Skin diseases such as acne are sometimes thought of as unimportant, even trivial, when compared with diseases of other organ systems. To address this point directly, validated generic questionnaires were used to assess morbidity in acne patients and compare it with morbidity in patients with other chronic diseases. For 111 acne patients referred to a dermatologist, quality of life was measured using the Dermatology Life Quality Index, Rosenberg's measure of self-esteem, a version of the General Health Questionnaire (GHQ-28) and the Short Form 36 (SF-36). Clinical severity was measured using the Leeds Acne Grade. Population quality of life data for the SF-36 instrument were available from a random sample of adult local residents (n = 9334) some of whom reported a variety of long-standing disabling diseases. All quality of life instruments showed substantial deficits for acne patients that correlated with each other but not with clinically assessed acne severity. The acne patients (a relatively severely affected group) reported levels of social, psychological and emotional problems that were as great as those reported by patients with chronic disabling asthma, epilepsy, diabetes, back pain or arthritis. Acne is not a trivial disease in comparison with other chronic conditions. This should be recognized in the allocation of health care resources.

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SUMMARY.— A series of 104 cases of generalized pustular psoriasis has been studied. The syndrome occurs predominantly in the second half of life, affecting both sexes. Two quite distinct sub‐groups were discernible. In the first the pre‐pustular phase of psoriasis began early in life, was typical through‐out and was prolonged. At least one third of these cases were apparently precipitated by the withdrawal of systemic corticosteroid therapy. Others were provoked by pregnancy or infection. It is likely that this type is usually extraneously provoked. In the second, the psoriasis was of late onset and atypical, acral or flexural patterns predominating in the pre‐pustular phase. In these progress to generalized pustular disease was rapid and apparently spontaneous. Four clinical patterns of generalized pustular phase were apparent and have been named the Zumbusch, annular, localized and exanthematic types. The Zumbusch type was characterized by widespread fiery erythema, sheeted pustulation and scarlatiniform peeling, accompanied by malaise, fever and often leucocytosis. The annular type was a more low‐grade sub‐acute affection characterized by gyrate and annular pustular lesions and little systemic disturbance. The exanthematic type arose de novo, usually as a single short‐lived episode following infection or drug exposure. In the localized type restricted areas of pustular psoriasis developed in and around ordinary psoriatic plaques. Two thirds were erythrodermic at some stage and one third had polyarthritis. Oral lesions occurred in 5 and hypocalcaemia in 5 during pustular phases. The different clinical patterns of pustular psoriasis have been interpreted in terms of the balance between vascular hypertrophy, epidermopoiesis and leucocytic immigration into the epidermis.

A structured nurse-led patient concordance programme is effective in preventing venous leg ulcer recurrence and increasing the time patients spend with their legs elevated at heart level. Having both full ankle movement and full mobility reduces the risk of recurrence.

The use of maggots for wound debridement has a long history and has lately gained ground in several countries. We collected prospective data to examine the current use of larva therapy (LT) in the UK. Quantitative information was collected on 70 patients treated in nine hospitals. LT is used primarily to treat leg ulcers and generally involves three applications of larvae at two to three day intervals. This method is judged effective in wound debridement and promotes the growth of granulation tissue. Wound exudate, odour, infection and pain are all reduced by the treatment. Adverse reactions are infrequent but include pain, bleeding, pyrexia and influenza-like symptoms. Prevention of hospital admission and surgery, reduced need for antibiotics and reduced hospital stay are all identified as outcomes of LT. The nurse practitioners who used LT believed it to have an important role in wound management. A randomized clinical trial, comparing LT with other debriding agents, is required for evaluation of cost effectiveness.

Lymphatics are large vessels with a lumen potentially ten times wider than blood vessels and have a mean mesh diameter in the upper dermis of approximately 504 +/- 88 microns. The plexus lies just deep to the subpapillary venous plexus and when functioning well it is difficult to identify because of the attenuated endothelium and collapsed lumen. The role of the lymphatic as a pathway for the Langerhans cell and as an exit for macromolecules such as lipid and protein make it an essential organ for normal skin biology. When this system fails, impaired immunity, fibrosis, and recurrent infections are inevitable. Even vasculitis may be a consequence of failure of clearance of immune complexes from the interstitium. The adipose tissue and deep dermis are especially vulnerable in this respect. Elastin fibers support cutaneous lymphatics and may be low resistance pathways through the connective tissues into the lymphatic. Identification of lymphatics by special markers is a concept that currently fails to take into account that changing roles in disease may be associated with a change in the specificity of markers. The anatomy of lymphatic vessels in the skin is described and the role of the lymphatic is emphasized.

A retrospective review of patch test results from all new patients with venous leg ulcers was performed for the preceding 11 months. Eighty one patients referred from general practitioners and district nurses with venous stasis ulcers were included. Positive patch tests were found in 54 patients (67%), including a continued high incidence of allergy to lanolin and topical antibiotics. Multiple allergies were found in 48 patients (58%). In addition, a new problem of allergy to cetearyl alcohol, a constituent of commonly used creams and paste bandages, was identified in 13 patients. There is a continuing high incidence of contact sensitivity in patients with venous stasis ulcers which has important implications for the management of these patients.

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