Serological response to syphilis treatment in HIV-positive and HIV-negative patients attending sexually transmitted diseases clinics

BACKGROUND: HIV-positive patients treated for syphilis may be at increased risk for serological failure. OBJECTIVE: To compare follow-up serologies and serological responses to treatment between HIV-positive and HIV-negative patients attending two sexually transmitted disease (STD) clinics. STUDY DESIGN: Existing records were reviewed from HIV-positive patients who were diagnosed and treated for syphilis at the public STD clinics in Baltimore, Maryland, USA, between 1992 and 2000. Results of their serological follow-up were compared with those of HIV-negative clinic patients at the time of syphilis treatment. Failure was defined as lack of a fourfold drop in rapid plasma reagin (RPR) titre by 400 days after treatment or a fourfold increased titre between 30 and 400 days. RESULTS: Of the 450 HIV-positive patients with syphilis, 288 (64%) did not have documented follow-up serologies and 129 (28.5%) met the inclusion criteria; 168 (17%) of 1000 known HIV-negative patients were similarly eligible. There were 22 failures in the HIV-positive group and 5 in the HIV-negative group (p<0.001). The median times to successful serological responses in both groups were 278 (95% confidence interval (CI) 209 to 350) and 126 (95% CI 108 to 157) days, respectively (p<0.001). A multivariate Cox's proportional hazards model showed an increased risk of serological failure among the HIV-positive patients (hazards ratio 6.0, 95% CI 1.5 to 23.9; p = 0.01). CONCLUSION: HIV-positive patients treated for syphilis may be at higher risk of serological failure. Despite recommendations for more frequent serological follow-up, most patients did not have documentation of serological response after standard treatment for syphilis.     

Prevalence of human immunodeficiency virus in the patient population of a sexually transmitted disease clinic. Association with syphilis and gonorrhea.

An unlinked seroprevalence survey of human immunodeficiency virus (HIV) antibody was conducted using stored sera from all patients who attended the sexually transmitted disease (STD) clinic in Halifax, Nova Scotia between 1980 and 1986. None of the sera collected from 584 patients during 1980 were HIV positive. Of the 2867 patients who visited the clinic between 1981 and 1986, 27 (0.9%; 95% CI 0.6% to 1.2%) had the antibody. None of the 784 female patients were HIV seropositive. Of the 1,884 heterosexual men in the study, 5 (0.3%; 95% CI 0.1% to 0.5%) were HIV seropositive, and 22 (11.1%; 95% CI 6.7% to 15.5%) of the 199 homosexual men were HIV seropositive. There was a strong association between a history of syphilis and HIV antibody among heterosexual men (OR = 76.8; 95% CI 12.0 to 491.3; P = 0.001). Among homosexual men younger than 30 years of age, HIV infection was associated with a history of syphilis (OR = 18.2; 95% CI 5.1 to 64.7; P = 0.035) and a history of gonorrhea (OR = 8.2; 95% CI 4.2 to 16.0; P = 0.001). The association between a history of gonorrhea and HIV infection was strongest among homosexual men who had three or more sexual partners in the last month. These findings supplement existing evidence that STDs increase the likelihood of HIV transmission.     

Post-kala-azar dermal leishmaniasis in the Sudan: clinical presentation and differential diagnosis

Post-kala-azar dermal leishmaniasis (PKDL) is a common complication following kala-azar (visceral leishmaniasis). In a prospective study in a village in the endemic area for kala-azar in the Sudan, 105 of 183 (57%) kala-azar patients developed PKDL. There was a significantly higher PKDL rate (69%) in those who received inadequate and irregular treatment of kala-azar than in those who were treated with stibogluconate 20 mg kg-1 daily for 15 days (35%). The group of patients who developed PKDL did not differ from those who did not develop PKDL with regard to age and sex distribution, reduction in spleen size, and conversion in the leishmanin skin test (LST). In a clinical study, 416 PKDL patients were analysed and divided according to grade of severity. Severe PKDL was more frequent in younger age groups (P < 0.001); there was an inverse correlation between grade and conversion in the LST (P < 0.01). In 16% of patients tested, parasites were demonstrated in inguinal lymph node or bone marrow aspirates, indicating still visceral disease (para-kala-azar dermal leishmaniasis); there was no correlation between the presence of parasites and grade of severity. Conversion rates in the LST were lower than in those who did not have demonstrable parasites (11% and 37%, respectively; P < 0.01). In the absence of reliable and practical diagnostic tests, PKDL may be diagnosed on clinical grounds and differentiated from other conditions, of which miliaria rubra was the most common. Differentiation from leprosy was most difficult.     

Rescreening for gonorrhea and chlamydial infection through the mail: a randomized trial

BACKGROUND: Rescreening patients after treatment of Chlamydia trachomatis or Neisseria gonorrhoeae infection has had high yield but low rates of participation. GOAL: The goal of this study was to determine if rescreening for gonorrhea and chlamydial infection in a largely urban sexually transmitted disease population would be more successful if individuals were given the option of submitting a specimen for testing through the mail. STUDY DESIGN: We conducted a randomized clinical trial involving 122 patients of whom 62 were assigned to clinic rescreening and 60 were given the option of either mailing a specimen for testing or going to a clinic for rescreening. RESULTS: Twenty-seven patients (45%) given the option of either rescreening in the clinic or through the mail and 20 (32%) assigned to clinic rescreening were rescreened within 28 days of enrollment in the study (odds ratio, 1.7; 95% confidence interval, 0.8-3.8). Of the 60 patients randomized to the clinic rescreening or mailing option, 11 of 18 (61%) who opted to mail in a specimen and 16 of 42 (38%) who chose clinic rescreening were rescreened within 28 days of enrollment (P = 0.10). CONCLUSIONS: Although not statistically significant, this study indicates that mailed rescreening could be a successful method to increase rescreening rates.     

Effect of monochromatic excimer light on palmoplantar pustulosis: A clinical study performed in a private clinic by a dermatological specialist

Palmoplantar pustulosis (PPP) is currently treated with various modalities, including excimer light, a form of ultraviolet lamp. This study reports effect of excimer light treatment in 34 Japanese PPP patients treated at a private clinic by one doctor, who was certified as a dermatological specialist by the Japanese Dermatological Association. The statistical analyses were performed upon a collaborative basis with faculties in universities. Disease response scores were determined by response to excimer light treatment. Scores of 1, 2, 3 or 4 were assigned to patients whose palmoplantar pustular psoriasis area and severity index (PPPASI) decreased to 25% or less, 25.1–50%, 50.1–75% or more than 75.1% of pretreatment PPPASI, respectively. In this study, 44.1% PPP cases had scores of 1 or 2, and considered good responders to excimer light treatment. There were no statistical differences between males and females, and between older (≥40 years) and younger groups (≤39 years) in terms of disease response score. Disease duration did not show any significant difference among these scores. Treatment times, total amount of ultraviolet and total treatment duration showed significant differences between score 1 and score 4 groups (P = 0.0164, =0.0137 and =0.0267, respectively). Particular interest was paid to smoking habits. Smoking in male patients was significantly higher than that in female patients (P = 0.0169). There was no statistical difference between smokers and non‐smokers in terms of response to excimer light. In conclusion, this study suggested that excimer light is useful for both initial regimen and suppression of exacerbation in treatments of PPP.     

Sentinel lymph node biopsy for evaluation and treatment of patients with Merkel cell carcinoma: The Dana-Farber experience and meta-analysis of the literature

OBJECTIVE: To determine the diagnostic accuracy and usefulness of sentinel lymph node biopsy (SLNB) and computed tomographic scans in the initial evaluation and treatment of patients with Merkel cell carcinoma (MCC). DESIGN: Single-institution case series and literature-based case-level meta-analysis. SETTING: Academic cutaneous oncology clinic.Patients Sixty-one adults with biopsy-proven MCC (30 who had undergone SLNB) plus 92 cases from the literature of patients who had undergone SLNB. MAIN OUTCOME MEASURES: Relapse-free survival. RESULTS: In 122 patients with no nodal disease found by physical examination, SLNB findings revealed nodal involvement in 39 cases (32%). At 3 years, the recurrence rate for those with a positive SLNB was 3 times (60%) higher than for those with a negative SLNB (20%; P = .03). Patients with a positive SLNB who received adjuvant nodal therapy had a relapse-free survival rate of 51% at 3 years (n = 26) compared with 0% for patients who did not receive nodal therapy (n = 3; P < .01). In contrast, among patients with a negative SLNB there was no significant difference in 3-year relapse-free survival rates for those who did (90%; n = 24) or did not (70%; n = 19; P = .26) receive adjuvant nodal therapy. Using SLNB plus clinical follow-up as a gold standard, computed tomographic scans had low sensitivity (20%) for detecting MCC that had spread to the lymph node basin and low specificity for distant disease (only 4 of 21 "positive" scans were confirmed during 6 months of follow-up). CONCLUSIONS: Sentinel lymph node biopsy detects MCC spread in one third of patients whose tumors would have otherwise been clinically and radiologically understaged and who may not have received treatment to the involved node bed. There was a significant benefit of adjuvant nodal therapy, but only when the SLNB was positive. Thus, SLNB is important for both prognosis and therapy and should be performed routinely for patients with MCC. In contrast, computed tomographic scans have poor sensitivity in detecting nodal disease as well as poor specificity in detecting distant disease.     

Histoid leprosy: a retrospective study of 40 cases from India

Background Rare variants of leprosy pose a diagnostic challenge even to astute clinicians and histoid leprosy is one such form of disease with unique clinical and histopathological features. There are very few large series on this entity, mainly reported from India. Objectives To study the epidemiological and clinical characteristics of patients with histoid leprosy. Methods We undertook this retrospective study including patients registered with the leprosy clinic of our tertiary care referral centre from January 1991 to December 2006. Data regarding demographic details, clinical features, treatment, complications and course following treatment were extracted from the records of the leprosy clinic. Results The incidence of histoid leprosy among the registered patients of our clinic was 1·8% (40 of 2150). There was a significant male preponderance with a male/female ratio of 5·7 : 1. The anatomical areas of involvement were thighs/buttocks (67·5%), arms (62·5%), back (52·5%), face (47·5%), forearms (47·5%) and legs (35%) in descending order of frequency. This variety of leprosy was found most commonly in patients with a primary diagnosis of lepromatous leprosy (40%). De novo histoid lesions, i.e. lesions of histoid leprosy developing without evidence of lesions of other types of leprosy in the Ridley–Jopling classification, appeared in 12·5% of patients only. Only three patients had received antileprosy treatment before presentation. Episodes of erythema nodosum leprosum (ENL) had occurred in 40% of patients, although only one patient manifested ENL after the diagnosis of histoid leprosy. The disease responded satisfactorily to the respective World Health Organization multidrug therapy regimens in all except in one patient who relapsed with borderline lepromatous leprosy. Conclusions As the bacillary load is very high in these patients, they can form a potential reservoir of the infection in the community especially in the postleprosy elimination era. Contrary to the earlier belief in the dapsone era, most of our patients manifested disease without any history of inadequate or incomplete antileprosy therapy.     

Nicorandil: do the dermatological and gastrointestinal risks outweigh the benefits?

Background Nicorandil has been available in the U.K. since 1994 for the prophylaxis and treatment of angina. Since the first reported case of nicorandil‐associated oral ulceration in 1997 complications elsewhere in the gastrointestinal tract have been reported. Objectives Our case series highlights this serious drug complication. Methods We reviewed the records of all patients referred to our specialist stoma dermatology clinic who had stoma surgery for diverticular disease and all patients referred with persistent parastomal or perianal ulceration that was not attributable to Crohn’s disease or pyoderma gangrenosum. Patient demographics, nicorandil ingestion, bowel involvement, stoma type, cutaneous ulceration and outcome were recorded. Results A total of 36 patients had stoma surgery performed as a consequence of diverticular disease. The proportion of patients taking nicorandil (in all cases at a dose of 40 mg or more daily) was one third, higher than expected. There was a higher incidence of enteric fistula formation and bowel perforation among those taking nicorandil, 92% (11/12) and 50% (6/12), respectively, compared with those not on the drug, 0% and 21% (5/24), respectively. In addition, parastomal ulceration was seen more often in those taking nicorandil, 100% (12/12), compared with those not, 8% (2/24). Even without a history of diverticular disease we observed a high incidence of bowel perforation and parastomal and/or perianal ulceration among patients taking nicorandil. In the vast majority of cases ulceration healed upon cessation of nicorandil. Conclusions For those with diverticular disease taking nicorandil is strongly associated with fistula formation or bowel perforation; as such the risk‐benefit equation for nicorandil needs careful consideration given that other nitrates are available.     

Screening HIV-infected women for cervical cancer in Thailand: findings from a demonstration project

OBJECTIVES: Although cervical cancer is an AIDS-defining illness, few HIV-infected women are routinely screened for cervical cancer in Thailand. We screened HIV-infected women for cervical cancer as a component of HIV care and assessed high-risk human papillomavirus (HPV) and cervical cancer prevalence. METHODS: From July 2003 through February 2004, HIV-infected women attending either an infectious disease clinic or a sexually transmitted infection (STI) clinic in Bangkok were tested for high-risk HPV types by Hybrid Capture 2 and screened for cervical cancer by Pap test; those with abnormal cervical cytology were referred for diagnosis and treatment. RESULTS: Two hundred ten HIV-infected women at an infectious disease clinic (n = 150) and an STI clinic (n = 60) received cervical cancer screening. The high-risk HPV prevalence was 38.6% and the prevalence of abnormal cervical cytology was 20.4%. Abnormal cervical cytology and high-risk HPV detection were associated (P < 0.001). We received pathology reports for 23 (53.5%) of 43 women, including all those with a Pap test showing high-grade squamous intraepithelial lesions; the cervical cancer prevalence was 1.9% (4 of 210; 95% confidence interval, 0.5-4.8%). CONCLUSION: The estimated prevalence of high-risk HPV and cervical cancer among HIV-infected women in Thailand was high. This emphasizes the need to integrate cervical cancer screening into HIV care.     

Chlamydial genital infection in Ibadan, Nigeria. A seroepidemiological survey.

Sera from patients attending a sexually transmitted diseases (STD) clinic, a family planning clinic, and an antenatal clinic in Ibadan, Nigeria, as well as from male blood donors from the same area were tested for the presence of type specific antichlamydial antibodies using a modified micro-immunofluorescence test. Among men and women attending the STD clinic the exposure rates to Chlamydia trachomatis serotypes D to K (genital pathogens) were 18.7% and 26.7% respectively. Antibody titres suggesting active disease in these men and women were found in 11.8% and 22.7% respectively. The highest rate of exposure (35%) was among women attending the family planning clinic; of these women 25% had antibody suggesting active disease. Titres of IgG antibody in this study were similar to those found among men and women with chlamydial genital infections in the United Kingdom. Antibodies to serotypes D to K were also detected in 10.3% of women attending an antenatal clinic and in 9.9% of male blood donors. The prevalence of antibodies to C trachomatis serotypes A to C and lymphogranuloma venereum serotypes was low. These results suggest that the prevalence of chlamydial genital infections in Ibadan, both among STD patients and especially among those individuals not seeking treatment (family planning and antenatal clinic patients), is high. Since serious sequelae can follow chlamydial genital infections it is imperative to carry out further investigations in this area.     

Carbon dioxide laser for the treatment of lupoid cutaneous leishmaniasis (LCL): a case series of 24 patients

We report the use of a carbon dioxide laser to vaporize local cutaneous leishmaniasis. We used CO2 laser for the treatment of 24 patients with lupoid cutaneous leishmaniasis in Isfahan. We identified 24 patients with lupoid cutaneous leishmaniasis (LCL) for evaluation. All of the patients had clinical signs of LCL and had the lesion for more than 1 year. LCL diagnosis was confirmed by both direct smear and biopsy. The efficacy of laser was determined on the basis of cure and lack of relapse after 1 year. Treatment was performed using a CO2 laser (Lasersonic LS500 machine). The maximum power was 100 Watts and the pulse width was 0.5-5 seconds. There were 21 patients, 13 females and 8 males, who were treated and followed for 1 year. Mean duration of the lesions was 4.1+/- 3.9 years. The treatment was well tolerated and complications were minimal, and included pain, xerosis, and mild erythema. Of these patients, 19 were disease free (90.47 % efficacy based on clinic and laboratory). Only 2 patients were treatment failures (9.5 %). Our results indicate that CO2 laser radiation is highly effective for treatment of lupoid cutaneous leishmaniasis.     

Behavioural and demographic characteristics of attenders at two genitourinary medicine clinics in England.

OBJECTIVES: To investigate how attenders with sexually transmitted disease (STD) differ from the general population with respect to sexual behaviour, and to identify which attenders at genitourinary medicine (GUM) clinics are at particular behavioural risk for acquiring STD. DESIGN: Multicentre cross sectional survey. SETTING: Two genitourinary medicine clinics, one in London and one in Sheffield SUBJECTS: 20,516 patients attending the two clinics over an 18 month period. MAIN OUTCOME MEASURES: Behavioural and demographic characteristics and clinical diagnoses were recorded for each patient. RESULTS: 8862 patients, in whom 12,506 diagnoses were made, were seen in the Sheffield clinic, and 11,654 patients, in whom 20,243 diagnoses were made, were seen in the London clinic. When compared with the reported results from a general population survey, there were higher proportions of clinic attenders reporting two or more sexual partners in the preceding 12 months (p < 0.001), and a higher proportion of males reporting homosexual contact (13% compared with 1%, p < 0.001). Only age and number of sexual partners in the past 12 months were significantly associated with acute STDs for each sex in each clinic. Acute STDs tended to occur with greater frequency in the younger age groups, peaking among 16-19 year olds, particularly among females. CONCLUSIONS: The results have confirmed that patients with STDs exhibit higher risk sexual behaviour than the general population, and have highlighted the problem of continuing high risk behaviour among younger attenders, particularly younger homosexual men. This study has demonstrated that among GUM clinic attenders age and number of sexual partners are key risk factors for the acquisition of an acute STD. The results of this survey also indicate, however, that half of the females and more than one quarter of males with acute STDs reported only one sexual partner in the past 12 months, suggesting that health education messages should point out that it is not only those who have multiple recent sexual partners, or who have recently changed sexual partner, that are at risk of STD, including HIV.     

Chlamydia trachomatis in women attending a gynaecological outpatient clinic with lower genital tract infection

In a study of 3794 consecutive women attending a gynaecological outpatient clinic with symptoms of lower genital tract infection (LGTI) 350 (9.2%) harboured Chlamydia trachomatis and 83 (2.2%) Neisseria gonorrhoeae. One hundred and ninety-five patients who were later found to have acute salpingitis and 109 other women in whom the chlamydial cultures were spoiled were excluded from the series. Of the remaining 3490 women, 281 were infected with C trachomatis, 42 with N gonorrhoeae, and 17 with both. Of the 3150 women who were infected with neither organism, 146 were randomly selected as controls. The chlamydia-positive patients were younger (P less than 0.001), did not complain of pelvic discomfort or pain (P less than 0.01), and used oral contraceptives (P less than 0.001) more frequently than did the controls; intrauterine devices were used more often (P less than 0.01) by the controls. Increased vaginal discharge was reported significantly more often in chlamydia-positive patients than in the controls (P less than 0.05). Of 266 women harbouring C trachomatis the organism was still present in 22 (8.3%) when they were followed up from two to more than eight weeks after finishing treatment with doxycycline. Of 91 male consorts of chlamydia-positive women, 53 (58.2%) were infected with C trachomatis.     

Chlamydia trachomatis in women attending a gynaecological outpatient clinic with lower genital tract infection.

In a study of 3794 consecutive women attending a gynaecological outpatient clinic with symptoms of lower genital tract infection (LGTI) 350 (9.2%) harboured Chlamydia trachomatis and 83 (2.2%) Neisseria gonorrhoeae. One hundred and ninety-five patients who were later found to have acute salpingitis and 109 other women in whom the chlamydial cultures were spoiled were excluded from the series. Of the remaining 3490 women, 281 were infected with C trachomatis, 42 with N gonorrhoeae, and 17 with both. Of the 3150 women who were infected with neither organism, 146 were randomly selected as controls. The chlamydia-positive patients were younger (P less than 0.001), did not complain of pelvic discomfort or pain (P less than 0.01), and used oral contraceptives (P less than 0.001) more frequently than did the controls; intrauterine devices were used more often (P less than 0.01) by the controls. Increased vaginal discharge was reported significantly more often in chlamydia-positive patients than in the controls (P less than 0.05). Of 266 women harbouring C trachomatis the organism was still present in 22 (8.3%) when they were followed up from two to more than eight weeks after finishing treatment with doxycycline. Of 91 male consorts of chlamydia-positive women, 53 (58.2%) were infected with C trachomatis.     

HIV prevalence in patients with sexually transmitted diseases in Yaounde, (Cameroon) in 1989 and 1990: necessity of an STD control programme.

OBJECTIVE--To monitor HIV seroprevalence among STD clinic attenders as part of a sentinel surveillance programme. DESIGN--Seroepidemiological survey on randomly selected patients. SETTING--"Elig Essono" STD clinic, Yaounde; from February 1989 to December 1990. PATIENTS--1161 randomly selected patients. MAIN OUTCOME MEASURES--HIV and syphilis seroprevalence. RESULTS--Twenty six of the 1161 patients (2.4%; CI: 95%; 1.5%-3.3%) tested were found to be HIV positive (mostly due to HIV1); 35.4% had antibodies to Treponema pallidum. There was no association between HIV seropositivity and sex, marital status, or educational level. Genital ulcer disease did not correlate with HIV seroprevalence. However, patients with a positive serological test for T pallidum were more likely to have HIV infection (rr = 2.4; 95% CI; from 1.1 to 3.0). Results from 1990 were double those of 1989 (3.3% versus 1.6%, p = 0.02). CONCLUSIONS--Compared with the findings among the same groups in metropolitan areas of various other African countries, the HIV seroprevalence is still low; this could be due to many reasons, such as the recent introduction of the virus in the country, a different spectrum of STDs, the high level of circumcision of males. HIV infection trends should continue to be monitored among risk groups such as STD patients and control programmes implemented to reduce the rapid spread of AIDS in the country.     

Dexamethasone - Cyclophosphamide pulse (DCP) therapy in Pemphigus

Of the 37 patients enrolled for this treatment, 13 have been lost to follow up and 4 have died. Of the remaining 20, 8 are already in remission (40%), while 12 are still having active disease. Of the 8 patients who are now in remission, 1 is in phase II and taking monthly dexamethasone cyclophosphamide pulse and 50 mg cyclophosphamide daily while in 3 patients all the treatment has already been withdrawn (phase IV). All these patients are being followed up for any recurrence. The duration of remission has been more than 6 months in 7 patients (maximum 2 years). The chief side-effect observed was increased susceptibility to pyogenic and candidal infections of the skin and oral mucosa respectively. The other side-effects noted were generalized weakness and lethargy following DCP (1), irregular menstrual periods (1), amenorrhoea (1), general darkening of complexion (1), steroid psychosis (1), transient eosinophilia (1) and marked transient oligospermia.     

The psychosocial impact of testing individuals with no history of genital herpes for herpes simplex virus type 2

BACKGROUND: Although approximately 20% of the population has a genital herpes (HSV-2) infection, 80% of these infections are unrecognized or asymptomatic. Serologic identification of HSV-2 leads to recognition of infection, which could lead to behavioral changes that reduce transmission. However, there has been concern that HSV-2 testing among persons without symptoms will cause substantial psychosocial harm. GOAL: The goal of this study was to assess the psychosocial impact of an HSV-2 diagnosis among individuals without a history of genital herpes attending a sexually transmitted disease (STD) clinic. STUDY: We conducted a cohort study of persons with no history of genital herpes attending an STD clinic and seeking herpes testing. Two follow-up interviews were conducted 1 week and 3 months after persons received their test results. Serum was tested using HerpeSelect 2. Psychosocial morbidity was assessed at baseline and each follow up using a mental health score, sexual attitude score, and perception of genital herpes score. RESULTS: Twenty-one percent (41 of 196) of participants tested positive for HSV-2 antibody. Among patients who were HSV-2-positive, there was no significant change in mental health score from baseline during either follow-up visit, nor was there any difference compared with persons who were HSV-2-negative. Patients who were HSV-2-positive did have a decline (P = 0.01) in their sexual attitude scores at the 1-week follow up compared with persons who were HSV-2-negative, indicating a decrease in positive sexual attitude, but this difference no longer remained at the 3-month follow up (P = 0.74). Patients who were HSV-2-positive viewed having genital herpes as significantly less traumatic than patients who were HSV-2-negative at both follow-up visits (P <0.01). CONCLUSION: There was no apparent lasting adverse psychosocial impact of detecting HSV-2 infection among individuals without a history of genital herpes seeking herpes testing at an STD clinic.     

The use of complementary medicine in children with atopic dermatitis in secondary care in Leicester

BACKGROUND: The use of 'complementary' or 'alternative' medicine continues to rise in patients with skin disease, especially in those with chronic, inflammatory dermatoses. OBJECTIVES: To qualify and quantify the usage of complementary medicine (CM) in children with atopic dermatitis (AD) in secondary care. METHODS: A face-to-face structured questionnaire study of 100 consecutive children with AD and their parent or guardian. RESULTS: The mean age of the children interviewed was 7.3 years (median age 6.0 years, range 0.6-17.1) and ethnic origin was 59% white, 35% Indian, 3% Afro-Caribbean and 3% mixed race. Forty-six of 100 patients (46%) had used, or were currently using, CM. Of the 54 patients who had not yet used CM, 17 of 54 (31%) said they intended to try this in the future. The most commonly used CM was Chinese herbal medicine by 20 of 46 patients (43% of those who had used CM), followed by herbal medicine (41%) and homeopathy (35%). Of 74 patients using CM, 26 (35%) felt their AD had improved while 39 of 74 (53%) reported that it had remained unchanged. Twenty-six of 46 (56%) CM users in this study would not recommend CM to other patients with AD. There was a strong association between the use of CM and ethnicity (P = 0.01). Half of the patients who had used CM (23 of 46) had used it on the recommendation of family or friends with skin disease, 17 of 46 (37%) from family or friends without skin disease and three of 46 (6%) each from health professionals or from the media or internet. Twenty-five of 46 (54%) of CM users did so because conventional treatment was not working, and eight of 46 (17%) because they were worried about the side-effects of conventional treatment. While 39 of 100 (39%) of all patients felt that CM was safer than conventional medicine, only 14 of 100 felt it was more efficacious. Fifty-one of 100 were happy to combine both types of treatment and 66 of 100 felt that CM should be available from the National Health Service. CONCLUSIONS: In a population of children with AD attending a teaching hospital clinic in Leicester, U.K., 63% use or intend to use CM. This use is associated with ethnicity.     

Potential psychological benefits from early treatment of port-wine stains in children

There is a commonly held conception among referring doctors that very small children with congenital capillary malformations, so-called port-wine stains (PWS), should not be treated until they are older. Our experience leads us to believe that the flashlamp pulsed dye laser is a safe and effective treatment even for infants. We have not encountered any persistent pigmentation changes, post-treatment scarring or other adverse effects. It is important to quantify the psychological disabilities associated with this disorder to assess the need for and the benefits of treatment. Questionnaires were distributed to 259 patients and their families who visited our clinic because of their PWS. Patients who were on the waiting list for laser treatment, undergoing treatment or had completed their treatment received different questionnaires. The response rate was 89%. High emotional distress was encountered. During the age period 10–20 years, 73% (125 patients) were most disturbed by their PWS. That the PWS influenced their life negatively was experienced by 75% (171 patients), and 62% (106 patients) were convinced that their life would change radically if their PWS could be eliminated. Suffering from low self-esteem (in comparison with the same age group) was reported by 47% (87 patients). The PWS made their school life and education more difficult according to 28% (51 patients) of the sample. Of the families of patients, 76% (106 relatives) considered the patient to be negatively affected in some way by the PWS. After the laser treatment, all of these distress parameters were significantly relieved, together with a need to cover their PWS, their fear of going into conflict or quarrels, their social relationships, problems with the opposite sex, rage attacks, depressions and abnormal reactions from their peers. We believe there is potential psychological benefit in starting the treatments of PWS (including non-facial) at as early an age as possible.