fRITISHBRITISH MEDICAL JOURNAL 16 FEBRUARY 1974 283 Today's Treatment Br Med J: first published as 10.1136/bmj.1.5902.283 on 16 February 1974. Downloaded from

Diseases of the Skin

Present and Future Trends in Approaches to Skin Disease

J. A. A. HUNTER, T. J. RYAN, J. A. SAVIN

British Medical Journal, 1974,, 1 283-284 than building on current growing pints. Trends are always petering oust but ift is still worthwhile trying to extend them. The articles in this series have dealt with the maniagemenit of common skin condi-tions, and readers must have realized Psoriasis how much this depends on the same drugs used in other branches of medicine. Antibiotics and steroids have changed More work on cell turnover and its regulation will give the the pattern of dermatological practice. Tuberculosis and clue to psoriasis. Tissue-specific chalones may control the syphilis are now seldom seen in British skin clinics and replication of keratinocytes, but the chone -theory has re- a student can even complete his training without seeing a cently been questioned by those who thuink that epidermal patient with impetigo. Antibiotics have mean,t that infective turover is regula-ted through the cyclic AMP mechanisin. dermatoses are ofiten not recognized because they are rare. They think (that chalones from tissue homogenates may simply Nevertheless, skin ecology is a recent science which is con- represent cyclic AMP and molecules which increase its intra- cemed with the pollution of human skin by man-made agen,ts cellular levels. Actvation-for example, by adrenaline-of such as deodorants, antiseptics, and antibiotics. Resistant adenyl cyclase in keratinocyte membranes increases intra- bacteria are beginning to emerge: pseudomonas and cellular levels of cyclic AMP and depresses mitotic activity. other Gram-negative organisms cause most of the deaths in Voorhees thinks that psoriasis may result from a defect in burns units after the use of antibiotics aimed at the staphy- this mechanism, and that low epidermal intracellular levels of lococcus. Some units have even had a drop in the death rate cyclic AMP (causing increased mitotic activity) can be ex- when they stopped treating these infections; apparently the plained by imbalances in enzymes responsible for the forma- http://www.bmj.com/ staphylococci themselves lead to less morbidity. tion (adenyl cyclase) and degradation (cycLic phospho- Steroids have also had a dramatic influence; in dermatology diesterase) of cyclic AMP. If this is confirmed there are ex- they may be used in local preparations and, sensibly pre- citing possibilities for therapeutic agents acting through this scribed, they are the mainstay of the treatment of many skin mechanism. diseases. Today patients with eczema rarely have to stay in hospital over a fortnight. A skin doctor without steroids is like David without his sling. But-as their overuse in generalized Acne on 2 October 2021 by guest. Protected copyright. pustular psoriasis and perioral dermatitis ought to have shown--he Devil without his horns could be a better simile. Only a multidirecational approach can solve the problem of During ithe last 20 years other less dramatic, bu-t still im- acne. The answer is unlikely to come from itrying out more portant, advances in treatment have been made. Griseofulvin antibiotics and peeling agents, but from substances which for ringworm infections makes the previous treatments of lower the sebum-excreion rate. Continued research on tinea capitis seem barbaric. Immunosuppression for pem- systemic and topical antiandrogens is inevitable. Recoloniza- phigus, venesection for porphyria cutanea tarda, and systemic tion of the skin with lipase-deficient strains of Coryne- cytotoxic agents for severe psoriasis and local ones for solar bacterium acnes, if it worked, would be a logical development keratoses help with other problems. of bacteriological research. Advances in treatment are achieved by luck, as the result of careful research, or by a mixture of both. Not surprisingly, jobbing physicians and full-time research workers differ on the Eczema importance of each but fortunately they are not mutually ex- clusive. There is no easier way -to be wrong about the future At last the emphasis has switched from quibbles about the classification and morphology of the eczemas. The Inrterna- tional Contact Dermatitis Research Group are defining the common allergens and will surely see that the dangerous ones are outlawed. Or will contact dermatitis be treated by getting rid of clones of sensitive lymphocytes, or by specific de- Department of Dermatology, The Royal Infirmary Edinburgh sensitization, rather than by antigen avoidance? Our present- J. A. A. HUNTER, M.B., M.R.C.P.(ED.), Lecturer day tretmet of a(topic eczena is often ineffeotual and only J. A. SAVIN, M.B., M.R.C.P., Consultant Physician palliative. Cutting out certain foods in the earliest months of Department of Dermatology, United Oxford Hospitals life may be a promising approach in children at high risk; T. J. RYAN, M.B., M.R.C.P., Consultant Physician prevention rather than cure. 284 BRITISH MEDICAL JOURNAL 16 FEBRUARY 1974 Dermatitis Herpetiformis to clinch the diagnosis or monitor treatment in pemphigus. as different as contact derma- gut lesions of Immunology now covers topics There is encouraging news t-hat the skin and titis vasculitis, urticaria, and lupus erythematosus. It could Br Med J: first published as 10.1136/bmj.1.5902.283 on 16 February 1974. Downloaded from dermatitis herpetiformis improve with a gluten-free diet. This to the rare the provide answers to diseases ranging from leprosy is an uncommon disease but research has snowballed since halo naevus. discovery in 1966 that about 70% of patients have a jejunal mucosa similar to that of coeliac disease. Multiple small in- testinal biopsy specimens have shown that this enteropa.thy is General patchy, mostly affects the proximal small irntestine, and is present in nearly all patients. Pharmacology as applied to skin problems will also expand. The association of dermatitis herpetiformis wi-th thyro- Prostaglandins are beginning to emerge as importan-t in the toxicosis and pernicious anaemia prompted further immuno- skin, and trhe safety and uses of new vehicles, particularly dime- logical investigations. Raised IgA concentrations have been thyl-sulphoxide. urgen-tlv need study. Sun screens will halt the found in the serum and jejunal aspirates of patients. Nuclear, epidemic of skin cancer in sun worshippers and ouitdoor thyroid, and gastric autoantibodies oocur more often than in workers. If lotions are to be used, they must combine with the controls. Fixed IgA deposits in unaffected skin are a diagnostic hornv laver so that one or -two applications could cover a feature, and complemen.t (C 3) is found in the skin lesions. fortnight's holiday. Perhaps na;tural protective mechanisms will Circulating immune complexes are found in 80% of patient-s be mimicked. A suntan will be self-prescribed (using on a diet containing gluteni and in only 40% of those on a melanocy,te-stimulating substances) before holidays. gluten-free diet. The final explanation must relate gluten A greater understanding of the behaviour of normal skin is sensitivity ito the chain of events leading to a complement- essential. Ageing, with its atrophy, pruritus, and minor cos- dependent reaction in the dermal papillae. Circulating anti- metc problems causes much distress but gets little attention. reticulin antibodies have been found in 20% of patients, and To unders.tand cellular interactions in the skin all tissues must their cross-reaction with gluten helps to explain the localiza- be studied together. The lymphatics and peripheral nerves, tion of the skin lesions to that pant of the dermis-just deep and their role in the control of tissue behaviour in skin to the basal lamina-tich in reticular fibrils. disease, must be investigated. In.terdisciplinary reading and international meetings are first steps in ,this direction. Most dermatologists know little of current research on lymphatics Tumours or of -the Pavlovian concepts of neurovegative control so DNA popular in -the Russian literature. Already it is known that The role of the herpes virus in cervical canoer and of the control makes it easier to under- the autonomic nervous system may be linked wi-th repair in xeroderma pigmentosum of epidermal via the adenyl cyclase-cyclic AMP stand some aspects of cancer. There is also grea-t interest in turnover is system. This may be important in psoriasis. inmune responses -to tumours. The point of -this research into the mechanisms by reactions can be to encourage There must be further research to find out whether host changed which mental processes affect the skin. The placebo effect is tumour regression. Promising results after the immunotherapy other largely ignored but it can con-trol some skin diseases better of leukaemia suggest that this treament may help in is the least damaging and keratoacanthomas, than anv drug available at present. It conditions. It is a pity that viral warts of all therapeutic agents as it depends on, rather than inter- both self-limiting skin tumours, attract so little attention. of the T and B cell lymphocyte populations feres with, normal tissue behaviour. The detection Some diseases are due to a failure to remove micro-irritants is leading to a rational classification of the reticuloses. Mycosis increasing recognition http://www.bmj.com/ syndrome, seem to and ,to repair injurv. There will be an fungoides, and its rare cousin the Sezary that the skin is continually beint injured bv phvsical agents, be T-cell diseases. This might be important ,therapeautically as i Failure to of sub- ;nf'ction, and nervous and une phenomena. methods of causing systenmic depletion lymphocyte combat such insults results in disease. This is the Koebner populations are already being investiga-ted. Hodgkin's phenomenon in its broadest sense. For instance, multifactorial Slow motion epidemics, of the sort suggested for diseases, such as high blood pressure and psorisasis, may disease, will be detected only by advanced computer-record prevention is more im- out of date as are succeed a variety of stresses. Early linkage systems. Punch cards will become as portant than treatment in the later stages of a disease. names like pityriasis lichenoides et varioliformis acuta. on 2 October 2021 by guest. Protected copyright.

Genetic and Immunological Disorders Patient Care in the Future for will depend on new dis- There is a glimmer of hope in the rarer genetic disorders and Improved treatment patients on teaching of doctors and nurses; on closer t-he gap between -the clinical morphologist and biochemist is coveries; better its worth in co-operation between doctors, nurses, and the public; and on narrowing. Enzyme grafting has already shown Through renal transplants for Fabry's disease (a-galactosidase de- greater involvemennt and education of the public. fine organizations such as the Psoriasis Association the public are ficiency). Only the dermatologist can recognize the diseases which such single gene defects. becoming better informed than some doctors about clinical points distinguish must realize that if Histocompatibility artigens will be investigated in diseases which concern them. The Heal-th Service to vitiligo the public is to get the best from dermatology instruction is ranging from parapsoriasis and mycosis fungoides and, if advances in treatment and pemphigus. Immune responses to certain antigens are needed as much as treatment, are to be made, departments will have to be enlarged. controlled by immune-response determinants in or near the should of the chromosome. The Traditional care is no longer sufficient. Night beds major histocompatibility region who wish to continue to work by are becoming clearer-for example, be used more for those clinical implications -slowly day. Properly supervized nurses, technicians, and informed lay multiple sclerosis may resulit from an inherited immuno- skin diseases the incapable of eradicat- people could look after pa-tients wi.th (especially deficiency of T cells making patients Local authori-ties must pro- of skin diseases the elderly) in day-care oentres. ing an infectious agent. There are plenty work for whose dependence on are not known which are candidates for mech- vide alternative patients whose causes our of health care sort. national assisgtance shames programme anisms of this within the community. The outpatient treatment of psoriasis, research will increase. It has already suppor- Immunological pioneered in Leeds many years ago, has still not spread to ted the clinical distinction between dermatitis herpetiformis inertia rather than Few would have thought ten years ago that most centres. Clinical and administrative and pemphigoid. of research is now progress. circulating basement membrane antibodies would now be used a lack stopping