Characteristics of Superficial Basal Cell Carcinomas Containing More Aggressive Subtypes on Final Histopathologic Diagnosis.

BACKGROUND: The prognosis and treatment of basal cell carcinoma (BCC) are largely dependent on tumor subtype, which is typically determined by punch or shave biopsy. Data regarding concordance between BCC subtype on initial biopsy and final histopathology for Mohs micrographic surgery (MMS) or excision with frozen sections (EFS) are limited. OBJECTIVES: To determine the concordance between initial biopsy and final MMS or EFS subtyping of BCC. We aim to investigate the incidence and clinical characteristics of lesions initially diagnosed as superficial BCC (sBCC) that are later found to have a nodular, micronodular, or infiltrative component. METHODS: We conducted a retrospective review of all MMS or EFS cases performed at a single academic center from August 1, 2015, to August 31, 2017. Inclusion criteria were a biopsy-proven diagnosis of sBCC and presence of residual tumor following stage I of MMS or EFS. Fisher’s exact test was used to evaluate significance of clinical characteristics and outcomes associated with the presence of a nodular, micronodular, or infiltrative BCC component. RESULTS: A total of 164 MMS or EFS cases had an initial biopsy showing sBCC. Of these, 117 had residual BCC on stage I, and 43 (37%) were found to have a nodular, micronodular, or infiltrative component. Significant predictors of reclassified BCC subtype included age over 60 years (P= 0.006) and location on the head or neck (P=0.043). Reclassified lesions required significantly more stages of MMS to clear (P=0.036). Shave biopsy was used to diagnose 114 (97%) of the included cases. CONCLUSIONS: Over one third of shave biopsies that initially diagnosed sBCC failed to detect a nodular, micronodular, or infiltrative component. Management of biopsy-proven sBCC should take into account the possible presence of an undiagnosed deeper tumor component with appropriate margin-assessment treatment modalities when clinically indicated. J Drugs Dermatol. 2021;20(8):874-879. doi:10.36849/JDD.5838.

Characteristics of Superficial Basal Cell Carcinomas Containing More Aggressive Subtypes on Final Histopathologic Diagnosis.

BACKGROUND: The prognosis and treatment of basal cell carcinoma (BCC) are largely dependent on tumor subtype, which is typically determined by punch or shave biopsy. Data regarding concordance between BCC subtype on initial biopsy and final histopathology for Mohs micrographic surgery (MMS) or excision with frozen sections (EFS) are limited. OBJECTIVES: To determine the concordance between initial biopsy and final MMS or EFS subtyping of BCC. We aim to investigate the incidence and clinical characteristics of lesions initially diagnosed as superficial BCC (sBCC) that are later found to have a nodular, micronodular, or infiltrative component. METHODS: We conducted a retrospective review of all MMS or EFS cases performed at a single academic center from August 1, 2015 to August 31, 2017. Inclusion criteria were a biopsy-proven diagnosis of sBCC and presence of residual tumor following stage I of MMS or EFS. Fisher’s exact test was used to evaluate significance of clinical characteristics and outcomes associated with the presence of a nodular, micronodular, or infiltrative BCC component. RESULTS: A total of 164 MMS or EFS cases had an initial biopsy showing sBCC. Of these, 117 had residual BCC on stage I, and 43 (37%) were found to have a nodular, micronodular, or infiltrative component. Significant predictors of reclassified BCC subtype included age over 60 years (P=0.006) and location on the head or neck (P=0.043). Reclassified lesions required significantly more stages of MMS to clear (P=0.036). Shave biopsy was used to diagnose 114 (98%) of the included cases. CONCLUSIONS: Over one third of shave biopsies that initially diagnosed sBCC failed to detect a nodular, micronodular, or infiltrative component. Management of biopsy-proven sBCC should take into account the possible presence of an undiagnosed deeper tumor component with appropriate margin-assessment treatment modalities when clinically indicated. J Drugs Dermatol. 2021;20(3):283-288. doi:10.36849/JDD.5383.

A Split-Scar Study Investigating the Effectiveness of Early Intervention With Electroabrasion on Improving the Cosmetic Appearance of Postsurgical Scars.

BACKGROUND: Electroabrasion, which uses an in-office electrosurgical device, is a method of surgical planning that ablates the skin to the papillary dermis. Several reports demonstrate that intraoperative ablative interventions with lasers or dermabrasion can modulate scar formation more effectively. This investigation uses electroabrasion intraoperatively to mitigate scar formation. OBJECTIVE: To evaluate the effectiveness of intraoperative electroabrasion for scar revision. MATERIALS AND METHODS: This was a prospective, randomized, observer-blinded, split-scar study with 24 linear scar segments resulting from primary closures in patients undergoing Mohs micrographic surgery. After placement of dermal sutures, half of the wound was randomly treated with electroabrasion. The other half was used as the control. Scar appearance was assessed by a blinded observer and by the patient using the Patient and Observer Scar Assessment Scale at 1 to 2 weeks, 1 month, and 3 months after surgery. RESULTS: At the 3-month follow-up, both patient and observer variables measuring scar contour improved on the treated side, whereas erythema was worse. Overall, no difference was seen in total scores between the 2 sides. CONCLUSION: Based on this pilot study, scars treated with electroabrasion revealed improved surface topography but worsened erythema. Future studies with more refined electrosurgical settings are needed for further evaluation.

Treatment of Hypertrophic Granulation Tissue: A Literature Review.

BACKGROUND: Hypertrophic granulation tissue (HGT) is an uncommon but a frustrating complication of wound healing. Given its low prevalence and often refractory nature, many treatment options have been explored. OBJECTIVE: No comprehensive review exists on HGT management in dermatology literature; thus, the authors hope to compile a review of available treatments. MATERIALS AND METHODS: An exhaustive key word search of 3 databases was performed for treatment of HGT. Results from these reports were summarized in this review. RESULTS: Methods of treatment included silver nitrate, topical steroids (n = 11), intralesional steroids (n = 55), steroid tape (n = 25), surgical removal, polyurethane foam dressing (n = 32), and pulsed-dye laser (n = 13). CONCLUSION: With all treatment methods, the cases and studies reported varying degrees of successful treatment with HGT reduction. Given the lack of published literature, it remains unknown whether the initial injury preceding HGT formation determines treatment modality success. For HGT refractory to silver nitrate, choice of treatment depends on accessibility, ease of use, cost, and location of the wound. Intralesional and topical steroids should both be considered. Polyurethane foam can be considered an adjunct treatment. If resources allow, laser treatment should also be considered.

Skin lesions serve as clues to relapse of pediatric blastic plasmacytoid dendritic cell neoplasm.

A 10-year-old girl with a history of blastic plasmacytoid dendritic cell neoplasm, a rare malignancy in children, presented with recurrent skin eruptions beginning while on maintenance chemotherapy, including mildly pruritic skin-colored plaques, tender indurated nodules, and violaceous bound-down plaques. This case highlights an unusual presentation of relapsed blastic plasmacytoid dendritic cell neoplasm on chemotherapy, with skin lesions providing important clues to the progression of systemic disease.

Scalp Closures With Pulley Sutures Reduce Time and Cost Compared to Traditional Layered Technique-A Prospective, Randomized, Observer-Blinded Study.

BACKGROUND: Reconstruction of postsurgical scalp defects can be difficult and time-consuming using a conventional bilayered technique. A specialized closure using a pulley suture can assist in closing wounds under high tension and can decrease time and cost for the surgeon. OBJECTIVE: To determine if closing scalp defects with a single-layered closure using pulley sutures would result in decreased time but equivalent scar cosmesis compared to bilayered closures. MATERIALS AND METHODS: A total of 21 patients with postsurgical scalp defects were randomized to a bilayered or a pulley group, and time was measured for each closure. Scar appearance was assessed using the Patient and Observer Scar Assessment Scale at 2 weeks, 2 months, and 6 months postsurgery. Before and after photographs were also assessed by a blinded dermatologist using the visual analog scale. RESULTS: Compared to a bilayered closure, the pulley technique resulted in significantly reduced closure time (p < .001). Even though patient overall scores at 2 weeks and observer total score at 6 months were superior in the pulley group, the visual analog scale scores were similar between the 2 groups. CONCLUSION: Scalp reconstructions using a single layer of pulley sutures result in time and cost reduction and similar scar appearance compared to bilayered closures.

Congenital Ichthyosiform Erythroderma Superimposed with Chronic Dermatophytosis: A Report of Three Siblings.

Congenital ichthyosiform erythroderma is an autosomal recessive ichthyosis characterized by severe scaling and erythroderma. We report a family of three siblings who were all born with a collodion membrane and presented with diffuse scaling and pruritus. All three children subsequently developed chronic cutaneous dermatophyte infections requiring oral antifungals. One child developed superinfection with methicillin-resistant Staphylococcus aureus requiring antibiotics.

Evaluation of patients with photodermatoses.

The systematic evaluation of photosensitive patients involves a comprehensive history, physical examination, phototesting, and, if necessary, photopatch testing and laboratory evaluation. Polymorphous light eruption, chronic actinic dermatitis, solar urticaria, and photosensitivity secondary to systemic medications are the most commonly encountered photodermatoses in dermatology clinics worldwide.

Photoprotection and vitamin D: a review.

The topic of vitamin D is at the forefront of discussions due to evidence suggesting its role in extra-skeletal health. It is already established that vitamin D plays a key role in skeletal health in young and elderly adults. This vitamin is obtained mainly through sunlight; various factors such as skin pigmentation and seasons affect cutaneous synthesis. Debates about the effects of sunscreen use on cutaneous synthesis of vitamin D have arisen in recent years. An updated review of the literature emphasizes that adequate levels of vitamin D are needed to prevent osteoporosis, falls and fractures in the elderly population. Emerging data also point to its role in cardiovascular disease, auto-immune conditions and cancers. Normal usage of sunscreen by adults has not shown to decrease cutaneous synthesis of vitamin D. Recommended Daily Allowance for vitamin D, released in 2010, was based on studies examining skeletal effects of this vitamin. Oral intake with vitamin d-enriched foods or vitamin D supplements is recommended over prolonged ultraviolet exposure to maintain proper serum levels. Patients should not be discouraged from normal usage of sunscreens due to their well-established photoprotective effects.

The role of tumor necrosis factor-alpha and other cytokines in depression: what dermatologists should know.

Recent studies have suggested that inflammatory responses may play an important role in the pathophysiology of depression. In fact, depressed individuals have been found to have higher levels of pro-inflammatory cytokines, especially tumor necrosis factor-alpha (TNF-α) and interleukin-6. This appears to be independent of any pre-existing chronic inflammatory disorders. In this article, various studies correlating increased levels of cytokines to depression are reviewed. As much as 60% of individuals with psoriasis also suffer from clinical depression. TNF-α antagonists, frequently used in the treatment of psoriasis, may be helpful in directly reducing depressive symptoms for patients with psoriasis and other chronic inflammatory conditions.

IRF8 regulates acid ceramidase expression to mediate apoptosis and suppresses myelogeneous leukemia.

IFN regulatory factor 8 (IRF8) is a key transcription factor for myeloid cell differentiation and its expression is frequently lost in hematopoietic cells of human myeloid leukemia patients. IRF8-deficient mice exhibit uncontrolled clonal expansion of undifferentiated myeloid cells that can progress to a fatal blast crisis, thereby resembling human chronic myelogeneous leukemia (CML). Therefore, IRF8 is a myeloid leukemia suppressor. Whereas the understanding of IRF8 function in CML has recently improved, the molecular mechanisms underlying IRF8 function in CML are still largely unknown. In this study, we identified acid ceramidase (A-CDase) as a general transcription target of IRF8. We demonstrated that IRF8 expression is regulated by IRF8 promoter DNA methylation in myeloid leukemia cells. Restoration of IRF8 expression repressed A-CDase expression, resulting in C16 ceramide accumulation and increased sensitivity of CML cells to FasL-induced apoptosis. In myeloid cells derived from IRF8-deficient mice, A-CDase protein level was dramatically increased. Furthermore, we demonstrated that IRF8 directly binds to the A-CDase promoter. At the functional level, inhibition of A-CDase activity, silencing A-CDase expression, or application of exogenous C16 ceramide sensitized CML cells to FasL-induced apoptosis, whereas overexpression of A-CDase decreased CML cells' sensitivity to FasL-induced apoptosis. Consequently, restoration of IRF8 expression suppressed CML development in vivo at least partially through a Fas-dependent mechanism. In summary, our findings determine the mechanism of IRF8 downregulation in CML cells and they determine a primary pathway of resistance to Fas-mediated apoptosis and disease progression.

Actinic lichen nitidus.

We present the case of a 29-year-old black female with an initial clinical and histopathologic diagnosis of actinic lichen nitidus. Three years later, she presented with scattered hyperpigmented macules with oval pink/violaceous plaques bilaterally on her forearms and on her neck, clinically consistent with actinic lichen planus. She was treated with topical steroids at each visit, with subsequent resolution of her lesions. In this report, we discuss the spectrum of actinic lichenoid dermatoses and of disease that presents even in the same patient.

Giant verrucous nodules in a patient with tuberculosis.

Sarcoidosis is a systemic inflammatory disorder characterized histologically by noncaseating granulomas in affected organs. Cutaneous manifestations of the disease such as papules, nodules, plaques, and ulcerations occur in approximately 25% of the patients. Sarcoidosis can present with multiple different morphologies including annular, psoriasiform, ichthyosiform, morpheaform, and verrucous. In this study, we report a 30-year-old African American man with a history of spinal tuberculosis as a child and slowly enlarging verrucous nodules that appeared at the age of 5 years. After an extensive infectious disease evaluation, the diagnosis of verrucous sarcoidosis was established with the presence of noncaseating granulomas and a completely negative workup for infectious etiologies.