Correspondence 1567
2
3
4
5
6
7
8
9
10
MP, eds), 2006. Available at: http://www.ncbi.nlm.nih.gov/ books/NBK1280/ (last accessed 21 October 2014). Eliason MJ, Leachman SA, Feng BJ et al. A review of the clinical phenotype of 254 patients with genetically confirmed pachyonychia congenita. J Am Acad Dermatol 2012; 67:680–6. Leachman SA, Kaspar RL, Fleckman P et al. Clinical and pathological features of pachyonychia congenita. J Investig Dermatol Symp Proc 2005; 10:3–17. Wilson NJ, Leachman SA, Hansen CD et al. A large mutational study in pachyonychia congenita. J Invest Dermatol 2011; 131:1018– 24. McLean WH, Hansen CD, Eliason MJ et al. The phenotypic and molecular genetic features of pachyonychia congenita. J Invest Dermatol 2011; 131:1015–17. Covello SP, Smith FJ, Sillevis Smitt JH et al. Keratin 17 mutations cause either steatocystoma multiplex or pachyonychia congenita type 2. Br J Dermatol 1998; 139:475–80. Cogulu O, Onay H, Aykut A et al. Pachyonychia congenita type 2, N92S mutation of keratin 17 gene: clinical features, mutation analysis and pathological view. Eur J Pediatr 2009; 168:1269–72. Feng YG, Xiao SX, Ren XR et al. Keratin 17 mutation in pachyonychia congenita type 2 with early onset sebaceous cysts. Br J Dermatol 2003; 148:452–5. Smith FJ, Corden LD, Rugg EL et al. Missense mutations in keratin 17 cause either pachyonychia congenita type 2 or a phenotype resembling steatocystoma multiplex. J Invest Dermatol 1997; 108:220–3. Kanda M, Natsuga K, Nishie W et al. Morphological and genetic analysis of steatocystoma multiplex in an Asian family with pachyonychia congenita type 2 harbouring a KRT17 missense mutation. Br J Dermatol 2009; 160:465–8.
Funding sources: none. Conflicts of interest: none declared.
Sunscreen adherence: proffer patient preference DOI: 10.1111/bjd.13136 DEAR EDITOR, Sattler et al.’s1 paper exploring the factors underlying the lack of patient adherence to sun protective measures, overlooks a potentially critical facet, that of patient preference. Shared decision-making and the promotion of patient choice are requisite to good practice, as discussed in a recent Editorial2 and stipulated in the U.K. Dermatology Specialty Training Curriculum.3 This is perhaps best illustrated in dermatology in the realm of emollients, where patient concordance with prescribed therapy is greater when patients are encouraged to select the emollient of their choice, with patients often preferring lighter cream-based emollients to greasier ointments.4 While previous work suggests that 81% of patients would prefer an emollient of their choosing over their currently prescribed medication, the majority (72%) had never been asked which emollient they would like to use.5 Shared decisionmaking mandates that patients are equipped with the resources
© 2014 British Association of Dermatologists
necessary to make informed choices. In the case of emollients or sunscreens, this can be readily facilitated by providing patients with small samples of various topical agents in the clinic. Patient preferences can be extrapolated to other domains of therapy, such as choosing systemic medications, which, albeit, may require additional time for patients to be taught about the available options and to read information sheets, before arriving at a measured decision. Where practical and possible, physicians should account for patient preference in the prescription of treatments: a marginally increased cost accounting for such choice may offset some of the apparent lack of adherence to therapy and the burden of wasted medications.
Dermatology Centre, University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M6 8HD, U.K. E-mail: [email protected]
F.R. ALI A. ASLAM J.T. LEAR
References 1 Sattler U, Thellier S, Sibaud V et al. Factors associated with sun protection compliance: results from a nationwide cross-sectional evaluation of 2215 patients from a dermatological consultation. Br J Dermatol 2014; 170:1327–35. 2 Anstey A, Edwards A. Shared decision making in dermatology: asking patients, ‘What is important to you?’. Br J Dermatol 2014; 170:759–60. 3 Joint Royal Colleges of Physicians Training Board. Specialty Training Curriculum for Dermatology. August 2010 (Amended August 2012). Available at: http://www.jrcptb.org.uk/trainingandcert/ST3-SpR/ Documents/2010%20Dermatology%20Curriculum%20(AMENDME NTS%202012).pdf (last accessed 26 April 2014). 4 Holden C, English J, Hoare C et al. Advised best practice for the use of emollients in eczema and other dry skin conditions. J Dermatolog Treat 2002; 13:103–6. 5 Aslam A. Children’s preference in selecting an emollient of their choice. Br J Dermatol 2009; 161 (Suppl. 1):116. Funding sources: No external funding. Conflicts of interest: J.T.L. has accepted honoraria for speaking at meetings, by Leo, Galderma, Almirall, Astellas and GSK.
Two cases of bilateral earlobe cutaneous pseudolymphoma DOI: 10.1111/bjd.13145 DEAR EDITOR, Allergic contact dermatitis to metals including gold is well recognized; however, pseudolymphoma reactions remain rare, with only a small number of cases reported in the literature. Cutaneous pseudolymphoma, also known as cutaneous lymBritish Journal of Dermatology (2014) 171, pp1555–1608
1568 Correspondence
phoid hyperplasia, is characterized by an inflammatory response to a known or unknown stimulus resulting in a benign lymphoid infiltrate that resembles cutaneous lymphoma clinically and histologically.1 These reactions can be idiopathic or secondary to stimuli including drugs, trauma, insect bites, cowpox vaccinations and contact dermatitis. They can be classified according to the predominant cell-type infiltrate: T cell, B cell or mixed.2 Cutaneous T-cell pseudolymphomas are rare and result in a band-like pattern of infiltrate across the upper dermis similar to that seen in mycosis fungoides.2 A subset of cutaneous T-cell pseudolymphomas is associated with CD30-positive cells and linked mainly with viral infections and even drugs.2 They are often caused by antiepileptic drugs and also include solitary T-cell pseudolymphoma, lymphomatoid contact dermatitis and actinic reticuloid (chronic actinic dermatitis).2 Cutaneous B-cell pseudolymphomas are slightly more frequent than cutaneous T-cell
(a)
pseudolymphomas; however, the exact incidence is unknown. They cause a nodular or diffuse distribution of lymphocyte infiltrate admixed with histiocytes, eosinophils and plasma cells. Idiopathic lymphocytoma cutis, persistent reactions to arthropod bites, and postinjection or tattoo-induced pseudolymphomas are examples. Most cases are idiopathic; however, Borrelia burgdorferi infection is a frequent cause in endemic areas.2 Mixed-pattern pseudolymphoma causes a perivascular and nodular pattern of infiltrate and consists of a mixture of T and B cells.2 Pseudolymphoma of the earlobes due to ear piercing was first described by Zilinsky et al. in 1989.3 Herein we present two cases of bilateral pseudolymphoma of the earlobes secondary to metallic ear piercing. Case 1 is a 54-year-old woman who presented with a 4year history of nodular infiltrated dusky earlobes following ear piercing (Fig. 1a). Episodically these lesions would
(b)
(c)
(e)
(d)
Fig 1. Case 1 demonstrates nodular inflammatory infiltrate of the earlobe (a). Histology shows extension from dermis to subcutis (b) with a mixed cellular infiltrate of lymphocytes, plasma cells and eosinophils (c), without significant atypia (inset). Immunohistochemistry highlights germinal centres with CD20 (d). Scanning electron microscopy and X-ray microanalysis were positive for iron, nickel and titanium (e). British Journal of Dermatology (2014) 171, pp1555–1608
© 2014 British Association of Dermatologists
Correspondence 1569
(a)
(b)
(d) (c) Fig 2. Case 2 demonstrates swelling and erythema of the earlobe (a). Histology revealed extensive B and T lymphocytes, histiocytes, eosinophils and plasma-cell infiltrate (b). Immunohistochemistry highlighted CD21 reactive germinal centres (c), and scanning electron microscopy and Xray microanalysis were positive for gold and to a lesser extent zinc (d).
become swollen and pruritic despite discontinuation of earring use. They would reoccur following cessation of topical steroids and were refractory to antibiotics. Histological examination revealed dermal infiltrate extending to the subcutis with well-formed reactive germinal centres surrounded by mantle and containing tingible body macrophages. Additionally there was a mixed cellular infiltrate of lymphocytes, plasma cells and eosinophils, without significant atypia present (Fig. 1b,c). Immunohistochemistry showed a mixed population of B and T lymphocytes. The germinal centres were highlighted with CD20 and CD21, and the follicle centre cells were Bcl-6 and CD10 positive and Bcl-2 negative (Fig. 1d). The histological features initially suggested the possibility of a low-grade cutaneous marginal zone lymphoma. In situ hybridization of kappa and lambda light chains demonstrated a polytypic population of plasma cells. Borrelia serology was negative. Patch testing was not performed. Scanning electron microscopy and X-ray microanalysis showed iron, nickel and titanium with no gold or zinc (Fig. 1e). X-ray microanalysis involves the analysis of characteristic X-rays generated during scanning electron microscopy to determine the element composition of a specimen. Case 2 is a 43-year-old woman who developed bilateral ear lobe swelling 6 months after having her ears pierced (Fig. 2a). Oral antibiotics and topical steroids were ineffective, and intralesional triamcinolone injections provided only temporary relief. Patch testing to gold produced a florid eczematous reaction with persistent activity at the contact site, requiring intralesional triamcinolone. Interestingly the patient is able to wear her gold wedding band without inducing a reaction. Histological examination revealed an extensive focally diffuse cell infiltrate with germinal centres. The infiltrate was composed of B and T lymphocytes, histiocytes, eosinophils and plasma cells (Fig. 2b). Immunohistochemistry showed a similar profile to that of case 1, and again plasma cells were polytypic by kappa and lambda in situ hybridization (Fig. 2c). © 2014 British Association of Dermatologists
Scanning electron microscopy and X-ray microanalysis showed significant numbers of gold particles, and zinc particles to a lesser extent (Fig. 2d). The pathophysiology of cutaneous pseudolymphoma remains unclear, but it has been suggested that prolonged presence of metallic fragments directly within the dermis acts as an immunogenic pigment, and leads to a delayed direct hypersensitivity reaction and lymphocyte infiltration.4 Similar findings of pseudolymphoma due to pierced earlobes were also described by Wantanabe et al. in 2006.5 The lymphomatous appearance can cause difficulty in distinguishing whether this is a benign or malignant process. Diagnosis is reliant on clinical history, metallic particles identified within lesions on electron microscopy and positive patch tests. Intralesional triamcinolone and surgical excision have been proposed as potential treatment modalities. 1
St John’s Institute of Dermatology, Guy’s and St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH, U.K. 2 University Hospital Lewisham, Lewisham High Street, London SE13 6LH, U.K. 3 Gloucestershire Royal Hospital, Great Western Road, Gloucester GL1 3NN, U.K. 4 Cheltenham General Hospital, Sandford Road, Cheltenham GL53 7AN, U.K. E-mail: [email protected]
Z. LAFTAH1 E. BENTON1 K. BHARGAVA1 J. ROSS2 T. MILLARD3 P. CRAIG4 E. CALONJE1
References 1 Brodell RT, Santa Cruz DJ. Cutaneous pseudolymphomas. Dermatol Clin 1985; 3:719–34. 2 Ploysangam T, Breneman DL, Mutasim DF. Cutaneous pseudolymphomas. J Am Acad Dermatol 1998; 38:877–95. 3 Zilinsky I, Tsur H, Trau H, Orenstein A. Pseudolymphoma of the earlobes due to ear piercing. J Dermatol Surg Oncol 1989; 15:666–8. British Journal of Dermatology (2014) 171, pp1555–1608
1570 Correspondence 4 Suzuki H. Nickel and gold in skin lesions of pierced earlobes with contact dermatitis. A study using scanning electron microscopy and x-ray microanalysis. Arch Dermatol Res 1998; 290:523–7. 5 Wantanabe R, Nanko H, Fukuda S. Lymphocytoma cutis due to pierced earrings. J Cutan Pathol 2006; 33:16–19. Funding sources: none. Conflicts of interest: none declared.
Sun exposure: perceptions and behaviours in outdoor workers DOI: 10.1111/bjd.13149 DEAR EDITOR, Outdoor workers are regularly exposed to solar ultraviolet (UV) radiation and bear an increased risk of developing actinic keratoses, squamous cell carcinoma and possibly basal cell carcinoma.1,2 Squamous cell carcinoma and multiple actinic keratoses induced by natural sunlight are therefore about to be listed as an occupational disease in Germany.3 While employers are required to facilitate strategies to reduce occupational UV exposure, such as avoiding outdoor work at noon and providing shade, outdoor workers also need to apply personal measures in order to gain adequate protection from solar UV exposure. While studies around the world often show that protective strategies are applied insufficiently, little is known about the behaviour of European outdoor workers concerning sun exposure. We developed a questionnaire, which was completed by a convenience sample of 26 male and 14 female outdoor workers employed in eight companies in Dresden, Germany. Six participants were skin type I, 18 skin type II and 16 skin type III. These proportions resemble those in the general population.4 It seems safe to assume that there is no self-selection of less sun-sensitive individuals in outdoor workplaces in Germany. Overall 25% of our participants reported occasionally or regularly getting a sunburn at work. In accordance with other studies reviewed by Reinau et al.,5 an overwhelming majority (73%) of our patients disclosed that they never or rarely (once to twice per week) used sunscreen at work. Older participants used sunscreen less often than younger people (Table 1). In agreement with various studies,5 women were more likely to use sunscreen at work (Table 2). The workers also participated in a cross-over study, in which the correct application had been demonstrated and practised. Under these conditions, they applied approximately 70% of the required quantity of sunscreen.6 Much lower amounts (about 25%) were reported in other studies.7 It is therefore fundamental to educate outdoor workers on how to apply sunscreen adequately and also to emphasize the importance of textile protection by headgear and clothing. Overall, 45% of our study participants reported wearing protective clothing; 58% opted for headgear such as a helmet or a British Journal of Dermatology (2014) 171, pp1555–1608
Table 1 Spearman’s rank correlation of different sun protection behaviours (n = 32–40) Sunbathing Skin cancer screening rs 0192 P-valuea 0234 Skin type rs 0429 P-valuea 0006 Age rs 0025 P-valuea 0626 Sunburn at work rs 0159 P-valuea 0327 Sunscreen use at work rs 0137 P-valuea 0398 a
Skin cancer screening
Skin type
Age
Sun burns at work
0183 0259 0141 0384
0145 0371
0237 0140
0421 0007
0123 0450
0367 0020
0124 0446
0323 0042
0263 0101
Exploratory two-tailed testing of significance.
hat. The rate was highest in the building/construction sector (89%), probably due to safety regulations and not because of sun protection concerns. Moreover, the helmets used were neither broad rimmed nor supplemented by neck protection. Among other workers the rate was only 38% (P = 0004). In total, 58% of participants viewed tanned skin as attractive and a sign of fitness. Likewise, this attitude was demonstrated for most outdoor workers in a variety of studies summarized by Reinau et al.5 Accordingly, 60% of our patients acknowledged that they occasionally or regularly spent their free time in the sun for the purpose of tanning. Outdoor workers who viewed tanned skin as attractive occasionally spent their leisure time sun bathing; the others did so rarely (Table 2). That attitude was more common among darker skin types (Table 2), probably because it is hard for fairer-skinned persons to achieve a tan. Those participants were also less likely to wear protective clothing at work (relative risk 054, 95% confidence interval 029–101); however, they did not use sunscreens less often (Table 3). Employees in the landscape gardening/agriculture sector were most likely to receive sun protection information by their employers, while bicycle couriers, riding instructors or social workers received none at all (P = 0014). There were no other significant differences between occupational groups (Table 4). Receiving sun protection information had a moderate impact on some sun protection behaviours (Table 2). These participants used sunscreen at work more often, enjoyed sunbathing less often and never went to a tanning salon. However, 62% of the outdoor workers indicated that they did not receive any information regarding sun protection from their employer. With the effectiveness of sun safety programmes shown in other regions,5 it is obvious to promote them in Central Europe as well. A majority (53%) of the outdoor workers revealed that they had never attended the skin cancer screening programme rec© 2014 British Association of Dermatologists
2
3
4
5
6
7
8
9
10
MP, eds), 2006. Available at: http://www.ncbi.nlm.nih.gov/ books/NBK1280/ (last accessed 21 October 2014). Eliason MJ, Leachman SA, Feng BJ et al. A review of the clinical phenotype of 254 patients with genetically confirmed pachyonychia congenita. J Am Acad Dermatol 2012; 67:680–6. Leachman SA, Kaspar RL, Fleckman P et al. Clinical and pathological features of pachyonychia congenita. J Investig Dermatol Symp Proc 2005; 10:3–17. Wilson NJ, Leachman SA, Hansen CD et al. A large mutational study in pachyonychia congenita. J Invest Dermatol 2011; 131:1018– 24. McLean WH, Hansen CD, Eliason MJ et al. The phenotypic and molecular genetic features of pachyonychia congenita. J Invest Dermatol 2011; 131:1015–17. Covello SP, Smith FJ, Sillevis Smitt JH et al. Keratin 17 mutations cause either steatocystoma multiplex or pachyonychia congenita type 2. Br J Dermatol 1998; 139:475–80. Cogulu O, Onay H, Aykut A et al. Pachyonychia congenita type 2, N92S mutation of keratin 17 gene: clinical features, mutation analysis and pathological view. Eur J Pediatr 2009; 168:1269–72. Feng YG, Xiao SX, Ren XR et al. Keratin 17 mutation in pachyonychia congenita type 2 with early onset sebaceous cysts. Br J Dermatol 2003; 148:452–5. Smith FJ, Corden LD, Rugg EL et al. Missense mutations in keratin 17 cause either pachyonychia congenita type 2 or a phenotype resembling steatocystoma multiplex. J Invest Dermatol 1997; 108:220–3. Kanda M, Natsuga K, Nishie W et al. Morphological and genetic analysis of steatocystoma multiplex in an Asian family with pachyonychia congenita type 2 harbouring a KRT17 missense mutation. Br J Dermatol 2009; 160:465–8.
Funding sources: none. Conflicts of interest: none declared.
Sunscreen adherence: proffer patient preference DOI: 10.1111/bjd.13136 DEAR EDITOR, Sattler et al.’s1 paper exploring the factors underlying the lack of patient adherence to sun protective measures, overlooks a potentially critical facet, that of patient preference. Shared decision-making and the promotion of patient choice are requisite to good practice, as discussed in a recent Editorial2 and stipulated in the U.K. Dermatology Specialty Training Curriculum.3 This is perhaps best illustrated in dermatology in the realm of emollients, where patient concordance with prescribed therapy is greater when patients are encouraged to select the emollient of their choice, with patients often preferring lighter cream-based emollients to greasier ointments.4 While previous work suggests that 81% of patients would prefer an emollient of their choosing over their currently prescribed medication, the majority (72%) had never been asked which emollient they would like to use.5 Shared decisionmaking mandates that patients are equipped with the resources
© 2014 British Association of Dermatologists
necessary to make informed choices. In the case of emollients or sunscreens, this can be readily facilitated by providing patients with small samples of various topical agents in the clinic. Patient preferences can be extrapolated to other domains of therapy, such as choosing systemic medications, which, albeit, may require additional time for patients to be taught about the available options and to read information sheets, before arriving at a measured decision. Where practical and possible, physicians should account for patient preference in the prescription of treatments: a marginally increased cost accounting for such choice may offset some of the apparent lack of adherence to therapy and the burden of wasted medications.
Dermatology Centre, University of Manchester, Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester M6 8HD, U.K. E-mail: [email protected]
F.R. ALI A. ASLAM J.T. LEAR
References 1 Sattler U, Thellier S, Sibaud V et al. Factors associated with sun protection compliance: results from a nationwide cross-sectional evaluation of 2215 patients from a dermatological consultation. Br J Dermatol 2014; 170:1327–35. 2 Anstey A, Edwards A. Shared decision making in dermatology: asking patients, ‘What is important to you?’. Br J Dermatol 2014; 170:759–60. 3 Joint Royal Colleges of Physicians Training Board. Specialty Training Curriculum for Dermatology. August 2010 (Amended August 2012). Available at: http://www.jrcptb.org.uk/trainingandcert/ST3-SpR/ Documents/2010%20Dermatology%20Curriculum%20(AMENDME NTS%202012).pdf (last accessed 26 April 2014). 4 Holden C, English J, Hoare C et al. Advised best practice for the use of emollients in eczema and other dry skin conditions. J Dermatolog Treat 2002; 13:103–6. 5 Aslam A. Children’s preference in selecting an emollient of their choice. Br J Dermatol 2009; 161 (Suppl. 1):116. Funding sources: No external funding. Conflicts of interest: J.T.L. has accepted honoraria for speaking at meetings, by Leo, Galderma, Almirall, Astellas and GSK.
Two cases of bilateral earlobe cutaneous pseudolymphoma DOI: 10.1111/bjd.13145 DEAR EDITOR, Allergic contact dermatitis to metals including gold is well recognized; however, pseudolymphoma reactions remain rare, with only a small number of cases reported in the literature. Cutaneous pseudolymphoma, also known as cutaneous lymBritish Journal of Dermatology (2014) 171, pp1555–1608
1568 Correspondence
phoid hyperplasia, is characterized by an inflammatory response to a known or unknown stimulus resulting in a benign lymphoid infiltrate that resembles cutaneous lymphoma clinically and histologically.1 These reactions can be idiopathic or secondary to stimuli including drugs, trauma, insect bites, cowpox vaccinations and contact dermatitis. They can be classified according to the predominant cell-type infiltrate: T cell, B cell or mixed.2 Cutaneous T-cell pseudolymphomas are rare and result in a band-like pattern of infiltrate across the upper dermis similar to that seen in mycosis fungoides.2 A subset of cutaneous T-cell pseudolymphomas is associated with CD30-positive cells and linked mainly with viral infections and even drugs.2 They are often caused by antiepileptic drugs and also include solitary T-cell pseudolymphoma, lymphomatoid contact dermatitis and actinic reticuloid (chronic actinic dermatitis).2 Cutaneous B-cell pseudolymphomas are slightly more frequent than cutaneous T-cell
(a)
pseudolymphomas; however, the exact incidence is unknown. They cause a nodular or diffuse distribution of lymphocyte infiltrate admixed with histiocytes, eosinophils and plasma cells. Idiopathic lymphocytoma cutis, persistent reactions to arthropod bites, and postinjection or tattoo-induced pseudolymphomas are examples. Most cases are idiopathic; however, Borrelia burgdorferi infection is a frequent cause in endemic areas.2 Mixed-pattern pseudolymphoma causes a perivascular and nodular pattern of infiltrate and consists of a mixture of T and B cells.2 Pseudolymphoma of the earlobes due to ear piercing was first described by Zilinsky et al. in 1989.3 Herein we present two cases of bilateral pseudolymphoma of the earlobes secondary to metallic ear piercing. Case 1 is a 54-year-old woman who presented with a 4year history of nodular infiltrated dusky earlobes following ear piercing (Fig. 1a). Episodically these lesions would
(b)
(c)
(e)
(d)
Fig 1. Case 1 demonstrates nodular inflammatory infiltrate of the earlobe (a). Histology shows extension from dermis to subcutis (b) with a mixed cellular infiltrate of lymphocytes, plasma cells and eosinophils (c), without significant atypia (inset). Immunohistochemistry highlights germinal centres with CD20 (d). Scanning electron microscopy and X-ray microanalysis were positive for iron, nickel and titanium (e). British Journal of Dermatology (2014) 171, pp1555–1608
© 2014 British Association of Dermatologists
Correspondence 1569
(a)
(b)
(d) (c) Fig 2. Case 2 demonstrates swelling and erythema of the earlobe (a). Histology revealed extensive B and T lymphocytes, histiocytes, eosinophils and plasma-cell infiltrate (b). Immunohistochemistry highlighted CD21 reactive germinal centres (c), and scanning electron microscopy and Xray microanalysis were positive for gold and to a lesser extent zinc (d).
become swollen and pruritic despite discontinuation of earring use. They would reoccur following cessation of topical steroids and were refractory to antibiotics. Histological examination revealed dermal infiltrate extending to the subcutis with well-formed reactive germinal centres surrounded by mantle and containing tingible body macrophages. Additionally there was a mixed cellular infiltrate of lymphocytes, plasma cells and eosinophils, without significant atypia present (Fig. 1b,c). Immunohistochemistry showed a mixed population of B and T lymphocytes. The germinal centres were highlighted with CD20 and CD21, and the follicle centre cells were Bcl-6 and CD10 positive and Bcl-2 negative (Fig. 1d). The histological features initially suggested the possibility of a low-grade cutaneous marginal zone lymphoma. In situ hybridization of kappa and lambda light chains demonstrated a polytypic population of plasma cells. Borrelia serology was negative. Patch testing was not performed. Scanning electron microscopy and X-ray microanalysis showed iron, nickel and titanium with no gold or zinc (Fig. 1e). X-ray microanalysis involves the analysis of characteristic X-rays generated during scanning electron microscopy to determine the element composition of a specimen. Case 2 is a 43-year-old woman who developed bilateral ear lobe swelling 6 months after having her ears pierced (Fig. 2a). Oral antibiotics and topical steroids were ineffective, and intralesional triamcinolone injections provided only temporary relief. Patch testing to gold produced a florid eczematous reaction with persistent activity at the contact site, requiring intralesional triamcinolone. Interestingly the patient is able to wear her gold wedding band without inducing a reaction. Histological examination revealed an extensive focally diffuse cell infiltrate with germinal centres. The infiltrate was composed of B and T lymphocytes, histiocytes, eosinophils and plasma cells (Fig. 2b). Immunohistochemistry showed a similar profile to that of case 1, and again plasma cells were polytypic by kappa and lambda in situ hybridization (Fig. 2c). © 2014 British Association of Dermatologists
Scanning electron microscopy and X-ray microanalysis showed significant numbers of gold particles, and zinc particles to a lesser extent (Fig. 2d). The pathophysiology of cutaneous pseudolymphoma remains unclear, but it has been suggested that prolonged presence of metallic fragments directly within the dermis acts as an immunogenic pigment, and leads to a delayed direct hypersensitivity reaction and lymphocyte infiltration.4 Similar findings of pseudolymphoma due to pierced earlobes were also described by Wantanabe et al. in 2006.5 The lymphomatous appearance can cause difficulty in distinguishing whether this is a benign or malignant process. Diagnosis is reliant on clinical history, metallic particles identified within lesions on electron microscopy and positive patch tests. Intralesional triamcinolone and surgical excision have been proposed as potential treatment modalities. 1
St John’s Institute of Dermatology, Guy’s and St Thomas’ Hospital, Westminster Bridge Road, London SE1 7EH, U.K. 2 University Hospital Lewisham, Lewisham High Street, London SE13 6LH, U.K. 3 Gloucestershire Royal Hospital, Great Western Road, Gloucester GL1 3NN, U.K. 4 Cheltenham General Hospital, Sandford Road, Cheltenham GL53 7AN, U.K. E-mail: [email protected]
Z. LAFTAH1 E. BENTON1 K. BHARGAVA1 J. ROSS2 T. MILLARD3 P. CRAIG4 E. CALONJE1
References 1 Brodell RT, Santa Cruz DJ. Cutaneous pseudolymphomas. Dermatol Clin 1985; 3:719–34. 2 Ploysangam T, Breneman DL, Mutasim DF. Cutaneous pseudolymphomas. J Am Acad Dermatol 1998; 38:877–95. 3 Zilinsky I, Tsur H, Trau H, Orenstein A. Pseudolymphoma of the earlobes due to ear piercing. J Dermatol Surg Oncol 1989; 15:666–8. British Journal of Dermatology (2014) 171, pp1555–1608
1570 Correspondence 4 Suzuki H. Nickel and gold in skin lesions of pierced earlobes with contact dermatitis. A study using scanning electron microscopy and x-ray microanalysis. Arch Dermatol Res 1998; 290:523–7. 5 Wantanabe R, Nanko H, Fukuda S. Lymphocytoma cutis due to pierced earrings. J Cutan Pathol 2006; 33:16–19. Funding sources: none. Conflicts of interest: none declared.
Sun exposure: perceptions and behaviours in outdoor workers DOI: 10.1111/bjd.13149 DEAR EDITOR, Outdoor workers are regularly exposed to solar ultraviolet (UV) radiation and bear an increased risk of developing actinic keratoses, squamous cell carcinoma and possibly basal cell carcinoma.1,2 Squamous cell carcinoma and multiple actinic keratoses induced by natural sunlight are therefore about to be listed as an occupational disease in Germany.3 While employers are required to facilitate strategies to reduce occupational UV exposure, such as avoiding outdoor work at noon and providing shade, outdoor workers also need to apply personal measures in order to gain adequate protection from solar UV exposure. While studies around the world often show that protective strategies are applied insufficiently, little is known about the behaviour of European outdoor workers concerning sun exposure. We developed a questionnaire, which was completed by a convenience sample of 26 male and 14 female outdoor workers employed in eight companies in Dresden, Germany. Six participants were skin type I, 18 skin type II and 16 skin type III. These proportions resemble those in the general population.4 It seems safe to assume that there is no self-selection of less sun-sensitive individuals in outdoor workplaces in Germany. Overall 25% of our participants reported occasionally or regularly getting a sunburn at work. In accordance with other studies reviewed by Reinau et al.,5 an overwhelming majority (73%) of our patients disclosed that they never or rarely (once to twice per week) used sunscreen at work. Older participants used sunscreen less often than younger people (Table 1). In agreement with various studies,5 women were more likely to use sunscreen at work (Table 2). The workers also participated in a cross-over study, in which the correct application had been demonstrated and practised. Under these conditions, they applied approximately 70% of the required quantity of sunscreen.6 Much lower amounts (about 25%) were reported in other studies.7 It is therefore fundamental to educate outdoor workers on how to apply sunscreen adequately and also to emphasize the importance of textile protection by headgear and clothing. Overall, 45% of our study participants reported wearing protective clothing; 58% opted for headgear such as a helmet or a British Journal of Dermatology (2014) 171, pp1555–1608
Table 1 Spearman’s rank correlation of different sun protection behaviours (n = 32–40) Sunbathing Skin cancer screening rs 0192 P-valuea 0234 Skin type rs 0429 P-valuea 0006 Age rs 0025 P-valuea 0626 Sunburn at work rs 0159 P-valuea 0327 Sunscreen use at work rs 0137 P-valuea 0398 a
Skin cancer screening
Skin type
Age
Sun burns at work
0183 0259 0141 0384
0145 0371
0237 0140
0421 0007
0123 0450
0367 0020
0124 0446
0323 0042
0263 0101
Exploratory two-tailed testing of significance.
hat. The rate was highest in the building/construction sector (89%), probably due to safety regulations and not because of sun protection concerns. Moreover, the helmets used were neither broad rimmed nor supplemented by neck protection. Among other workers the rate was only 38% (P = 0004). In total, 58% of participants viewed tanned skin as attractive and a sign of fitness. Likewise, this attitude was demonstrated for most outdoor workers in a variety of studies summarized by Reinau et al.5 Accordingly, 60% of our patients acknowledged that they occasionally or regularly spent their free time in the sun for the purpose of tanning. Outdoor workers who viewed tanned skin as attractive occasionally spent their leisure time sun bathing; the others did so rarely (Table 2). That attitude was more common among darker skin types (Table 2), probably because it is hard for fairer-skinned persons to achieve a tan. Those participants were also less likely to wear protective clothing at work (relative risk 054, 95% confidence interval 029–101); however, they did not use sunscreens less often (Table 3). Employees in the landscape gardening/agriculture sector were most likely to receive sun protection information by their employers, while bicycle couriers, riding instructors or social workers received none at all (P = 0014). There were no other significant differences between occupational groups (Table 4). Receiving sun protection information had a moderate impact on some sun protection behaviours (Table 2). These participants used sunscreen at work more often, enjoyed sunbathing less often and never went to a tanning salon. However, 62% of the outdoor workers indicated that they did not receive any information regarding sun protection from their employer. With the effectiveness of sun safety programmes shown in other regions,5 it is obvious to promote them in Central Europe as well. A majority (53%) of the outdoor workers revealed that they had never attended the skin cancer screening programme rec© 2014 British Association of Dermatologists
