To our knowledge, this is only the second reported case of a double aortic arch being diagnosed in a patient following removal of an oesophageal foreign body.

We estimated the diagnostic skill of clinicians managing melanocytic skin naevi by measuring the percentage of malignant melanomas, premalignant and potentially malignant naevi, in 1896 excised melanocytic lesions submitted to a pathology service over 11 weeks. They comprised 8 per cent. The percentage increased with age: 4 per cent in the under‐40s, 17 per cent in those aged 40–59, and 30 per cent in those over 60, (P < 0.001, sex‐adjusted). Although the percentage was twice as high in males (11 per cent) as females (6 per cent), after adjustment for age the difference was not significant. Invasive melanomas, 3 per cent of the total, were similar: 1 per cent were from under‐40s; 7 per cent from those aged 40–59 years; and 14 per cent from those over 60. They comprised 4 per cent of lesions from males and 2 per cent from females. These trends may indicate poor specificity of clinical diagnosis, notwithstanding other reasons for removal of naevi (cosmetic), particularly among patients under 40, and females.

. A patchy distribution has been suggested as a partial explanation of this variation in incidence (Brow et al., 1971;Scott and Losowsky, 1975). It has also been proposed (Fry et al., 1972;Stevens et al., 1975) (1972; 1974) have used the increased interepithelial lymphocyte count as an index of mucosal abnormality.In studying the skin lesions of DH Pierard and Whimster (1961) laid down criteria which they considered characteristic of the disorder. Subsequent studies (Lever, 1965;Connor et al., 1972) suggested that these criteria, although characteristic of DH, were not in fact pathognomonic. Recent studies Seah and Fry, 1975) propose that the finding of IgA in the dermal papillae of unaffected skin is the simplest and most reliable way of establishing the diagnosis.In the light of these developments we reviewed 18Received for publication 17 March 1977 clinically diagnosed, dapsone-treated patients with DH. Having confirmed the diagnosis by finding IgA in the dermal papillae of unaffected skin in all patients we withdrew dapsone and examined by biopsy both the affected skin (on the reappearance of the rash) and the small bowel in each patient. The purpose of the study was to see whether there was a correlation between the severity of the lesions in the skin and in the small bowel mucosa. Patients and methods Eighteen patients (11 men, 7 women) aged from 17 to 73 years were studied. Their DH had initially been diagnosed on the appearance, site, and pruritic nature of the rash together with its response to dapsone. They had been treated for periods varying from three months to 16 years and all were on a normal diet.The period between withdrawal of dapsone and the appearance of the rash varied from four days to eight weeks. Tissue from maculopapular or vesicular skin lesions was taken for biopsy under local anaesthesia from the elbow region and processed for routine microscopy. Punch (4 mm) biopsy specimens of unaffected skin were taken under local anaesthesia from the extensor surface of the forearm distal to the elbow and at least 2 cm from the site of biopsy of affected skin. These specimens were snap frozen and examined by direct immunofluorescence using monospecific fluorescein isothiocyanate (FITC) conjugated anti-human IgG, IgM, and IgA. 976 on 11 May 2018 by guest. Protected by copyright.

Fig 1. Computed tomography with contrast imaging demonstrating a widened right Vidian canal (bone window, axial) and invasion of the floor of the sphenoid sinus by the larger right-sided juvenile nasopharyngeal angiofibroma (soft tissue window, coronal).

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