Surgical treatment of basal cell carcinoma: a case series on factors influencing the risk of an incomplete primary excision.

BACKGROUND: Basal cell carcinoma (BCC) is the most common skin cancer form, and one first-line treatment is surgical excision. Complete excision is vital to minimize risk of recurrence. Studies on occurrence of incomplete excisions have given diverse results and seldom include large populations from a dermatological setting. OBJECTIVES: The rate of positive surgical margins in primary surgery of BCC at a tertiary dermatology clinic is studied. Factors associated with an incomplete primary excision are analysed. METHODS: Patients scheduled for standard excision, without perioperative margin control, of BCC during the years 2008-2015 were prospectively enrolled in the study. Tumour-specific factors, including histopathologic subtype, as well as postoperative outcome were registered. Incomplete excisions were analysed in relation to patient- and tumour-related factors. RESULTS: In total, 4.6% of 3911 BCC tumours were incompletely excised. The rate of incomplete excisions was higher for facial tumours and among tumours with an aggressive histological subtype. Morpheiform BCC on the nose or ear had the highest rate of an incomplete excision, 61.5% and 50%, respectively. CONCLUSIONS: Most BCCs, irrespective of subtype, were completely excised during the primary excision. Tumour sites nose and ears were associated with the highest rate of positive primary surgical margins, especially for infiltrative or morpheiform BCCs. Surgery with perioperative examination of margins is strongly recommended for these tumours.

Diagnostic agreement and interobserver concordance with teledermoscopy referrals.

BACKGROUND: Malignant melanoma and non-melanoma skin cancers are among the fastest increasing malignancies in many countries. With the help of new tools, such as teledermoscopy referrals between primary health care and dermatology clinics, the management of these patients could be made more efficient. OBJECTIVE: To evaluate the diagnostic agreement and interobserver concordance achieved when assessing referrals sent through a mobile teledermoscopic referral system as compared to referrals sent via the current paper-based system without images. METHODS: The referral information from 80 teledermoscopy referrals and 77 paper referrals were evaluated by six Swedish dermatologists. They were asked to answer questions about the probable diagnosis, the priority, and a management decision. RESULTS: Teledermoscopy generally resulted in higher diagnostic agreement, better triaging and more malignant tumours being booked directly to surgery. The largest difference between the referral methods was seen for invasive melanomas. Referrals for benign lesions were significantly more often correctly resent to primary health care with teledermoscopy. However, referrals for cases of melanoma in situ were also incorrectly resent five times. The interobserver concordance was moderate with both methods. CONCLUSION: By adding clinical and dermoscopic images to referrals, the triage process for both benign and dangerous skin tumours can be improved. With teledermoscopy, patients with melanoma especially can receive treatment more swiftly.

Preoperative prediction of histopathological outcome in basal cell carcinoma: flat surface and multiple small erosions predict superficial basal cell carcinoma in lighter skin types.

BACKGROUND: Prediction of the histopathological subtype of basal cell carcinoma (BCC) is important for tailoring optimal treatment, especially in patients with suspected superficial BCC (sBCC). OBJECTIVES: To assess the accuracy of the preoperative prediction of subtypes of BCC in clinical practice, to evaluate whether dermoscopic examination enhances accuracy and to find dermoscopic criteria for discriminating sBCC from other subtypes. MATERIALS AND METHODS: The main presurgical diagnosis was compared with the histopathological, postoperative diagnosis of routinely excised skin tumours in a predominantly fair-skinned patient cohort of northern Europe during a study period of 3 years (2011-13). The study period was split in two: during period 1, dermoscopy was optional (850 cases with a pre- or postoperative diagnosis of BCC), while during period 2 (after an educational dermoscopic update) dermoscopy was mandatory (651 cases). A classification tree based on clinical and dermoscopic features for prediction of sBCC was applied. RESULTS: For a total of 3544 excised skin tumours, the sensitivity for the diagnosis of BCC (any subtype) was 93·3%, specificity 91·8%, and the positive predictive value (PPV) 89·0%. The diagnostic accuracy as well as the PPV and the positive likelihood ratio for sBCC were significantly higher when dermoscopy was mandatory. A flat surface and multiple small erosions predicted sBCC. CONCLUSIONS: The study shows a high accuracy for an overall diagnosis of BCC and increased accuracy in prediction of sBCC for the period when dermoscopy was applied in all cases. The most discriminating findings for sBCC, based on clinical and dermoscopic features in this fair-skinned population, were a flat surface and multiple small erosions.

Determining venous incompetence: a report from a specialised leg ulcer clinic.

OBJECTIVE: To analyse the diagnosis, treatment and prognosis in patients attending a specialised leg ulcer clinic at a dermatology department. METHOD: In total, 345 patients were investigated and 332 registered and followed up prospectively. All patients had their arterial and venous circulation assessed with a hand-held Doppler ultrasound. RESULTS: The most frequent diagnosis was venous ulceration (153 patients, 46%) followed by hydrostatic ulceration (70 patients, 21%). Venous incompetence was classified as isolated superficial (n=86) or deep venous incompetence (n=57) in 143 out of the 153 patients. Previous deep vein thrombosis (DVT) was more frequent in patients with deep venous incompetence. Of patients with venous ulcers, 38 (25%) healed within 92 days, 77 (50%) within 155 days and 115 (75%) within 329 days. Healing time was influenced by patient age, ulcer duration and ulcer area, but not by type of venous incompetence or ankle brachial pressure index. After healing, 19% of venous patients (28/144), dominated by those with superficial disease, were subject to venous vascular surgery. CONCLUSION: Classification of venous insufficiency should be mandatory in patients with venous ulcers since it determines suitability for venous surgery.

Photoaugmentation in drug phototoxicity.

The phototoxic reaction to chlorpromazine and other drugs is provoked by long-wave ultraviolet light (UVA). It was shown by the in vivo mouse tail technique that the reaction is enhanced by medium-wave ultraviolet light (UVB), thus demonstrating the importance of photoaugmentation in this process.

Photohemolytic potency of tetracyclines.

Hemolysis induced by long-wave ultraviolet radiation (UVA) and 8 different commercial tetracycline derivatives was studied in a model using human red blood cells. Demethylchlortetracycline and doxycycline were shown to have pronounced hemolytic properties causing 88% and 85% hemolysis, respectively, at a concentration of 50 micrograms/ml and 72 J/cm2 of UVA. Tetracycline, oxytetracycline, and chlortetracycline caused maximally 18% hemolysis at 200 micrograms/ml and lymecycline only 7% at 100 micrograms/ml. Methacycline showed intermediate hemolytic effect of 36% at 200 micrograms/ml. Minocycline had no hemolytic effect whatsoever. These experimental data correlate very well with clinical reports and comparative phototoxicity trials in humans. Photohemolysis may thus be of value for predicting tetracycline phototoxicity.

Influence of tetracycline phototoxicity on the growth of cultured human fibroblasts.

The phototoxic effect of 8 different commercial tetracycline derivatives with long-wave ultraviolet radiation (UVA) on the growth pattern of normal human skin fibroblasts in culture was studied. Chlortetracycline and doxycycline both at a concentration of 50 micrograms/ml and 1.9 J/cm2 of UVA resulted in total cell death with no recovery during a 14-day observation period. Demethylchlortetracycline also showed strong photosensitizing properties with an arrested cell division for 7 days followed by a recurrence of cell growth. The other tetracyclines tested under identical conditions had only weak or no phototoxic influence on cell growth. These experimental data correlate very well with clinical reports and comparative phototoxicity trials in humans. This experimental method may thus be of value for predicting tetracycline phototoxicity in humans.

Dose-response relations in phototoxicity due to 8-methoxypsoralen and UV-A in man.

Serum levels and skin photosensitivity following different oral doses of 8-methoxypsoralen (8-MOP) were studied in 8 healthy volunteers. Two hours after ingestion of drug, serum levels of 8-MOP determined by high pressure liquid chromatography correlated well with oral dose. Serum concentrations after 8-MOP doses of 0.3, 0.6 and 0.9 mg/kg bodyweight were 25.9 (+/- 7.2), 148.9 (+/- 24.4) and 311.4 (+/- 55.6) ng/ml (mean and SEM) respectively. The minimal phototoxic dose (MPD) of UVA 2 hr after ingesting 8-MOP was determined in 6 volunteers for each of the 3 before-mentioned 8-MOP doses. The UV-A doses correlated inversely with the serum level for each individual (r = 0.92 +/- 0.02 SEM). For higher 8-MOP doses the numerical product of UV-A dose and 8-MOP serum concentration in each individual tended to be constant, indicating a reciprocal relationship between 8-MOP and UV-A doses in this interval. This did not hold true for the lowest 8-MOP-dose. These data confirm the relevance of using 8-MOP blood level determinations in monitoring psoralen-UV-A phototoxicity.

Experimental studies on the mechanism of benoxaprofen photoreactions.

Benoxaprofen (BP), a non-steroidal antiphlogistic drug causing skin and nail photoreactions, has been evaluated for photoactivity using three experimental techniques. In vivo in the mouse, BP was phototoxic in doses of 25 mg/kg in combination with UV-A 54J. The phototoxic potency could be confirmed in vitro with the Candida albicans test. In vitro, using photohemolysis, BP showed a dose-dependent activity causing 40% hemolysis at a concentration of about 25 micrograms/ml with UV-A. Also, small UV-B doses caused red cell lysis with a moderate BP concentration. Pre-irradiation experiments showed that UV-A, but not UV-B, photoproducts could account for some of the activity. The action spectrum of BP photoactivity lies mainly in the UV-A, but may also extend into UV-B. Compared with chlorpromazine in vivo and in vitro, and with doxycycline in vivo, BP showed intermediate phototoxic activity.

A novel dithranol formulation in the over night treatment of psoriasis at home.

The objective of this study was to compare the clinical efficacy and acceptability of two dithranol creams (Micanol and Amitase) in patients with plaque type psoriasis treating themselves daily at home. Thirty-five patients started with Amitase (0.1%) and 37 with Micanol (0.1%) applied at night in this 6-week single-blind parallel groups comparison study. Patients who responded more slowly than a theoretically estimated "standard" rate of improvement had their concentration increased to 0.25% at the visit after 2 or 4 weeks. By the end of the study slightly more than half of the number of patients remained on 0.1%. There was no difference between the treatment groups. In comparison with the level at start the composite sign severity score for patients in the Amitase group was reduced by 24% after 1 week, 36% after 2 weeks, 49% after 4 weeks and 62% after 6 weeks. The reduction in the Micanol group was similar. Patients in the Micanol group showed after 1 week of treatment more irritative reactions than patients in the Amitase group. At all follow-up visits, staining of perilesional skin was more prevalent in the Micanol group. Staining of clothing was, however, far more prevalent and severe for patients given the Amitase cream. It may be concluded that Micanol is an important alternative for home treatment of psoriasis.

Hydrostatic leg ulcers: a new classification.

The classification of leg ulcers into standard aetiologies was conducted using a sample of 205 patients referred to the department of dermatology, Malmö University Hospital in Sweden. Patients with venous ulcers formed the largest group (51%). Classification was not possible in 31 patients (approximately 15%) and this formed the second largest group. A comparison of ulcer characteristics between this unclassified group and the venous ulcer group showed that the unclassified ulcers occur in patients with little or no venous disease and display different characteristics from venous ulcers. As a result of these differences, we propose that there should be a further classification of ulcers, known as 'hydrostatic' ulcers. The identification of this type of ulcer has important consequences for future ulcer management as these patients will not require venous surgery or further compression therapy following healing.

Measuring the size of ulcers by planimetry: a useful method in the clinical setting.

OBJECTIVE: The aim of this study was to compare four measurement methods. Digital planimetry was compared with mechanical planimetry, placing the film over graph paper and counting the squares (grid tracing), and multiplying the two maximal perpendicular diameters of the ulcer (diameter product). METHOD: Twenty patients with 50 chronic leg ulcers of various aetiology and sizes (20 ulcers were < or = 3 cm2, 15 ulcers were > 3 cm2 and < or = 10 cm2, and 15 ulcers were > 10 cm2) were enrolled consecutively into this study. Ulcer area was calculated from film transparency tracings using a digital planimeter, a mechanical planimeter, grid tracing and diameter product. RESULTS: The mean difference of digital planimetry versus mechanical planimetry, grid tracing and diameter product was 0.51 cm2, 0.72 cm2 and -5.38 cm2, respectively. For all methods difference tended to increase with ulcer size. CONCLUSION: Digital and mechanical planimetry, together with grid tracing, appear to be appropriate means of obtaining accurate surface area measurements. Digital planimetry is a quick and practical method and could therefore be recommended in the clinical setting.

Pain in venous leg ulcers.

A prospective study was conducted to assess the prevalence, severity and diagnostic utility of pain in patients with venous leg ulcers. A semi-structured questionnaire was completed by 140 consecutive patients in two specialist centres caring for patients with leg ulcers. A high proportion (64%) of the 94 patients with ulcers of purely venous aetiology reported severe pain; 50% of these patients were taking either mild analgesia or none at all. In 10 of 72 cases, leg elevation made the pain worse. Venous ulcers are painful. Pain in three distinct locations was reported by patients-within ulcers, around ulcers and elsewhere in the leg. The presence of severe pain does not necessarily indicate arterial disease or infection. Pain is, in general, inadequately controlled in these patients.

Pinch grafting in hospital and primary care: a cost analysis.

The cost of treating venous leg ulcers with pinch grafting was evaluated for 58 consecutive patients: 29 in hospital care and 29 in primary care. The mean age was 76.8 and 74.3 years and the mean ulcer size 15.1 and 13.5 cm2, respectively. The operation technique, pinch grafting, was the same for all patients but primary care patients were not immobilised postoperatively. Healing rate within 12 weeks was the same for patients in hospital care and primary care (31%). Treatment costs for one week pre-operatively and three weeks postoperatively amounted to 5109 Pounds per patient in hospital care and 870 Pounds per patient in primary care (p < 0.001), and the costs for one week pre-operatively and 12 weeks postoperatively were 6738 Pounds and 1806 Pounds, respectively (p < 0.001). Costs for patients whose ulcers healed within 12 weeks were 5552 Pounds for those receiving hospital care and 1676 Pounds for those receiving primary care (p < 0.001). Pinch grafting in primary care was shown to cost 3.3 to 5.9 times less, with the same healing outcome, than pinch grafting in hospital care.

Letters.

A NEW CLASSIFICATION OF LEG ULCERS CYTOCOMPATIBILITY OF HYDROCOLLOID DRESSINGS CORRECTION.

Letters.

HYDROGELS AND FOAM DRESSINGS IN COMBINATION CONTROLLING BLEEDING IN FUNGATING WOUNDS HYDROSTATIC LEG ULCERS COMMUNITY LEG ULCER CLINICS.

Expression of tissue-type and urokinase-type plasminogen activator activities in chronic venous leg ulcers.

BACKGROUND: Chronic wounds have been shown to exhibit elevated levels of several classes of proteinases. Plasminogen activators (PAs) are proteinases which play a major role in the biological processes involved in wound healing and abnormalities in PAs may play a role in the pathology associated with chronic wounds. Here, we investigated the expression of tPA and uPA activities in chronic venous ulcer biopsies. PATIENTS AND METHODS: In 22 patients with chronic venous leg ulcers, punch biopsies were taken from the ulcer base, ulcer margin and uninvolved skin from the thigh of the affected limb and PA activities were assessed using in situ histological zymography. RESULTS: tPA is the main PA activity in uninvolved skin but was reduced in ulcer margin skin and venous leg ulcer tissue compared to normal skin. uPA activity appeared throughout the ulcer margin skin but was at low levels in normal skin. Ulcer base tissue appeared to exhibit a plasminogen-independent proteinase activity not seen in normal or ulcer margin skin. CONCLUSION: PA activities are altered in and around chronic venous leg ulcers and their distribution suggests that blood vessels in CVI may be damaged and that the tissue is in an inflamed state.

Nail-changes induced by penicillamine.

Peculiar nail-changes in a 70-year-old woman with rheumatoid arthritis occurring after approximately 1 year of penicillamine treatment are described. After cessation of treatment there was a gradual resolution with regain of normal nails after 7 months. Reinstitution of penicillamine treatment caused a recurrence thus proving a causal relationship between penicillamine and the described nail-changes. The fingernails were more affected than the toenails and clinically the changes consisted of absence of lunulae, longitudinal ridging, transverse or longitudinal defects of the nailplate and a tendency of onychoschizia.