Mohs micrographic surgery for basal cell carcinomas: appropriateness of 'Rotterdam' criteria and predictive factors for three or more stages.

BACKGROUND: In the Netherlands basal cell carcinomas (BCC) are eligible for Mohs microscopic surgery (MMS) if certain criteria are fulfilled. OBJECTIVE: To study the MMS indication criteria practised at the department of dermatology of the Erasmus University Medical Center, Rotterdam and to identify predictive factors for extensive subclinical tumour spread among BCCs eligible for MMS. METHODS: Pre-operative patient and tumour characteristics were derived retrospectively between January 2nd 2006 and December 28th 2009 from 1174 patient records, accounting for 1464 BCCs. Multivariate logistic regression models were used to calculate crude and adjusted odds ratios (OR) with 95% confidence intervals (CI) for one vs. two or more stages and for narrow (≤ 2 stages) vs. extensive subclinical spread (≥ 3 stages). RESULTS: H-zone location [adjusted OR 1.51 (95% CI 1.16-1.96)], recurrent tumour [adjusted OR 1.50 (95% CI 1.11-2.02)], aggressive subtype [adjusted OR 1.25 (95% CI 1.01-1.56)] and tumour size ≥ 11 mm [adjusted OR 1.53 (95% CI 1.20-1.96)] were significantly associated with two or more stages. Predictive factors for extensive subclinical spread were recurrent tumour [adjusted OR 2.26 (95% CI 1.61-3.17)], tumour size ≥ 21 mm [adjusted OR 1.69 (95% CI 1.13-2.51)] and location in the H-zone [adjusted OR 1.68 (95% CI 1.15-2.46)]. CONCLUSION: 'Rotterdam' indication criteria used for MMS are appropriate. Predictors for extensive subclinical spread are important for patients' and surgeons' expectations prior to the operation about time span, defect size, reconstruction and possible associated morbidity.

Treatment of vitiligo with khellin liposomes, ultraviolet light and blister roof transplantation.

BACKGROUND: Various surgical and non-surgical methods are available to treat vitiligo. Surgical techniques such as epidermal blister graft transplantation may be effective for the re-pigmentation of stable, but refractory vitiligo areas. Khellin has phototherapeutic properties that are similar to those of the psoralens, but with substantially lower phototoxic effects and DNA mutation effects. Its penetration into the hair follicles is enhanced by encapsulating it into liposomes. Subsequent activation of the khellin with UV light stimulates the melanocytes in the hair follicles. OBJECTIVE: The first objective was to evaluate the additional value of combining blister roof transplantation (BRT) with khellin in liposomes and ultraviolet light (KLUV) in the treatment of recalcitrant vitiligo patches. The second objective was to assess patients' satisfaction. MATERIALS AND METHODS: Nineteen patients with vitiligo lesions which did not respond to KLUV treatment for at least a year were treated with BRT followed by KLUV. The transplantation was performed by creating blisters with a suction device, preparing the target site with Erbium laser ablation and the actual transplantation. Locations where randomly assigned. A blinded observer established the results. RESULTS: Seventy-five percent of the patients were satisfied with the cosmetic result. All of the patients would recommend the treatment to other vitiligo patients. More than 75% re-pigmentation of the vitiligo areas was noted in 47% of the patients according to the blinded evaluation of photographs taken before and after the treatment.

Donor hair follicle preservation by partial follicular unit extraction. A method to optimize hair transplantation.

BACKGROUND: There are different stem cell pools located in the hair follicle. OBJECTIVE: To try to determine whether follicular units can survive a partial extraction and whether this partial extracted follicular unit can regenerate new hairs. METHODS: From five individuals, between 100 and 150 grafts were harvested from the occipital area of the scalp. Suitable grafts were implanted into the recipient area. Hair growth and characteristics in the donor area and the recipient area were observed at different intervals. RESULTS: After 3 months, between 92.1% and 104.1% (mean 97.7%) of the partial follicular units in the donor sites survived and produced hairs with the same characteristics. After 1 year, 91.1­101.7% (mean 95.9%) of the implanted partial follicular units regenerated hair growth with the same characteristics as the hairs in the donor area. CONCLUSIONS: We revealed that extracted partial longitudinal follicular units transplanted to the recipient area can be used as complete follicular units to regenerate completely differentiated hair growth with the same characteristics as in the donor area. We also revealed that the partial follicular units in the donor area can survive and produce the same number of hairs with the same characteristics. This technique enables us to generate two hair follicles from one follicle with consistent results and preserve the donor area.

Optimizing ALA-PDT in the management of non-melanoma skin cancer by fractionated illumination.

The aim of this review was to describe briefly the mechanism and history of photodynamic therapy (PDT). The achieved preclinical and clinical results in Rotterdam are discussed in the light of a search to optimize aminolevulinic acid-photodynamic therapy (ALA-PDT). As the incidence of skin cancer is rising, an optimized treatment in non-melanoma skin cancer is needed.

Heat conduction from the exceedingly hot fiber tip contributes to the endovenous laser ablation of varicose veins.

Lower-extremity venous insufficiency is a common condition, associated with considerable health care costs. Endovenous laser ablation is increasingly used as therapy, but its mechanism of action is insufficiently understood. Here, direct absorption of the laser light, collapsing steam bubbles and direct fiber-wall contact have all been mentioned as contributing mechanisms. Because fiber tips have reported temperatures of 800-1,300 degrees C during endovenous laser ablation, we sought to assess whether heat conduction from the hot tip could cause irreversible thermal injury to the venous wall. We approximated the hot fiber tip as a sphere with diameter equal to the fiber diameter, having a steady state temperature of 800 degrees C or 1,000 degrees C. We computed venous wall temperatures due to heat conduction from this hot sphere, varying the pullback velocity of the fiber and the diameter of the vein. Venous wall temperatures corresponding to irreversible injury resulted for a 3 mm diameter vein and pullback velocities <3 mm/s but not for 5 mm and > or =1 mm/s. The highest wall temperature corresponded to the position on the wall closest to the fiber tip, hence it moves longitudinally in parallel with the moving fiber tip. We concluded that heat conduction from the hot fiber tip is a contributing mechanism in endovenous laser ablation.

A comparative study on the efficacy of treatment with 585 nm pulsed dye laser and ultraviolet B-TL01 in plaque type psoriasis.

BACKGROUND: Narrow-band ultraviolet-B and pulsed dye laser (PDL) affect psoriasis but via different pathways. OBJECTIVE: To compare the results of PDL with ultraviolet-B light therapy (UVB) and to look for synergism of both therapies in patients with plaque type psoriasis. METHODS: In each eligible individual, four similar target plaques were selected, and halves of these plaques were treated using PDL, UVB, or a combination of PDL and UVB or were not treated. Results were recorded single-blind using the Physician's Global Assessment score at study enrolment and Week 13. Nonparametric, paired statistical tests were used to test for differences within and between therapies.The results were also analyzed after dichotomization of the changes in the Physician's Global Assessment score into responsive and nonresponsive to treatment. RESULTS: A significant improvement of the psoriasis lesions was noted at Week 13 (P<.001) with each therapy. No significant differences were noted between the therapies. Synergism of PDL and UVB was not observed. CONCLUSIONS: PDL is safe for treating plaque type psoriasis, but its efficacy is limited to a subgroup of patients. Combining PDL with UVB has no additional benefit.

Fractionated illumination significantly improves the response of superficial basal cell carcinoma to aminolevulinic acid photodynamic therapy.

Photodynamic therapy (PDT) of superficial basal cell carcinoma (sBCC) using topical 5-aminolevulinic acid (ALA) and a light fluence of 75-100 J cm(-2) yields unsatisfactory long-term results. In several animal models, illumination with two light fractions 2 hours apart was considerably more effective than single illumination. Response is further enhanced if the fluence of the first light fraction is reduced, although the cumulative fluence is maintained. We compared the response of sBCC to a single illumination and 2-fold illumination scheme in which two light fractions of 20 and 80 J cm(-2) are performed 4 and 6 hours after the application of a single dose of 20% ALA. We randomly assigned 154 patients with a total of 505 primary sBCC into two treatment groups. Two hundred and forty-three lesions were treated using a single illumination of 75 J cm(-2) at a fluence rate of 50 mW cm(-2). Fractionated PDT, at the same fluence rate, was performed on 262 lesions. The complete response (CR) following a 2-fold illumination scheme is significantly greater than that following a single light fraction (P=0.002, log-rank test). Twelve months after therapy, CR rate to a 2-fold illumination is 97%, whereas the CR to a single illumination is 89%.