Revised UK guidelines for the management of cutaneous melanoma 2010.

These guidelines for the management of cutaneous melanoma present an evidence-based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiology, diagnosis, investigation, and follow-up.

Necrobiotic xanthogranuloma without paraproteinaemia: marked improvement with psoralen ultraviolet A treatment.

Necrobiotic xanthogranuloma (NXG) is a rare granulomatous condition that is often associated with a paraproteinaemia and in some cases multiple myeloma. Treatment is therefore aimed at the underlying associated haematological abnormality. However, isolated NXG cases have been reported. We report a case of isolated NXG that responded very well to systemic psoralen ultraviolet A (PUVA) treatment. The rationale for this treatment was the successful use of PUVA treatment in other necrobiotic conditions such as granuloma annulare and necrobiosis lipoidica.

Shave biopsy without local anaesthetic to diagnose basal cell carcinoma and other skin tumours prior to definitive treatment: analysis of 109 lesions.

BACKGROUND: Diagnostic biopsy of basal cell carcinoma and other skin tumours may be necessary prior to definitive treatment. OBJECTIVES: To assess whether shave biopsy sampling of tumours without local anaesthetic can provide adequate tissue to make an accurate histological diagnosis, and to determine whether any discomfort is associated with the technique. METHODS: One hundred and nine lesions from 99 patients were sampled by shave biopsy without local anaesthetic. Any discomfort associated with the procedure, and the adequacy of the histological specimen, were documented. The pathology diagnosis was also compared against the clinically suspected diagnosis. RESULTS: In 108 of the 109 lesions sampled, sufficient tissue was obtained to make an accurate histological diagnosis. In only six of the 109 procedures was any discomfort reported and in all cases this was rated as minor. A high correlation was found between histological diagnosis and initial clinical suspicion. CONCLUSIONS: Shave biopsy without local anaesthetic is a simple, relatively pain-free method of obtaining tissue samples for histological diagnosis in appropriate tumours.

Extensive bullous lichen sclerosus with scarring alopecia.

We describe details of a very rare variant of lichen sclerosus in an elderly man. This pattern was characterized by involvement of most of the body surface by bullae, erosions and scarring, including scarring alopecia. Our patient responded to topical corticosteroids and doxycycline. Borrelia spp. have been implicated in a previous case of this variant, but we could not find any evidence of this in our patient.

Purpura and bleeding due to calcium-channel blockers: an underestimated problem? Case reports and a pilot study.

BACKGROUND: Surgical bleeding and occasionally purpura due to calcium-channel blockers have been described. AIM: To present cases in whom purpura or internal bleeding due to calcium-channel blockers was a presenting feature, including one subject with drug-induced haematuria and haematospermia due to amlodipine and one with the Rumpel-Leede sign. Further support for a true association was sought in a pilot study using Hess testing to provoke purpuric skin lesions. METHODS: Four representative cases presenting due to purpura or bleeding are described, all of whom had an abnormal Hess test. A further 19 patients taking calcium-channel blockers and 13 control subjects were also tested. RESULTS: Of 19 patients on calcium-channel blockers, 16 had either abnormal Hess results (n = 13) or marked acral purpura (n = 3) after a Hess test procedure. A similar abnormal response, of milder degree, occurred in only 2 of 13 control subjects. CONCLUSIONS: The high frequency of purpura shown in this study, whether spontaneous or provoked, suggests that this is a pharmacological class effect rather than idiosyncratic. Purpura in patients taking these drugs may be a clue to diagnosis of internal or postsurgical bleeding. We conclude that purpura related to calcium-channel antagonists is probably underestimated, but further studies are needed to identify the mechanism by which this occurs.

The U.K. skin cancer 'two-week rule' proforma: assessment of potential modifications to improve referral accuracy.

BACKGROUND: In England and Wales, patients with suspected skin cancer are referred to specialists within 2 weeks ('two-week rule', TWR) by tick-box proforma. OBJECTIVES: To evaluate proforma details that might be amended to improve sensitivity and specificity. METHODS: Five hundred and six TWR referrals were evaluated. Potential proforma changes were criteria for melanoma, and guidance that most squamous cell carcinomas (SCCs) measure >or= 1 cm. We compared melanomas vs. benign pigmented lesions using seven-point, and amended (10-point), checklist scores. We examined sizes of 82 SCCs and investigated influence of size on TWR referral. RESULTS: Of 506 TWR referrals, 381 (75%) were suspected melanoma [30 (7.8%) correct], and 125 (25%) were suspected SCC [22 (17.6%) correct]. Fifty per cent of melanomas were referred by TWR, but only 8% of SCC. No combination of seven-point checklist criteria had discriminatory value for melanoma; total scores (seven- or 10-point) were not significantly different between melanomas and nonmelanomas. No total score, using either system, had acceptable sensitivity and specificity. Measured size of SCCs varied from 4 to 30 mm; 88% were >or= 1 cm. Reducing the 'cut-off' to 7 mm identified only another 3.5%. Even at 2.5-3 cm, only 50% of SCCs were referred by TWR. CONCLUSIONS: The seven-point checklist for melanoma, when used in TWR format, does not have discriminatory value for melanoma. Altering the suggested cut-off size for SCC is unlikely to alter referrals. Education may be a more important factor in refining use of the TWR.