Spontaneous resolution of a giant keratoacanthoma penetrating through the nose.

Although keratoacanthomas are common and spontaneous resolution well recognized, case reports with photographic documentation of resolution are few. The subtype of giant keratoacanthoma (GKA) can give rise to severe cosmetic destruction because of their size and their predilection for cosmetically sensitive areas (nose and eyelids). Spontaneous resolution of GKAs has not been widely reported. We present an impressive series of clinical photographs documenting the spontaneous resolution of a GKS on the nose of a 56-year-old patient.

Topical photodynamic therapy in the treatment of hidradenitis suppurativa.

Topical photodynamic therapy (PDT) is well established for the treatment of malignant and pre-malignant skin lesions and now it is increasingly used to treat benign dermatological conditions. The studies reporting the use of PDT in hidradenitis suppurativa are reviewed. Though small in number, there is considerable variation in the application of topical photosensitisers, light sources used and treatment regimes. In addition there is often limited information about patient selection in terms of disease severity and measuring precise patient outcome. These issues need to be addressed in future studies in order to accurately determine the role of PDT in this disease.

Microbiological effect of photodynamic therapy (PDT) in healthy volunteers: a comparative study using methyl aminolaevulinate and hexyl aminolaevulinate cream.

BACKGROUND: Acne vulgaris is a common skin problem that affects up to 90% of adolescents. Colonization of the duct with Propionibacterium species is one of the factors implicated in the development of acne. Owing to the increasing incidence of antibiotic resistance, there has been an greater interest in the development of new methods to treat acne. Early studies have shown that photodynamic therapy (PDT) with aminolaevulinic acid (ALA) can lead to prolonged improvement in acne. Newer derivatives of ALA such as methyl aminolaevulinate hydrochloride (MAL) and hexyl aminolaevulinate hydrochloride (HAL) have been developed for use in PDT, with the potential benefits of higher lipophilicity and penetration potential. OBJECTIVES: To determine the microbiological effect and tolerability of a single application of HAL-PDT and to compare it with MAL-PDT in healthy volunteers. METHODS: This was a randomised double-blind study to examine the microbiological effects and safety of a single application of MAL-PDT and HAL-PDT on normal skin in 18 healthy volunteers. Bacterial skin samples for Propionibacterium spp. and Micrococceae were obtained at baseline and 2, 4, 7 and 14 days. RESULTS: Following PDT with MAL and HAL, a statistically significant transient reduction in mean density of Propionibacterium spp. 2 days after treatment using each agent (P < 0.05 for both) was found. There were no significant changes in mean number of Micrococceae for the duration of the study period. Treatment with HAL-PDT and MAL-PDT was well tolerated. Overall, HAL-PDT was associated with fewer side-effects compared with MAL-PDT (P < 0.01) over the 14 day study period. CONCLUSION: HAL-PDT and MAL-PDT transiently reduce density of Propionibacterium spp. density to a similar degree in normal healthy individuals. The transient reduction in Propionibacterium spp. suggests that the prolonged antiacne effect of PDT relies on factors independent of bacterial density. HAL-PDT appears to be better tolerated than MAL-PDT.

Topical photodynamic therapy for non-cancerous skin conditions.

Topical photodynamic therapy (PDT) is a non-invasive therapeutic modality which is developing increasing use in dermatology. It is a well established treatment for pre-malignant and malignant skin tumours and over recent years there has also been encouraging evidence for its use in treating benign cutaneous disorders. We review the literature and clinical trials utilising topical PDT for non-cancerous skin conditions. Recalcitrant warts, acne vulgaris and psoriasis have so far been studied in most detail. At present, photosensitisers, light sources and treatment parameters of PDT vary in different clinical trials even for the same conditions. Optimum parameters for PDT need to be established and comparison randomised studies are required to clarify whether PDT for benign dermatoses is significantly superior to existing therapeutic modalities.

Efficacy of oral isotretinoin in the control of skin and nasal colonization by antibiotic-resistant propionibacteria in patients with acne.

BACKGROUND: Skin colonization by antibiotic-resistant propionibacteria is commonplace among acne patients globally. Increasing attention is now being paid to how resistance rates might be reduced to preserve the future efficacy of antibiotics, especially erythromycin and clindamycin in acne therapy. OBJECTIVE: To assess the efficacy of oral isotretinoin in the control of antibiotic-resistant propionibacteria. METHODS: Acne patients (72 in the U.K., 62 in the U.S.A.) colonized with high numbers of antibiotic-resistant propionibacteria were sampled before, during and 12 weeks after oral isotretinoin therapy. Propionibacterial samples were collected from five acne-prone skin surface sites using a detergent scrub method and from the anterior nares using moistened swabs. Total and antibiotic-resistant propionibacteria were enumerated by viable counting on media with and without selective antibiotics. RESULTS: After 16 weeks of oral isotretinoin therapy, mean population densities of viable propionibacteria and variants resistant to erythromycin, clindamycin or tetracycline had fallen by more than 90% at all skin sites and in the nares. The sole exception was a smaller reduction in tetracycline-resistant strains on the lower back. In general, greater reductions were observed on skin than in the nares. By the end of the treatment period only three patients (all in Philadelphia) yielded no antibiotic-resistant strains from any site. Post-treatment, propionibacterial counts remained well below pretreatment levels but had begun to recover on the face and in the nares. The recovering propionibacterial population included both susceptible and resistant strains. Changes during and post-treatment at the two centres were similar but not identical. CONCLUSIONS: Oral isotretinoin effectively reduced skin and nasal colonization by antibiotic-resistant propionibacteria. However, viable populations of resistant isolates persisted post-treatment at multiple sites. Novel methods are required to eradicate antibiotic-resistant propionibacteria completely, especially from the nasal reservoir.

Investigation of the use of the pulsed dye laser in the treatment of Bowen's disease using 5-aminolaevulinic acid phototherapy.

BACKGROUND: The use of 5-aminolaevulinic acid photodynamic therapy (ALA-PDT) for the treatment of Bowen's disease is well established. However, treatment with a continuous light source has the disadvantage of prolonged treatment time during which patients often experience significant discomfort requiring the use of local anaesthetic. OBJECTIVES: The aim of this study was to assess the efficacy and safety of the pulsed dye laser (PDL) as the light source for photoactivation of the protoporphyrin IX to treat Bowen's disease by PDT. METHODS: Thirteen patients with a total of 17 patches of histologically proven Bowen's disease were treated with 20% 5-ALA in Unguentum M (Crookes Healthcare, Nottingham, U.K.) under occlusion for 4 h. The patches were then irradiated using a Candela SPLTL-1b (Candela Corporation, Wayland, MA, U.S.A.) PDL using a wavelength of 585 nm, with a 7-mm diameter spot at a fluence of 10 J cm(-2). The spots overlapped by 50% to cover the lesion and extend beyond the clinical margin of the patch of Bowen's disease by 0.5 cm. Patients were then followed up initially at 2 months, then at 3-monthly intervals for a period of 12 months to assess treatment success and recurrence rate. RESULTS: Subjects consisted of 10 females and three males, between 47 and 88 years. The mean area of the patches of Bowen's disease was 315.4 mm(2) (range 36-2464 mm(2)) requiring a median of 32 pulses (range 3-260). Lesions sites were hands (two), foot (one) and lower leg (14). All patients experienced varying degrees of discomfort during treatment but none required the use of local anaesthetic. At 2 months eight treatment sites could not be assessed due to loose overlying crusts and removal of these revealed superficial erosions in seven patients. Of the 17 lesions treated, on follow-up at 1 year, 14 patches (82%) demonstrated a complete clinical response, although one of these had required a second treatment. Two patients with three lesions that would have required further therapy refused a second treatment. Prolonged crusting lasting 8 weeks occurred in eight patches and prolonged discomfort lasting 6 weeks occurred in four patients. CONCLUSIONS: This study has shown that the PDL is an effective light source for ALA-PDT of Bowen's disease. Light source exposure times are shorter, although overall treatment time may not always be significantly reduced for larger lesions. The procedure was well tolerated. However, the post-treatment morbidity was relatively high compared with the more conventional treatment modalities. Further studies are needed to determine whether lower energy fluences can maintain similar efficacy while reducing post-treatment morbidity.

An unusual case of a compound depressed skull fracture after an assault with a stiletto heel.

Compound depressed skull fractures occur commonly from assault with various sharp and blunt objects. The use of a stiletto heeled shoe as an offensive weapon has not been reported before as a cause of such an injury. However unusual the history of assault, a clear picture of the mechanism of the injury is vital. Patients with scalp lacerations following a direct blow to the head must be evaluated thoroughly. Early investigation and treatment are necessary to reduce the risk of complications, as illustrated by this case.

Compliance of renal transplant recipients with advice about sun protection measures: completing the audit cycle.

Renal transplant recipients are at increased risk for development of nonmelanoma skin carcinoma, owing to a number of causes, including ultraviolet exposure. It has been shown that, despite education, there is poor compliance by these patients with the advice given for protecting their skin from the sun. This repeat study was conducted to determine whether there had been an improvement in compliance over the last 6 years. Two hundred twenty-seven patients were invited to complete the questionnaire used in the previous study. This questionnaire was designed to establish whether patients understood the need for extra care, whether they recalled any education about protective measures, and what actual measures were taken. There was a significant increase in the proportion of patients taking appropriate precautions. Hence there has been a significant improvement in the compliance of renal transplant recipients in Yorkshire with skin protection measures since this was originally audited in 1998.

Topical aminolaevulinic acid-photodynamic therapy for the treatment of acne vulgaris: a study of clinical efficacy and mechanism of action.

BACKGROUND: Acne affects 83-95% of 16-year-olds of both sexes, and many seek help from a clinician. Emerging problems with conventional acne treatments, specifically antibiotic resistance of Propionibacterium acnes and fears over the safety and tolerance of oral isotretinoin, create a demand for novel treatment modalities in acne. OBJECTIVES: To study the efficacy of aminolaevulinic acid-photodynamic therapy (ALA-PDT) in the treatment of acne and to identify the mode of action, looking specifically at the effects on surface numbers of P. acnes and on sebum excretion. METHODS: Ten patients (nine men and one woman, age range 16-40 years) with mild to moderate acne on their backs were recruited. Each patient's back was marked with four 30-cm2 areas of equal acne severity. Each site was then randomly allocated to either ALA-PDT treatment, light alone, ALA alone or an untreated control site. At baseline, numbers of inflammatory and noninflammatory acne lesions were counted, sebum excretion measured by Sebutapes (CuDerm, Dallas, TX, U.S.A.) and surface P. acnes swabs performed. ALA cream (20% in Unguentum Merck) was applied under occlusion to the ALA-PDT and ALA alone sites for 3 h. Red light from a diode laser was then delivered to the ALA-PDT and light alone sites (635 nm, 25 mW cm(-2), 15 J cm(-2)). Each patient was treated weekly for 3 weeks. At each visit acne lesion counts were performed and 3 weeks following the last treatment sebum excretion rates and P. acnes swabs were repeated. RESULTS: There was a statistically significant reduction in inflammatory acne lesion counts from baseline after the second treatment at the ALA-PDT site but not at any of the other sites. No statistically significant reduction in P. acnes numbers or sebum excretion was demonstrated at any sites including the ALA-PDT site. CONCLUSIONS: ALA-PDT is capable of clinically improving acne. An alternative mode of action for ALA-PDT other than direct damage to sebaceous glands or photodynamic killing of P. acnes is suggested from the results of this study.

Disseminated cutaneous infection with Mycobacterium chelonae in a patient with steroid-dependent rheumatoid arthritis.

Mycobacterium chelonae is a rapidly growing atypical mycobacterium that is a normal commensal of water and soil. We report a case of a 61-year-old man with seronegative rheumatoid arthritis and fibrosing alveolitis on long-term prednisolone who presented with a number of tender, red, subcutaneous nodules on his upper arms and a pustule on his left cheek. Histopathologic examination revealed dense neutrophilic collections within the deep dermis and subcutaneous fat with abscess formation. Long filamentous organisms were seen within these collections and were subsequently identified by special stains and PCR as Mycobacterium chelonae. Treatment was not possible as the patient developed bacteria bronchopneumonia before identification of the organism and he subsequently died. Post-mortem revealed no extra-cutaneous evidence of mycobacterium infection.