any naevi that showed significant fading, as compared to previous imaging of the same lesion, were included in the analysis. Results A total of 47 naevi in 21 patients were found to have significantly faded over a span of 2–11 years. The dermatoscopic fading was observed to occur in two patterns. The most common pattern observed was generalised fading (n = 45), where fading was present over all the naevus. There were two cases of focal fading (n = 2) where fading was present only over one area of the naevus. Conclusions Fading melanocytic naevi are uncommon. Melanocytic naevi fade in recognisable patterns, with generalised fading most commonly observed in our series.

Background The importance of the cumulative dose of isotretinoin with respect to relapse of acne vulgaris remains controversial. Although guidelines recommend 0.5–1.0 mg/kg/d to a minimum cumulative dose of 120 mg/kg, there has been a trend toward the use of lower daily dosages with no reference to cumulative dose. Objectives This study aimed to determine the influence of daily and cumulative dosage on relapse in acne. Methods Charts of patients with acne treated with isotretinoin were reviewed. Demographic details and daily cumulative doses and duration were compared between patients who received one course and two or more courses, respectively. Results Of 1453 patients, 326 (22.4%) received a second course of treatment (study population). The remainder served as controls (n = 1127). Dosage varied from 10 mg/week to 1.1 mg/kg/d, cumulative dosage from 1 to >300 mg/kg, and duration of treatment from 8 weeks to 5 years. Compared with controls, patients who received a second course were more likely to be women (61 vs. 47%; P < 0.001) and received higher daily (0.71 vs. 0.58 mg/kg/d; P < 0.001) and cumulative (126 vs. 101 mg/kg; P < 0.001) doses. Patients treated with very low doses (e.g. 10 mg three times per week) and/or low cumulative doses (e.g. 25–50 mg/kg) did not relapse more often than controls. Conclusions Neither daily nor cumulative dosages influenced relapse of acne vulgaris in patients treated with varying doses of isotretinoin as long as treatment was continued for ≥2 months after the acne had completely resolved.

Drug-induced hypersensitivity syndrome (DIHS) is a multi-system syndrome resulting from an idiosyncratic reaction to medication. While it commonly results in multi-organ involvement, particularly the liver, there are few reports of DIHS causing cerebral vasculitis and neurological deficits. We report the case of a 63-year old woman with DIHS secondary to allopurinol leading to multiple neurological deficits with magnetic resonance imaging findings consistent with a cerebral vasculitis.

With 30 years of clinical use, it is appropriate to review the use of isotretinoin. We now understand that retinoids influence cellular growth, differentiation, morphogenesis and apoptosis, inhibit tumour promotion and malignant cell growth, exert immuno-modulatory actions and alter cellular cohesiveness. This has expanded the indications of isotretinoin from just acne and rosacea to a wide range of inflammatory and malignant skin disorders. While the standard dose of 0.5 to 1 mg/kg per day for 4 months to a cumulative dose of 120-140 mg/kg per day has served us well in the management of acne vulgaris, there is emerging evidence that much lower dosages (as low as 5 mg/day) are just as effective but have significantly fewer adverse effects. Relapse of acne vulgaris continues to be a problem but we are beginning to recognise that this is related less to the cumulative dose and more to the length of sebaceous gland suppression. Other factors important for relapse include a macrocomedonal pattern of acne, smoking and age, both younger (under 14 years) and older (over 25 years). After 30 years of use, we now understand why isotretinoin is such an effective drug. Not only does it clear acne in almost all patients, long-term remission can be achieved in 70-80% of patients with a single course. Important changes in the use of isotretinoin include using a lower daily dose for a longer period of time. New indications continue to emerge, particularly as a potential treatment for both intrinsic and extrinsic (photo) aging. Teratogenicity however, remains a very significant concern.

Background/Objectives: A virtual lesion clinic (VLC) using store-and-forward teledermoscopy was introduced to reduce waiting times and improve access for skin lesion assessment by dermatologists. We aimed to review the efficiency and patient acceptance of a new community-based teledermoscopy service by comparing it to hospital-based face-to-face (FTF) skin lesion clinics. Methods: A prospective study compared patient flow through a community-based VLC and a tertiary hospital FTF dermatology clinic. Surveys were sent to patients and their referring doctors after attendance. Waiting times, diagnosis, outcomes, financial costs, patient acceptability and convenience were compared. Results: A total of 300 patients were assessed; 200 were seen in the VLC and 100 in the conventional FTF clinic. Of the 200 patients seen in the VLC, 88% did not require a subsequent FTF clinic assessment to establish the diagnosis. Mean waiting times for first assessment were reduced by two thirds (from 114 days to 39 days) in those seen by the VLC compared to FTF. Financial analysis demonstrated cost savings of 14%. Surveyed patients were highly satisfied and confident in the VLC service. Conclusions: A community-based teledermoscopy service may allow improved management of outpatient referrals while providing a better, quicker and more convenient service. It may also provide cost savings, as teledermoscopy assessment can be cheaper than traditional assessment.

We compared the thickness of both dermis and subcutis (measured using ultrasound) in overweight and obese adults with type 1 (n = 10) or type 2 (n = 8) diabetes mellitus. When adjusted for confounding factors, patients with type 1 diabetes had thicker subcutis than those with type 2 diabetes, with this difference being particularly marked in the abdomen. There were no observed differences in dermal thickness between the groups.

Background/Objectives: Children with atopic dermatitis often have infective exacerbations which are treated with antibiotics and/or antiseptics. The most common infective cause is Staphylococcus aureus with a worldwide trend towards antibiotic resistance. This prospective observational audit aimed primarily to establish the prevalence of S. aureus colonisation in New Zealand children with atopic dermatitis attending a specialised paediatric dermatology clinic. Secondary aims were to assess whether S. aureus colonisation correlated to clinical severity, the sensitivity patterns to antibiotics (in particular methicillin-resistant S. aureus, and to identify any demographic or management risk factors. Methods: Subjects were children aged 18 years or younger attending a tertiary public hospital dermatology clinic with a diagnosis of atopic dermatitis. Demographic and social data, as well as current and previous systemic and topical treatments, were recorded. Patients were examined and the extent of atopic dermatitis determined using a standardised scale (Scoring Atopic Dermatitis (SCORAD)). Two skin swabs were taken for culture and standard sensitivities; one from the left antecubital fossa and one from the worst area of atopic dermatitis. Microbiological cultures and density of S. aureus colonisation were recorded. SCORAD and density of S. aureus culture were correlated. Demographic and clinical data from children with S. aureus was analysed. Results: One hundred children were recruited from March 2007 to May 2008. S. aureus was isolated from68 patients. There was a positive correlation between the density of S. aureus culture and severity of SCORAD (Spearman r = 0.55, P

Background/Objectives: Isotretinoin has revolutionized the management of acne vulgaris. However, concerns continue regarding the adverse effect profile of isotretinoin. This study aims to review the adverse effects experienced by patients started on isotretinoin by a single dermatologist. Methods: Retrospective chart review of 1743 patients started on isotretinoin for various dermatological conditions over a 6-year period. Details of the dose of isotretinoin used, concomitant medications, adverse effects and outcome were recorded. Results: One-fifth (18.5%) of patients reported no adverse effects during the study period. Cheilitis was the most commonly reported adverse effect, affecting 78% of users, followed by eczema and tiredness, seen in 12% each. However, these were clearly dose-dependent, as the group treated with doses of isotretinoin under 0.25 mg/kg/day only reported cheilitis in 47%, eczema in 7% and tiredness in 5%, compared with 96%, 16% and 18%, respectively, in those treated with more than 0.75 mg/gm/day. Twenty-four patients (1.4%) stopped isotretinoin because of adverse effects; a further three patients complained of severe adverse effects on at least one occasion, but continued taking the medication. The adverse effect(s) that led to patients stopping isotretinoin were cheilitis (22 patients), mood change (13), tiredness (12), eczema (6) and pregnancy (2). There were no reported instances of suicidal ideation or attempted suicide. Conclusions: Other than the two oral contraceptive failures, there were no serious adverse events recorded during this review period. Isotretinoin is a very effective medication with a low adverse-effect profile when used at lower doses.

Background: Phototherapy is effective for many dermatoses in adults, but there is a paucity of data for its use in children. Objectives: To review the efficacy and tolerability of narrowband UVB phototherapy in children at a tertiary centre in New Zealand, and determine if there were any factors that differentiated responders from non-responders. Methods: A prospective analysis of children (

Three women with known breast cancer presented with very similar annular erythemas of their chest walls. All women were in remission from their breast cancer for at least 6 months. Their breast cancers had initially responded well to multi-modality treatment with no clinical or radiologic evidence of recurrence, until the development of the annular erythema. In the first case, the annular erythema was treated unsuccessfully as a dermatitis and then as tinea corporis. In the second case, subacute cutaneous lupus was considered but lupus antibodies were negative. In the third case, the annular erythema was promptly recognized and biopsied. Histology in all three cases revealed identical findings of invasive ductal carcinoma involving the lymphatics of the skin. Immunohistochemical staining of the carcinoma was positive for human epidermal growth factor receptor 2 but negative for oestrogen and progesterone receptors. Annular erythema can pose a wide differential but rarely has it been described as a sign of locally recurrent cancer. These cases highlight the importance of recognizing this entity in the oncologic patient, where prompt skin biopsies can confirm the diagnosis and allow early initiation of therapy.

There are a number of reports in the literature of allergic contact dermatitis as a result of exposure to the sawdust and plant parts of Grevillea robusta. While this tree is prevalent in New Zealand, there seems to have been no previous published accounts of contact dermatitis, although anecdotal evidence indicates that such cases may be common. Two brief case reports are provided regarding severe phytodermatitis to G. robusta among professional arborists in New Zealand. As with other common plants capable of inducing allergic contact dermatitis, greater awareness among arborists, orchardists, forestry workers, gardeners, and health professionals will likely result in a reduction of cases.

A 33-year-old woman attended for skin examination bydigital dermoscopy (mole mapping). She was fair skinned(Fitzpatrick phototype I) with blue eyes and red hair. Shereported many sunburns in childhood, and exposure tosunbeds two or three times weekly for several years duringher early 20s. There was no known personal or familyhistory of skin cancer. Examination revealed moderatefreckling and few tan-coloured melanocytic naevi. Thepatient was concerned about a lesion that first appearedover her right hip 6–12 months ago, and had recently dark-ened in colour.Examination revealed a dome-shaped pink papule, 6 mmin diameter (Fig. 1a). Dermoscopy revealed a prominentcentral cluster of red globules and red dotted vessels(Fig. 1b). There was no pigment network.

The aim of this study was to review and compare melanomas referred by general practitioners and melanomas identified at specialist clinics. The medical records relating to 113 primary melanomas excised at Waikato Hospital (a specialist regional base hospital) during 2002 and 2003 were reviewed retrospectively. Forty-seven melanomas (41%) were detected when patients attended specialist clinics (mainly plastic surgery and dermatology), and 66 melanomas (59%) were specifically referred by general practitioners. The melanomas detected at specialist clinics had a lower mean Breslow thickness than those referred by general practitioners (0.57 mm compared with 1.45 mm). Patients referred by general practitioners waited a mean of 26.5 days (range 0-94 days) for first specialist assessment. Following specialist assessment, patients waited a mean of 24.2 days (0-81 days) before excision biopsy.

A 55-year-old woman with severe, chronic, treatment-resistant ulcerating necrobiosis lipoidica of the shins was commenced on oral cyclosporin at a dose of 2.5 mg/kg/day. Improvement started within 1 week of commencing treatment, and the lesions healed completely over 8 months. Further ulceration occurred 3 months after discontinuing cyclosporin, with improvement on reintroduction of cyclosporin. There have been four previous case reports of healing of treatment-resistant ulcerating necrobiosis lipoidica with cyclosporin.

An 83-year-old woman presented with primary multifocal cutaneous B-cell lymphoma, presenting as discrete nodules on the right pinna and nail-bed of the left middle finger, diffuse swelling and erythema of several other nail-beds of the fingers and toes, with associated pincer nail deformity and rhinophyma. Because of the involvement of several sites not amenable to radiotherapy, she was treated with oral cyclical chlorambucil with good result.

Blastic plasmacytoid dendritic cell neoplasm (BPDCN) is a rare haematological malignancy that originates from the precursors of plasmacytoid dendritic cells. It commonly presents with findings isolated to the skin although it usually progresses to a leukaemic phase. It has a poor prognosis but is curable, particularly in younger patients treated with allogeneic bone marrow transplantation. We report a case of a 79-year old man who had 6 months of progressive, asymptomatic BPDCN manifestations limited to the skin, before developing a leukaemic phase.

Acquired palmoplantar keratoderma (PPK) is a rare group of conditions with a number of aetiologies, including adverse reactions to drugs. Herein, we report a case of acquired PPK in association with influenza vaccination, confirmed by rechallenge.

Between 1994 and 2000, 63 isolates of Trichophyton violaceum and five isolates of Trichophyton soudanense were recorded in both private and public laboratories in Hamilton, New Zealand. A retrospective analysis of medical records of these patients was performed. From these 68 isolates, 58 were recovered from scalp specimens and 10 were recovered from other body sites. There were 51 patients with tinea capitis and nine patients in the tinea corporis group. Six patients had more than one isolate reported at different laboratories. As expected, the vast majority of scalp infections (46/51 patients) were children, with an overall median age of 6 years (range 8 months to 66 years). All patients in the tinea capitis group, except one, were refugee immigrants from East Africa. Of nine patients in the tinea corporis group, six were refugees from the same area. For tinea capitis, 31 patients received systemic antifungal therapy for at least 4 weeks, with either terbinafine (21 patients), griseofulvin (four patients) or itraconazole (six patients). Five patients received topical antifungal creams or shampoo as monotherapy only. The remainder (15 patients) received either no therapy or no record was available. The emergence of these two pathogens as causes of tinea capitis in Hamilton closely correlates with the increasing number of refugees from endemic areas. There is a high rate of person-to-person transmission with these anthropophilic organisms in children as well as adults in the family. Transmission of infection to the local population has been observed, but there is no evidence to date to suggest that these organisms have become endemic in the local population.

A 57-year-old man is presented with blue pseudochromhidrosis affecting the face and neck following combination treatment with lansoprazole, a proton pump inhibitor, and ranitidine, a type two histamine receptor antagonist. The diagnosis was made on the basis of clinico-histological features and growth of Malassezia furfur, and Bacillus species, not Bacillus cereus, in the absence of lipofuscin. The pseudochromhidrosis resolved on stopping both medications and did not recur on restarting only the proton pump inhibitor.

Necrotising fasciitis represents a spectrum of disease which ranges from fulminant through acute to subacute varieties. While fulminating necrotising fasciitis is a well recognised entity the subacute variety is not. Aim: To assess six years' experience of necrotising fasciitis at Waikato Hospital. Method: Cases of necrotising fasciitis were identified from discharge statistics for the period 1990-1 995. Records were reviewed for clinical features, predisposing factors, microbiology, histology, treatment and outcome. Results: Fifteen cases were identified of which ten were female. The average age was 55 years (range of 15-92 years). One patient presented with fulminant, eight with acute and six with subacute necrotising fasciitis. Significant blister formation was noted in eight cases. Risk factors were identified in 14 patients including trauma, renal impairment, diabetes mellitus, and various drugs including diclofenac (four patients), naproxen (one patient) and prednisone (two patients). Group A beta haemolytic streptococcus (GABHS) was identified in ten cases. Swab or tissue cultures had the highest yield for isolating the organism. Blood cultures grew GABHS in only three of 12 cases. Eight patients (53%) died. Of the survivors all but one patient required debridement and skin grafting. Conclusions: Necrotising fasciitis is a clinical spectrum of disease. It affects a wide age group and can have associated morbidities. It is often a fatal disease. Early recognition, high dose antibiotics and surgical debridement are important in the management of the entire spectrum of necrotising fasciitis. (Aust NZ J Med 1997; 27: 29-34.)

Pemphigus vulgaris (PV) is a rare but potentially fatal autoimmune bullous disorder which frequently affects the oral mucosa. Although the essential cause of PV is unclear, its onset has occasionally been associated with drug therapy, in particular penicillamine. The patient described in this paper was a 78-year-old diabetic man who developed oral lesions of PV following institution of glibenclamide therapy.

Two female commercial hydrangea growers, from separate nurseries, presented with similar hand and facial dermatitis. Both had a hand dermatitis affecting particularly the first three fingers and backs of both hands and complained of a recurrent facial dermatitis affecting the forehead, around both the eyes and bridge of nose. They related their dermatitis to their work. Patch tests confirmed allergy to all components of hydrangeas including petal, leaf and stem. Avoidance resulted in resolution of their dermatoses. Allergy to hydrangeas has been reported previously although infrequently.

A 53-year-old farm worker presented with a 3-year history of an occupational allergic contact dermatitis to asparagus. The dermatitis cleared quickly with courses of systemic corticosteroids but relapsed within days of further exposure to asparagus. The genera Asparagus is made up of some 300 species. It belongs to the family Liliaceae which includes tulips, onions and garlic. Asparagus contains asparagin, coniferin and the glucoside vanillin. The allergen may be a plant growth inhibitor, 1,2,3-Trithiane-5-carboxylic acid, which is present in young shoots.

A 48-year-old clerical officer with a recurrent facial eruption had positive patch test reactions to nickel, fragrance mix and lichen acid mix. On testing to individual ingredients of fragrance mix and lichen acid mix, she had 2+ reactions to oak moss, which is thought to be the main allergen in fragrance mix, and to usnic acid, which is one of a number of lichen acids comprising oak moss. Avoidance of fragrance use resulted in clearing of the eruption but, subsequently, an acute vesicular flare on her face and hands occurred after exposure to lichen on garden shrubs.

A case is presented of a 5 year old girl, who over 12 months developed multiple asymptomatic yellow-brown nodules over the distal digits and nail beds, in association with joint stiffness and swelling. Biopsy of a representative nodule showed a nodular non-encapsulated dermal histiocytic infiltrate. Within this were scattered multinucleate giant cells with a ground glass eosinophilic cytoplasm consistent with multicentric reticulohistiocytosis (MR). This is a rare subgroup of the non-Langerhans cell histiocytoses which in contrast to solitary giant cell reticulohistiocytomas, is associated with a destructive arthritis. Typically MR affects Caucasian adults, with paediatric cases being rarely reported. Coeliac antibodies, strongly positive in this case, have only once been described in association with this disease, and may support an autoimmune pathogenesis.

Emulsifiers are an uncommon cause of allergic contact dermatitis. Five cases or allergic contact dermatitis to cetostearyl alcohol are presented. In all five cases, multiple positive reactions to otherr allergens were present, usually topical corticosteroid creams.

Medicament allergies in patients with chronic leg ulcers is well recognized. 1-5 In the past, topical antibiotics, rubber additives and wool alcohols have been the most common reported allergens. 1-5 Allergy to topical corticosteroids has been reported. 6 We document two cases of multiple corticosteroid allergy in patients with chronic leg ulceration.