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Preference is given to letters commenting on contributions published recently in the JRSM. They should not exceed 300 words and should be typed double spaced
Hidradenitis suppurativa
Though we enjoyed the review on hidradenitis suppurativa (HS) by Dr Mortimer and Mr Lunniss (August 2000, JRSM, pp. 420±22) we feel that their brief comments on androgen dependence and antiandrogen therapy need quali®cation. They cite evidence from the study by Barth and Kealey1, who investigated androgen converting enzyme activity in the apocrine glands of HS patients and found no increase in activity. These data are interpreted as re¯ecting lack of apocrine sensitivity to androgens, but this inference is misleading, since the data relate to the quantity of active metabolite (dihydrotestosterone) and not the androgen response at receptor level. In this regard it is noteworthy that ®nasteride, a type 2 5a-reductase inhibitor of testosterone to dihydrotestosterone conversion, gave apparent bene®t in 4 recalcitrant cases of HS2. In higher primates apocrine glands are androgen dependent, as manifest by the role of these glands in cutaneous chemical communication during mating activities. This important body odour is formed at the piloapocrine sites (mainly axillae, inguinal region and perianal and natal cleft areas) by the bacterial decomposition of apocrine secretions. In humans a similar, albeit more re®ned, process of apocrine maturation and function occurs with the onset of body odour at adolescence and not before, substantiating the basis of androgen dependency. Although HS has occurred in a girl of 7 years, this was the presenting feature of premature adrenarche3. Observational studies have shown that HS ¯ares premenstrually but tends not to during anovulatory cycles4. Affected women also have a high prevalence of acne and hirsutism which are known androgenic conditions. Initial studies showed that HS patients had biochemical hyperandrogenism5 but this was refuted by a comparison with controls matched for age, weight and hirsutes6. However, androgen pro®les can be normal in known androgenic conditions such as acne vulgaris, hirsutism and androgenic alopecia. The mode of action is therefore considered to be at the receptor level, as supported by the association of dissecting folliculitis, acne conglobata and HSÐthe `follicular occlusion triad'. Ebling and Randall from a zoological background (with Sawers) suggested antiandrogen therapy on the basis of comparative endocrinology. A pilot study con®rmed the hypothesis by demonstrating bene®ts from antiandrogen therapy in HS7. Despite the disparate views on the aetiological signi®cance of apocrine glands in HS and androgen dependence, antiandrogen therapy is clinically helpful in HS patients7,8. We feel that female patients without contraindications should be offered an antiandrogen
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preparation such as Dianette as an adjunct to other medical and surgical treatment. The ef®cacy of short-course, highdose cyproterone acetate should not be underestimated7. Even brief remission in a refractory case may be very advantageous. B C Gee R P Dawber Dermatology Department, Churchill Hospital, Headington, Oxford OX3 7LJ, UK E-mail:
[email protected]
REFERENCES
1 Barth JH, Kealey T. Androgen metabolism by isolated human axillary apocrine glands in hidradenitis suppurativa. Br J Dermatol 1991;125:304±8 2 Farrell AM, Randall VA, Vafaee T, Dawber RP. Finasteride as a therapy for hidradenitis suppurativa. Br J Dermatol 1999;141:1138±9 3 Lewis F, Messenger AG, Wales JKH. Hidradenitis suppurativa as a presenting feature of premature adrenarche. Br J Dermatol 1993;129:447±8 4 Harrison BJ, Read GF, Hughes LE. Endocrine basis for the clinical presentation of hidradenitis suppurativa. Br J Surg 1988;75:972±5 5 Mortimer PS, Dawber RP, Gales MA, Moore RA. Mediation of hidradenitis suppurativa by androgens. BMJ 1986;292:245±8 6 Barth JH, Layton AM, Cunliffe WJ. Endocrine factors in pre- and postmenopausal women with hidradenitis suppurativa. Br J Dermatol 1996;134:1057±9 7 Sawers RS, Randall VA, Ebling FJG. Control of hidradenitis suppurativa in women using combined antiandrogen (cyproterone acetate) and oestrogen therapy. Br J Dermatol 1985;115:269±74 8 Mortimer PS, Dawber RPR, Gales MA, Moore RA. A double-blind controlled cross-over trial of cyproterone acetate in females with hidradenitis suppurativa. Br J Dermatol 1986;115:263±8
LETTERS TO THE EDITOR
JOURNAL
Hospitalists for the NHS
I write in response to the article by Dr Mainous and colleagues (October 2000 JRSM, pp. 504±506). As a geriatrician I regard myself as a general physician in the care of the elderly. I also work in an acute integrated care system and do on-call duties with post-take ward rounds. Over a period of time, I have realized that I need to specialize in a few diseasesÐnamely, gait and movement disorders including Parkinson's disease, heart failure, stroke, chronic obstructive pulmonary disease, detection of cancer in the elderly, urinary and faecal incontinence, falls and emergency treatment of acute haemorrhages. I do feel that a system including an organ specialist, a generalist and a general practitioner caring for the patient would be the ideal in a world constrained by time, ®nance and manpower. A hospital full of single organ specialists and a community full of GPs, with no `intermediate care physicians' in situ, would be a nightmare. J A Anandadas Trafford General Hospital, Moorside Road, Davyhulme, Manchester M41 5SL, UK
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Whiplash: a double injury
Dr Michael Livingston's review article (October 2000, JRSM, pp. 526±529) draws attention to the failure to understand whiplash injury. In the opening section on de®nition he indicates that the typical whiplash injury can often involve the upper dorsal spine and I would like to emphasize the involvement usually at the D3 level. However, it is equally important to draw attention to the involvement in the upper neck, with tenderness often found on pressing over the ®rst or second cervical vertebra, or both. We have been through the era of implicating X-ray degenerative spondylosis changes in the mid-cervical spine. It was acknowledged that these changes could be present in age-matched individuals without any history of injury. However, those who had recognized this problem were still implying that whiplash injury impairment was localized in the mid-neck region. The reason for looking elsewhere (i.e. above and below the mid-cervical region) was that it had been established1 that in rotation strain of the low back there was tenderness at the lumbosacral and dorsolumbar junctionsÐi.e. the top and bottom of the lumbar spine. The localizations have in common that ¯exible parts of the spine meet the immobile. Livingston also points out that whiplash injury is often associated with rotation strain. Press to either side of C1 and D3 to identify the whiplash asymmetry. The upper neck needs to be palpated with the patient supine and the dorsal vertebrae sprung with the patient prone. Do not miss the associated late onset re¯ex sympathetic dystrophy to the upper limb with stellate ganglion nearby. Neglect of these elements explains why so many cases suffer the psychosocial innuendo. The failure to understand whiplash injury is hardly surprising if the two sites of impairment, at C1 and D3, are not identi®ed. Brian Sweetman Department of Rheumatology, Swansea SA6 6NL, UK
REFERENCE
1 Sweetman BJ. Heavy work and low back pain. J Orthop Med 1999;21:75±9
Clinical diagnosis and the function of necropsy
In his excellent review of the importance of acquiring medical knowledge through the performing of necropsy
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(September JRSM, pp. 463±466) Dr Baron mentions the role played by the Vienna Medical Faculty in the eighteenth century and subsequently. Credit should be given to Gerhard van Swieten, founder of the Faculty and court physician to the Empress Maria Teresa and her husband Franz I. van Swieten was backed by the Imperial Couple in setting up the rules and regulations of the Viennese Faculty which included obligatory necropsies for anyone dying in the Allgemeine Krankenhaus. He had counselled Maria Teresa's husband in overcoming certain marital problems by instructing the latter as follows: clitoridem suam Majestatem titillandum esse. An obviously successful prescription since Maria Teresa produced sixteen children including the illfated Marie Antoinette. F Berger P O Box 75, Station Cote St-Luc, Montreal QC H4V 1H8, Canada
Contemporary medical historyÐhelp wanted
I seek specialist help from RSM members in identifying signi®cant contemporary medical developments. My book on the NHS, From Cradle to Grave (reviewed in the JRSM April 1998), contained substantial sections on clinical progress, chronologically and by specialty. It has sold well. I have now established a website [www.nhshistory.com] to keep the story going (free access of course). With weekly updating I ®nd it fairly simple to track organizational, political and ®nancial developments. It is harder to identify major, important and new clinical treatments and techniques. These inevitably impact on the patient and the health service. If members of the Society, covering as they do the entire spectrum of medicine, could let me know of signi®cantÐ even historicÐchanges in their specialty, I would be most grateful. Indeed I view the writing and web-publication of this next chapter of my book, covering 1998 onwards, as an interesting experiment in interactive and cooperative history writing. I hope it will also prove a useful resource for those seeking a brief account of current NHS. Those looking at [www.nhshistory.com] will ®nd a page covering clinical progress, and probably there will be a skeletal paragraph on their ®eld already. There is also a link to my e-mail address. Geoffrey Rivett 173 Shakespeare Tower, Barbican, London EC2Y 8DR, UK E-mail:
[email protected]
