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Background: Observation of patients with morbilliform eruptions reveals a distinctive demarcation line on the upper arms. Objective: We studied the origin of this sharp "drug line." Methods: We performed a literature search of all known variables. Results: The drug line represents clinical expression of the pigmentary Voigt-Futcher line. Conclusion: The drug line reveals the otherwise inapparent embryologic ventral axial line, which marks the precise border between the sensory innervation of the lateral and medial upper arm. The significance of the cutaneous sensory nerves is thus apparent. The drug line is further evidence of the segmental nature of human skin, as evidenced in evolutionary and embryologic studies.(J Am Acad Dermatol 1999;40:736-40.)

In an open uncontrolled study of 3 patients with balanitis xerotica obliterans we have observed significant improvement after long-term systemic antibiotic therapy. Two of the patients noticed softening of the skin as well as disappearance of pruritus, tenderness, and inflammatory changes within 3 weeks of receiving oral and intramuscular penicillin. The third patient experienced the same degree of improvement after a regimen of dirithromycin, 500 mg/day. Stopping the antiobiotic for 1 month resulted in relapse, with improvement again on resumption.

We report two patients with the typical clinical picture of bullous pemphigoid who lacked two critical diagnostic immunopathological features of the disease, namely IgG or C3 bound to the epidermal basement membrane and circulating IgG antibodies directed against the basement membrane zone (BMZ). Both patients had dense infiltrates of eosinophils within their skin lesions, as well as markedly elevated serum IgE levels, while immunofluorescent studies with anti-IgE antibody revealed heavy IgE deposition on inflammatory cells within the dermis surrounding the bullae. These cells were confirmed to be eosinophils by means of specific staining with antibody to major basic protein (MBP). We speculate that this 'IgE bullous disease' resulted from IgE-mediated hypersensitivity induced by focal infection, both patients initially being helped by antibiotics. However, dramatic clearing of bullae was seen following surgical removal of a battery implant (Patient 1), and bilateral above-the-knee amputations of gangrenous legs (Patient 2).

Background: Severe palmar hyperhidrosis is a chronic disease, resistant to conventional therapy. Botulinum toxin inhibits sweat production by blocking release of acetylcholine from presynaptic membranes. Objective: Our purpose was to evaluate the short- and long-term effectiveness of botulinum toxin therapy in treatment of palmar hyperhidrosis. Methods: Four patients with severe palmar hyperhidrosis were treated with subepidermal injections of botulinum toxin. Fifty injections, 2 mouse units each, were used in each palm. Regional nerve blocks of the median and ulnar nerves were performed before the procedure. Patients were observed for 12 months after treatment. Results: Botulinum toxin injections significantly reduced sweat production in the treated areas of the palms. Anhidrosis lasted for 12 months in one patient, 7 months in two patients, and 4 months in one patient. Mild weakness of the thumb lasting 3 weeks occurred in one patient. No other side effects were observed. Conclusion : Botulinum toxin provides an effective, safe, and long-lasting alternative therapeutic modality for treatment of severe palmar hyperhidrosis. Additional studies are needed for optimization of the technique.(J Am Acad Dermatol 1998;38:227-9.)

The transverse nasal line has long been neglected and frequently overlooked. This narrow pink or hyperpigmented line or groove extends transversely between the upper two-thirds and the lower third of the nose. It is often hereditary and may be the locus of comedones and milia. Eighteen examples are reported by us, along with a possible embryological interpretation.

Schwannomatosis: dermatological relevance of an unusual form of neurofibromatosis type 2(NF-2). J Eur Acad Dermatol Venereol 1992; 1:269-79. 7. Takano M, Hayashi N, Toshitani S, et al. A case of neurilemmomatosis. Jpn J Dermatol 1989;99:67-71. 8. Sasaki T, Nakajima H. Congenital neurilemmomatosis. J Am Acad Dermatol 1992;26:786-7. 9, Schmidt MA, Michels VV, Dewaid GW. Cases of neurofibromatosis with rearrangements of chromosome 17 involving band 17ql 1.2. Am J Med Genet 1987;28:7717. 10. Rouleau GA, Wertelecki W, Haines JL, et al. Genetic linkage of bilateral acoustic neurofibromatosis to a DNA marker on chromosome 22. Nature 1987;329:246-8. 11. Honda M, Arai E, Sawada S, et al. Neurofibromatosis 2 and neurilemmomatosis gene are identical. J Invest Dermatol 1995;104:74-7.

Transverse bands of leukonychia are reported in a 7-year-old boy following a 10-day course of daunorubicin given for the treatment of lymphoblastic leukemia. A variety of other chemotherapies did not induce any nail changes in this patient.

A 23-year-old man developed cellulitis and ascending lymphangitis of the right leg. Blood cultures and skin saline aspirates were sterile. Gram stain of the aspirate did not show any bacteria. Direct and indirect immunofluorescent staining with polyclonal and monoclonal antibodies to Streptococcus pyogenes revealed streptococci in the reticular dermis. The cellulitis resolved following treatment with intravenous cefazoline.

An 83-year-old woman consulted us for evaluation of a 1·0 cm nodule on her right anterior shoulder (figure). It was symptomless and had arisen at the site of clonidine patches applied during the past year. No lesions were seen on her legs where the patches are now being applied. Her past history included left hemiplegia, aphasia following a right cerebrovascular accident 5 years ago, and bullous pemphigoid. Her blood count was normal. A skin biopsy specimen showed no changes in the Mutations in the MEN I gene in sporadic neuroendocrine tumours of gastroenteropancreatic system

Molluscum contagiosum is unique among the viral induced growths of the skin. Unlike other viral tumors, the molluscum contagiosum lesion is a mass made up of myriads of free, discrete virions. It is not a proliferating growth of epidermal keratinocytes such as one observes in the common wart. There is no better way to perceive the nature of this tumor mass than by scanning electron microscopy.Skin lesions of molluscum contagiosum were excised from patients and immediately fixed in 2.5% glutaraldehyde. After fixation the specimens were rinsed in Millonig’s Phosphate buffer. The entire lesion was than cross-sectioned with a razor blade, postfixed in 1% OsO4, rinsed again in buffer, dehydrated in grading ETOH, critical point dried, positioned on an aluminum stub and gold-coated. Examination was made using a JEOL SEM (JSM-35).

For the laboratory diagnosis of fungal disease, fragments of epidermis are removed from skin lesions with a curette or a scalpel, placed on a glass slide, immersed in a drop of 10% to 15% potassium hydroxide, and examined for hyphae and spores. 1 We describe a new technique for secming large nonfragmented specimens of stratum comeum from patients with hyperkeratotic lesions of the palms and soles, It gJ~atly amplifies the size of the specimen as well as the speed with which it can be scanned in the search for fungal elements. A single Super-Blue Gillette razor blade is broken transversely by hand. 2 The two half blades are held in close opposition and slowly drawn through the stratum corneum at the selected site. Removal of the top blade reveals a thin solid specimen that may measure as large as a square cenlimeter (Fig. 1), Placing this specimen on a glass slide for potassium hydroxide examination affords a panoramic field for microscopic viewing. Alternatively, the specimen

Dermatology is not a giant among the specialties, but by standing on the shoulders of the basic science giants it has achieved remarkable advances. The resurfacing and rejuvenation of sundamaged facial skin is now routinely secured by use of an ingenious tool: the ultrapulsed carbon dioxide laser. Its uniquely superficial vaporisation removes just the epidermis, thus clearing away freckles, lentigines, First came the laser to peel the tomato surface naevi, and wrinkles. The H J Heinz Company developed this tool 15 years ago for skinning tomatoes, but it did not prove cost effective. Today, it is the laser of youth. Bioengineers can now nqanufacture a pure cultured skin for grafting bums and ulcers with both epidermis and dermis (Lancet 1996; 348: 466). Being free of immunogenic components, it does not trigger the feared rejection of ordinary skin grafts. The pharmaceutical industry is currently converting the practice of dermatology from topical to systemic therapy, and new drugs are bringing insights into many skin diseases. The erythromycin derivatives azithromycin and clarithromycin control bacteria hitherto beyond our reach. Antibiotic therapy for previously undetected organisms is helping in scleroderma, scleroedema (Brit J Dermatol 1996; 134: 593), erythema annulare centrifugum (Lancet 1996; 347: 897), and confluent and reticulated papillomatosis (,7 Am Acad Dermatol 1996; 346: 253). In psoriasis, streptococci have just been demonstrated in the lesions of some patients, who may respond dramatically to antibiotics. In atopic dermatitis, elimination of the staphylococcal superantigen with antibiotics has been remarkably helpful. In rosacea and chronic urticaria, eradication of Helicobacter pylori from the stomach cures some cases (JAm Acad Derrnatol 1996; 34: 253). Certain exanthems have now been shown to be due to Arcanobaaerium haemolyticum infections of the throat, which are responsive to antistreptococcal treatment. However, many pathogenic bacteria remain unidentifiable, casting antigens and emboli from occult foci of infection, such as dental, otolaryngological, and urological infections, to incite a variety of cutaneous reaction patterns. In this golden age of antibiotics, trials with the new broad-spectrum agents often bring about remarkable resolution of skin lesions. Equally impressive are the new antiviral agents. Acyclovir has spawned valacyclovir, famciclovir, and ganciclovir, proven effective for treating herpes simplex

Professors W B SHELLEY and E D SHELLEY and Assistant Professor N Y Talanin (Department of Medicine, Medical College of Ohio, PO Box 10008, Toledo, Ohio 43699-0008, USA) write: McCormick reported local inflammatory reactions after intramuscular injections of vitamin A and concluded that the vehicles used to make vitamin A water soluble were responsible.1 Our observations show that vitamin A (retinol) can itself cause an inflammatory hypersensitivity reaction. A 66 …

A multiple puncture technique using a bifurcated vaccination needle to introduce bleomycin sulfate (1 U/mL sterile saline solution) into warts resulted in elimination of 92% of a random series of 258 warts after a single treatment. Recurrence was not observed during a 6-month follow-up period. Six of the 66 patients required two to seven treatments for wart eradication, and four patients requested alternative therapy after initial failure with a single bleomycin treatment.

Scanning and transmission electron microscopic studies were done on scalp hairs of four patients infected with ectothrix Microsporum canis. Both freeze fracture and cross-sectioning of hairs revealed a thick sheath of fungal spores encircling the hair shaft beneath an intact cuticle. These spores were not visible on surface inspection but became apparent only where the cuticle had been rubbed off or broken. Daily selenium sulfide shampoos removed all of the spores from these sites. The cuticle is viewed as being an effective barrier to the penetration of fungi, so that the hair is vulnerable to fungus infection only deep within the hair follicle below the level of the mature cuticle. Once the fungus enters the hair cortex just above the hair bulb, it produces myriads of spores that remain trapped and hidden beneath the cuticle for the length of the intact hair.

Three children are reported with uncombable hair syndrome, consisting of slow-growing, straw-colored scalp hair that could not be combed flat. The hairs appeared normal on light microscopy but on scanning electron microscopy were triangular in cross section, with canal-like longitudinal depressions. Oral biotin, 0.3 mg three times a day, produced significant improvement after 4 months in one patient, with increased growth rate and with strength and combability of the hair, although the triangular shape remained. The other two patients were unique in having associated ectodermal dysplasia. Their hair slowly improved in appearance and combability over 5 years without biotin therapy.

Three children had striking localization of varicella lesions to skin overlying a diphtheria-pertussis-tetanus toxoid (DPT) immunization injection site, a facial abrasion, and a sunburn of the trunk, respectively. Presumably, during the viremic stage of varicella, the virus passed from damaged blood vessels into the skin. A disabling myalgia in the thigh at the DPT site in one child may also have been the result of localization of the varicella virus in the muscle during the inapparent viremic stage. This suggests that an injection given during an occult viremia could trigger an unexpected reaction at the site.

Radially oriented acicular crystalline aggregates could be induced by incubating heparinised blood with bacterial endotoxins. These aggregates did not appear in the blood of 37 healthy volunteers but were observed in the blood of 130 patients, predominantly those with vasculitis, psoriasis, and bacterial infections. Study of these asteroid structures, which resemble "sunbursts", led to the view that they are oriented crystals of fibrin radiating from a central platelet mass undergoing lysis.

During an investigation of coproporphyrin excretion in cases of idiopathic hair loss an unexpected blue fluorescence was detected in the urine. Chromatographic and spectrophotofluorimetric properties characterised this " blue spot " as being caused by o-hydroxyhippuric acid, a urinary metabolite of salicylate. The blue spot disappeared if salicylates were forbidden, but could be induced in previously normal urine if clinical doses were given to controls. This unexpected " aspirin addiction " might reflect underlying chronic disease in patients with unexplained hair loss, cause gastrointestinal bleeding leading to anaemia and hair loss, or act directly by interfering with cellular activity necessary for hair production.

A unique, progressive syndrome of muscle weakness, ascending telangiectasia, and venous ectasia of the legs developed in a 55-year-old woman with autoimmune thyroiditis. Myopathy was documented by electromyography and electron microscopy. Her constellation of findings is considered to be of autoimmune origin. Treatment with acyclovir eliminated the patient's generalized telangiectasia. Cyclosporine therapy resulted in a marked but temporary reduction of the enlarged thyroid and of her elevated thyroglobulin and microsomal antibodies. Neither acyclovir nor cyclosporine had any demonstrable effect on the patient's muscle function or venous ectasia.

Recurrent, deep, painful, noninflammatory blisters on the volar fingertips proved to be a variant of bullous dermatosis of hemodialysis.

We present evidence that lichen aureus results from extravasation of red blood cells into the dermis caused by incompetence of an underlying perforator vein. The sudden appearance of the lesion suggests a "blow out" of the microvasculature of the lower dermis caused by failure of the valves in the perforator vein. This incompetence of the perforator vein induces a permanent reversal in normal blood flow. The consequent continuous high pressure in the cutaneous microvasculature is responsible for long-term leakage of red blood cells. Digestion of the extravasated red cells by macrophages leaves an "auto-tattoo" of insoluble hemosiderin granules, which produce the distinctive golden or burnt orange color of lichen aureus.

SUMMARY Cutaneous telangiectatic vessels from two cases of unilateral dermatomal superficial telangiectasia were shown under electron microscopy to be venular capillaries with thick walls composed of multiple basement membranes. We suggest that this special capillary structure, seen in a variety of telangiectatic and disease states, should be called the ‘laminate capillary’.

Using scanning electron microscopy to study molluscum contagiosum lesions, it has been possible to demonstrate a unique, well defined sac enclosing the virion colony of each infected keratinocyte. This confirms the presence of a structure demonstrated over 50 years ago by micro-dissection, but ignored since it is not seen on either light or transmission electron microscopy. It is postulated that this sac, of unknown origin, favours replication of the virions by providing a site that is both anatomically and immunologically privileged. Such relatively unimpeded growth of the virions results in an enlarged cell in which the cytoplasm and nucleus are compressed into a thin outer shell. In the aggregate, this produces a tumour of virus-packed cells rather than a tumour composed of virus-induced cell hyperplasia.

X-ray microprobe and electron microscopic study was made of the remarkable blue-black pigmentation that sunlight elicits in patients with argyria. The patient under study had developed argyria following injection of silver nitrate as a sclerosant into his varicose veins 41 years ago. Similarities are demonstrated between the darkening of the skin and the darkening of a photographic film following light exposure. In both instances, colorless silver salts and compounds present in an inert matrix (collagen versus gelatin) are reduced by incident light to black metallic silver. This passive photosensitivity reaction leads to silver tattooing of the light-exposed skin and to photographic imaging in the film.

SOLVING the mystery of an unexplained dermatitis calls not only for informed curiosity on the part of the physician, but also for careful detective work on the part of a well-instructed patient. In this instance, the combination of these two avenues of inquiry led to an awareness of a new vector for skin disease. Report of a Case A 21-year-old man presented with a pruritic erythematous eruption of the volar forearms, lower parts of the legs, and eyelids, present with increasing severity for 12 days. It had appeared suddenly within hours of returning from vacation to his work in a wholesale florist supply shop. Severe pruritus had prevented him from working for the past six days. He had worked for six years in this shop, with only one prior attack of dermatitis occurring four months previously. The cause had remained unexplained and he had been treated successfully with intramuscular steroid