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Summary Background The diagnosis of mycosis fungoides (MF) is notoriously difficult to establish because in the early stages, histological features may be nonspecific or merely suggestive. Objectives To standardize the diagnosis of MF. Methods We studied 138 patients with suspected MF referred over a 7-year period to a university department of a dermatology-based cutaneous lymphoma clinic. Six diagnostic criteria were evaluated: clinical morphology, clinical distribution, skin biopsy T-cell receptor gene rearrangement (TCR-GR), skin biopsy pan T-cell marker loss ≥ 2, skin biopsy CD4/CD8 ratio ≥ 6, and skin biopsy diffuse epidermal HLA-DR expression. These six clinical and laboratory criteria were compared by logistic regression analysis in patients with histologically diagnosed MF and those with benign disease. Results Of the 138 patients, 74 had histology of MF, 47 of benign dermatoses and 17 were indeterminate. Close associations were found between a histological diagnosis of MF and TCR-GR (odds ratio 14·4), classical morphology (7·5), classical distribution (2·5) and diffuse epidermal HLA-DR expression (2·8). Logistic regression models were developed depending on the availability of data (either TCR-GR or HLA-DR). Probabilities for correctly diagnosing MF compared with histology as the ‘gold standard’ were derived from these logistic regression models. A scoring system assigning point values based on these probabilities was then created in order to assist the clinician in making the diagnosis. If using TCR-GR data, a positive TCR-GR = 2·5 points, the presence of classical morphology = 2·0 points, and the presence of classical distribution = 1·5 points. A total score of ≥ 3·5 points assigns a high probability (> 85%) of having MF. If using HLA-DR expression, then the presence of classical morphology = 2·5 points, a positive diffuse epidermal HLA-DR expression = 2·0 points, and the presence of classical distribution = 1·5 points. In this case, a total score of ≥ 4·0 points assigns a high probability (> 85%) of MF. Conclusions The logistic regression models and scoring systems integrate clinical and laboratory assessments, allow rapid probability estimation, and provide a threshold for the diagnosis of MF in an objective, standardized manner. [ABSTRACT FROM AUTHOR]

Atopic dermatitis is a common, chronic, relapsing cutaneous disease with typical cellular and humoral immunologic abnormalities that can result in significant physical and psychological morbidity to the patient. Atopic dermatitis typically begins in childhood and can often persist through adolescence into adulthood. Although there are a variety of treatments for atopic dermatitis, many patients' symptoms do not improve or they have adverse reactions to medications, requiring the search for other, effective therapeutic agents. A number of inflammatory and immunological abnormalities have long been noted in patients with atopic dermatitis. Although great strides have been made in understanding the causes, the complex pathophysiology of atopic dermatitis is still not completely understood. Most notably, patients with atopic dermatitis often have an elevation of serum immunoglobulin (Ig) E levels, depressed cellular immunity, elevated blood eosinophilia, and increased interleukin (IL)-4 production. In addition, peripheral blood mononuclear cells of patients with atopic dermatitis produce reduced levels of interferon-γ spontaneously and in response to stimuli. Due to this constellation of features, atopic dermatitis was initially viewed as a prototypical type 2 helper T lymphocyte (T) disease. These immunological findings led to a number of clinical trials with recombinant interferon-γ in patients who had severe, unremitting atopic dermatitis. Treatment with recombinant interferon-γ was postulated to be able to correct the immunological imbalances in patients with atopic dermatitis by decreasing serum IgE levels, IL-4 levels, restoring immune balance, and thereby leading to clinical improvement. Initial open-label studies, a double-blind placebo trial, and long-term open-label studies have demonstrated the clinical efficacy and tolerability of recombinant interferon-γ in a subset of patients with severe, unremitting atopic dermatitis. Patients receiving treatment often had marked decreases in severity of clinical parameters: erythema, edema/indurations, pruritus, excoriations, dryness, lichenification and associated reduction in total body surface area involvement. Surprisingly, treatment with recombinant interferon-γ did not lower serum IgE levels refuting the hypothesized mechanism by which interferon-γ would bring about clinical improvement in patients with atopic dermatitis. Instead, decreases were noted in absolute white blood cell and eosinophil counts that tended to correlate with clinical improvement. Although the exact mechanism by which recombinant interferon-γ brings about clinical changes in patients with atopic dermatitis is unknown, recombinant interferon-γ should be considered a possible therapy for patients with atopic dermatitis. [ABSTRACT FROM AUTHOR]

Allergic skin disorders in the elderly may arise from contact with or ingestion of offending allergens. Itching associated with skin allergy must be distinguished from other causes of itching in the elderly such as xerosis, itching due to systemic disease and bullous disease. Although elderly people have somewhat decreased cell-mediated immunity and may be harder to sensitise under experimental conditions, they have had many years to acquire allergic responses, and therefore develop contact dermatitis frequently. Patch testing is a valuable tool to diagnose contact allergy and should be used often in the elderly, particularly in patients at high risk of contact dermatitis, such as those with chronic lower extremity dermatitis or ulcers due to venous stasis. When prescribing topical medications to high risk patients, a knowledge of the common sensitisers is important. In addition to allergy to medicaments and dressings used to treat stasis ulcers, contact allergy to dental prostheses and medications used to treat ocular disease are common in the elderly as a result of increased usage and exposure. Rash caused by ingested allergens is much more commonly due to medications than to food in the elderly. Allergic noneczematous dermatoses in the elderly are commonly drug-induced. Urticarial skin reactions are often associated with the administration of antibacterials, nonsteroidal anti-inflammatory drugs (NSAIDs), antidepressants or opioids. Morbilliform rashes are a common sign of systemic reaction to anticonvulsants, gold, allopurinol or diuretics. Phototoxic reactions may be associated with the administration of tetracyclines, diuretics, NSAIDs and antihyperglycaemic agents. Patient-specific variables such as HLA type and concomitant medication may affect the likelihood of an allergic response to medication. Many elderly patients take multiple medications, which can make diagnosis of drug allergy difficult because diagnosis is most commonly accomplished by observing clinical response once the medication is withdrawn. In the case of lichenoid cutaneous reactions, clinical improvement may take several months after withdrawal of the offending drug. Laboratory tests to detect drug-induced allergic skin disorders may be available in the future. [ABSTRACT FROM AUTHOR]