NITROSOGENESIS LESSONS FROM DERMATOLOGISTS-NITROSAMINES/ NDSRIS CONTAMINATION OF THE POLIMEDICATION IN POLIMORBID PATIENTS AS THE MOST POWERFUL SKIN CANCER INDUCTOR: DOUBLE HATCHET FLAP FOR SCC OF THE SCALP OCCURRING DURING TREATMENT WITH VALSARTAN/ HYDROCHLOROTHIAZIDE AND LERCANIDIPINE.

Nitrosogenesis remains to be a topic that is and, in all likelihood, will be relevant in the near and distant future. The reason for this actuality is mainly due to the official data of the regulatory authorities in the face of the FDA, starting back in 2018 with the announcement of the contamination of Valsartan with nitrosamines. This issue only became more profound in April 2023, when again the FDA declared over 250 of the most widely distributed drugs worldwide as actually or potentially contaminated with ˝hypothetical˝ carcinogens. Unfortunately, according to the literature, it is the intake of ˝hypothetical carcinogens˝ that is associated with the development of real carcinomas, including cutaneous tumours. Additionally, the type of carcinogens that could ˝hypothetically˝ be found in these drugs (in the regulatory agency recommendations) has been added to the list, and they are categorized as having a ˝hypothetical carcinogenic potency˝ between 1 to 5 according to the FDA regulation as to pharmaceutical companies from August 2023. Reference values have also been established for each carcinogen. Interestingly, in certain geographic regions such as Eastern Europe, for example, in certain institutions, over periods of 10 years or more, over 98.9% of cases of actual cutaneous tumours (keratinocytic, melanocytic, etc.), could be linked/associated primarily (not hypothetically) to polymedication, which according to official FDA data from April 2023, could be defined as actually/potentially contaminated with up to several ˝hypothetical˝ carcinogens simultaneously. The lack of official data on the contamination of these batches of drugs (with nitrosamines/ NDSRIs) remain even for the period 2018-2023 more than worrying and are one indirect evidence of their real rather than hypothetical availability. Nonetheless, the 2023 FDA data cast considerable doubt as to whether, within the polymorbidity and contamination of polymedication, the allowable daily doses of carcinogens are being substantially exceeded. An open question for regulators remains: Did the giant Pfizer withdraw its high blood pressure drugs in 2022 (hydrochlorothiazide, quinapril) due to the presence of ˝hypothetical carcinogens˝? In practice, Pfizer appears to be one of the few or only companies to have openly stated the reason for withdrawing their preparations due to contamination with real carcinogens and thus protect end users. With this official preventive act, the Giant Pfizer gained the trust of patients worldwide. Another and even more serious dilemma remains whether this is a controlled contamination of certain batches of medicines in certain geographical regions? Indicative therefore are recently published data on the absence of contamination of all batches of a certain class of medicines in certain geographical regions. The genesis of the 'sporadicity' and the 'selectivity' of contamination remain for the time being unresolved and open new and novel questions. We present an 82-year-old patient with arterial hypertension taking hydrochlorothiazide, valsartan and lercanidipine for 3 years who developed a short-term squamous cell carcinoma of the scalp after taking them (1,5- 2 years later) , operated successfully by double hatchet flap. The pathogenesis of the skin tumor/keratinocytic cancer is commented in the context of nitrosogenesis and the officially announced contamination by the FDA with ˝hypothetical carcinogens˝ leading once again to the appearance of a real squamous cell carcinoma of the skin. The polycontamination of multimedication within polymorbidity appears to be problematic. It is thanks to the official FDA data that the strength of these interrelationships is beginning to become clearer although not at the desired speed of clinicians and end users. Discovering the logical relationship between databases (concerning the incidence of skin cancer, but not only) from different periods should only be relative or consistent with current bulletins of regulators and contaminated polymedication. This is what guarantees that the objective truth will be brought to the surface and ensure, through the possible rapid elimination of the contaminants: 1) better survival for patients and 2) better quality of life.