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the trouble began with a trivial eruption on the face.The nature of this primary dermatosis may be hard toascertain when the patient is first seen-perhaps a patchof erythema on the side of the chin or a paranasal sebor-rhceic eczema. Later superimposed on this is the groupedpapulo-pustular eruption of perioral dermatitis on apink background. The papulo-pustules often spread toform an incomplete circle around the mouth; later theeyelids and glabellar region may be affected. The pa-tient, usually a young woman, almost invariably admitsto having applied potent topical steroids over longperiods; sometimes the agent turns out to have been pre-scribed not for the patient but for another member ofthe family.

Habituation is an ever-present hazard of potent topi-cal steroid therapy.3 Once the patient is "hooked", with-drawal for more than a few days is followed by reboundexacerbation. The patient applies more medication torelieve the flare-up, and at this stage the clinician mayhave trouble convincing the patient that she (or he) hasbecome topically addicted. Fortunately a 6-8 weekscourse of systemic tetracyclines is curative in most

patients. All dermatologists discontinue the offendingtopical steroid immediately, although some replace itwith a weaker steroid such as hydrocortisone to lessenthe risk of rebound during the early stages of tetra-cycline therapy.

Over the years, the suggested explanations for peri-oral dermatitis have ’included exposure to fluorinated

toothpaste, demodex infection, and sensitivity to citrusfruits, moisturisers, and nasal drops. Wilkinson et al.1excluded toothpaste, demodex, moisturisers, and com-mon contact allergens and pointed to misuse of potenttopical corticosteroids as the most satisfactory explana-tion. All but 9 of his 259 patients had been applyingtopical steroids, although some were reluctant to say soat first. In the U.K. the decline in incidence since 1971is presumably due to more restrained prescription bygeneral practitioners. Cotteri114 describes 43 patientswith perioral dermatitis, 7 of whom had been using apotent yet non-fluorinated steroid, hydrocortisone butyr-ate. He suggests that an expiry date should be printedon the tubes of potent local steroids, together with awarning about the hazards of long-term use on the facewithout medical advice. Evidently a few family doctorsare still prescribing wrongly and here too the messagemust get through.The differential diagnosis of perioral dermatitis in-’

cludes rosacea, central facial seborrhoeic eczema, acneand the uncommon acne agnimata, and the followingsteroid-associated eruptions-acne, plethora, and hyper-trichosis seen with systemic steroid excess; the bright red"Betnovate face" with thin atrophic telangiectatic skindue to epidermal atrophy and loss of dermal collagen;and rosacea in rebound, which can cause diagnostic con-fusion if the patient is first seen within a few days ofceasing to apply potent steroids to a facial rosacea (aflorid papulo-pustular eruption on the rosaceous areas isset on a background of steroid atrophy, but the rosacearesponds rapidly to systemic tetracyclines and the

atrophy slowly recovers if the patient stays off potentsteroids). Although potent steroids are the major agent

3. Editorial. Hazardous jungle of topical steroids. Lancet 1977; ii: 487-88.4. Cotterill JA. Perioral dermatitis. Br J Dermatol 1979; 101: 259-61.

provocateur many unsolved problems remain concern-ing pathogenesis. Why should potent steroids produce aninflammatory dermatosis of the face? Why are tetra-cyclines so effective? These matters seem to have beenneglected by microbiologists. Whereas acne vulgaris hasbeen closely investigated, very little is known of themicroflora in perioral dermatitis. We need to know

something of the effects of steroids on the flora of theface; quantitative and serial studies, particularly of lipo-philic diphtheroids, lipofacial yeasts, and other

organisms of low inherent pathogenicity, are likely to beinformative. Do steroids influence the ecological balancebetween the diverse normal facial organisms-lipophilicdiphtheroids, yeasts, and other organisms of low inher-ent pathogenicity-or perhaps the balance betweenthose on the surface and those embedded in hair folli-cles ? Perhaps it is only in seborrhoeic subjects that

potent steroids provide a luxuriant habitat for the prolif-eration of normally harmless organisms. If these ques-tions can be answered perhaps we may see some progressin assessing the factors that contrive to cause this un-sightly yet preventable disease.

THE CHOICE OF VASCULAR PROSTHESES

SINCE the 1960s vascular surgeons have been blessedalmost yearly with a new type of prosthetic graft fortheir reconstructive work. Most of these are ’Dacron’based and many of the advances are reflections of im-

provements in textile technology. Thus there are woven,knitted, weave/knitted, velour, and double-velour grafts,each with its special properties-and its special price.The aim of the pioneers was to provide a graft whichwas easily worked by the surgeon and permanentlyaccepted by the patient. With regard to the latter, onemight expect the loose-knitted grafts and velours, byallowing ingrowth of the patients’ fibrous tissue, to bepreferable, but experimental proof of this is difficult tofind. Indeed one of the authorities on the subject, Sau-vage,l stated that "There is, apparently, a human heal-ing limitation with these prostheses as contrasted withthe healing ability of experimental animals". The out-come, irrespective of the weave or knit, is usually a graftflow surface which consists of compacted fibrin except atanastomoses, where there is partial epithelialisation for2-3 mm. For the patient, therefore, there seems little tochoose between the various types of graft.

For the surgeon the difference is enormous. To startwith, there is the porosity of the graft. This varies froma mere 40 ml/min per cm2 (i.e., virtually watertightfrom the time the clamps are removed) to over 2000ml/min per cm2. The low-porosity (woven) grafts needno pre-clotting whereas the knitted and velour graftsmust be handled carefully (sometimes with special tech-niques). This can be time-consuming and if not achievedsatisfactorily can be very expensive (because of the costof blood).

Having chosen the graft, the surgeon then has to sewit into position. Not all grafts are easy to handle. Someof the older woven ones were so tough that they tendedto bend the suture needles as readily as did the calcified

1. Berger K, Sauvage LR, Rao AM, Wood SJ. Healing of arterial prosthesesin man: its incompleteness. Ann Surg 1972; 175: 118-27.

2. Yates SG, Barros D’Sa AAB, Berger K, et al. The pre-clotting of porousarterial prostheses. Ann Surg 1978; 188: 611-22.

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blood-vessels they were replacing. Here the knitted andvelour grafts show their superiority, for all handle

beautifully. This is an important aspect of grafts, for asurgeon needs all the help he can get and a difficultfabric to sew can be very irritating. Lately the manufac-turers have produced "soft" woven-fabric grafts whichmay provide a useful working compromise.

Finally, there is the cost of these grafts. Physicians ornon-arterial surgeons might be surprised to know that atypical trouser graft (a tube of dacron measuring in its"crimped" unstretched state about 20 cm, with the pro-portions of an average aorta) costs between ,80 and,200 according to the textile technology used. Thewoven grafts are cheapest, the double velours the mostexpensive. For femoropopliteal reconstructions dacronprostheses are seldom of long-term value, and new pros-theses are available. The two currently most frequentlyused are ’Gore-tex’ ([134 for 40 cm) and the Dardik

. umbilical vein graft ([337 for 40 cm). Such grafts needvery careful clinical testing by vascular surgeons inde-pendent of the manufacturer, rather than the odd one-off operation "to gain an impression".

SMALL-CELL CARCINOMA OF THEBRONCHUS—REAL PROGRESS IS HARD TOCOME BY

Greco and Oldham, in the New England Journal ofMedicine, have outlined a peculiarly sanguine view ofsmall-cell carcinoma of the bronchus. Their article con-tains such statements as "... recently, the natural his-tory has been impressively modified by combinationchemotherapy. The protean clinical manifestations canoften be completely ameliorated for variable periods...Combination chemotherapy is superior to single drugsin eliminating all clinical evidence of the neoplasm (com-plete response). A complete response is the first step toincreasing useful survival ... The therapy availableoffers the patient the opportunity to obtain effective pal-liation and prolongation of life ..." A report from theMedical Research Council Lung Cancer Working Party2makes a sober contrast. Patients treated with radio-

therapy alone were compared with a group who receivedradiotherapy and then gruelling three-drug chemo-therapy (cyclophosphamide, methotrexate, lomustine).At one year there was a significant increase in thesurvival of patients treated with the dual regimen, 34%of 115 patients being alive compared with 18% of 121treated with radiotherapy only. The median survival inthe series receiving combined treatment was 43 weeks,as against 25 weeks in the patients treated by radio-therapy alone. Distant metastases developed in 57% ofthe combined-therapy group compared with 79% whoreceived only radiotherapy. However, these advantagesin patient survival were bought at a heavy price. Over80% of the patients who received combined therapy hadadverse reactions: nausea and vomiting was the com-monest, and was often severe despite routine administra-tion of antiemetics; mouth ulcers, sometimes causing

1. Greco FD, Oldham RK. Current concepts in cancer; small-cell lung cancerN Engl J Med 1979; 301: 355-58.

2. Medical Research Council Lung Cancer Working Party. Radiotherapy aloneor with chemotherapy in the treatment of small-cell carcinoma of the lung.Br J Cancer 1979; 40: 1-10.

dysphagia, and the more serious bone-marrow depres-sion, were other troublesome reactions. Only one-thirdof all patients randomised to receive combined therapyin this trial tolerated their cytotoxic treatment withoutmodification. Even the less critical Greco and Oldham,’commenting on the most frequently administered com-bination regimens of cyclophosphamide/adriamycin/vincristine, cyclophosphamide/methotrexate/vincristine,or cyclophosphamide/methotrexate/lomustine, say that"although current therapies are now more effective,toxicity and the high relapse rate remain major prob-lems ...", and survival rates in American series withoutblatant case selections are usually no higher than thosereported in the U.K.

Since the publication in 1966 of the earlier M.R.C.study comparing surgical and radiotherapeutic attackon small-cell carcinoma, medical opinion has swung dra-matically against surgical resection even in early cases.Some large thoracic surgical units are now questioningthe wisdom of this doctrine. Drakely, Matthews, andWatson3 reported a series of 1669 cases of oat-cell car-cinoma of the bronchus seen over 20 years at the Broad-

green and Fazakerley Hospitals in Liverpool. Of these,494 had been treated by surgery alone, 366 tumoursbeing successfully resected (73%). 52 of these patientssurvived more than 5 years without additional treat-ment. Histological review discarded 2, leaving a 13.7%survival after resection, or 10.6% survival for the groupas a whole-rather better than the radiotherapy resultsin the earlier M.R.C. study. Further follow-up has dis-closed at least a few survivors up to 20-25 years. Patient .

selection inevitably plays a role in any surgical series,but even if all the 1669 cases seen are taken as the "un-selected" reference population the "cure" rate

approaches that of the equally "unselected" M.R.C.series. It is perhaps time that we restored surgery to ourweaponry against small-cell carcinoma of the bronchusapparently confined within the thorax.What of that majority of patients whose disease is in-

operable when they are first seen? The M.R.C. LungCancer Working Party is at the moment doing pilot stu-dies for a new trial with three arms-two combiningradiotherapy and aggressive chemotherapy, one consist-ing of limited symptomatic treatment. Centres partici-pating in the trial may elect to draw patients for any twoof the three arms or for all three. The first Oxford trialin inoperable bronchial carcinoma,4 from which patientswith small-cell carcinoma were not excluded, suggestedthat immediate aggressive anti-cancer treatment withradiation, or single cytotoxic agents, or a combination ofthese two modalities neither extended life nor improvedits quality-rather the reverse, since the side-effects oftreatment were added to the symptoms of disease. Delayof aggressive local and systemic treatment until the pres-entation of symptoms demanding treatment resulted inno shorter overall remission from the time when treat-ment was applied. At long last a trial is to ask specifi-cally in small-cell carcinoma whether any of the treat-ments we have to offer really affects survival in themajority of patients. The two "aggressive" treatment

3. Drakeley MJ, Matthews HR, Watson CT. Oat cell carcinoma of the bron-chus: is there a place for surgery. Thorax 1979; 34:427 (abstr).

4. Durrant KR, Berry RJ, Ellis F, Ridehalgh FR, Black JM, Hamilton WS.Comparison of treatment policies in inoperable bronchal carcinoma.Lancet 1971; i: 715-19.