A Prospective, Randomized, Single-Blind Study Comparing Cyanoacrylate Adhesives to Sutures for Wound Closure in Skin Cancer Patients.

BACKGROUND: Cyanoacrylate tissue adhesives are not more likely to result in wound dehiscence or infection than sutured closures. However, suturing is the gold standard for optimal cosmetic appearance of scars. OBJECTIVE: To determine whether cyanoacrylate tissue adhesives produce a cosmetic outcome equivalent to sutures at 3 months. Secondary outcomes include time for wound closure, time spent on wound care, and surgeon and patient satisfaction. MATERIALS AND METHODS: Seventy-one patients scheduled for skin cancer excision at Beverly Hospital were included in this prospective, randomized, single-blind study. Cosmetic appearance was assessed by a masked panel of dermatologists and plastic surgeons who evaluated digital photographs. Secondary outcomes were assessed by nursing recordings and patient and surgeon evaluations. RESULTS: There was no significant difference in wound appearance (Visual Analog Scale: p = .4693, modified Hollander Wound Evaluation Score: p = .6413) between adhesives and sutures. It was faster and easier for a surgeon to use adhesives, and subjects spent less time caring for and were more satisfied by wounds sealed with adhesives than sutures. CONCLUSION: Cyanoacrylate tissue adhesives produce cosmetic outcomes that are not statistically significantly different than sutures; furthermore, they are associated with fast application, easy wound care, and patient satisfaction.

Pediatricians' perspectives on indoor tanning.

This report presents results from an online survey of New York State pediatricians regarding their counseling habits and attitudes toward indoor tanning among adolescents, as well as their awareness of current legislation that restricts youth access to tanning beds.

Incidence of invasive squamous cell carcinomas in biopsy-proven squamous cell carcinomas in situ sent for Mohs micrographic surgery.

BACKGROUND: Squamous cell carcinoma (SCC) in situ (SCCIS) is often treated without any pathologic confirmation of tumor clearance. It is unclear how often an invasive SCC is harbored within a lesion in which the initial biopsy demonstrated SCCIS because of inadequate sampling. This study examines the final histologic diagnosis of cases in which the initial biopsies were diagnosed as SCCIS and evaluates factors that may correlate with a histologic upstaging of the diagnosis. METHODS: We prospectively recruited 29 consecutive patients with biopsy-proven SCCIS sent for Mohs micrographic surgery (MMS). Each tumor underwent MMS, and the central blocks of the Mohs debulking specimens were horizontally sectioned at 30-µm intervals until exhausted. A fellowship-trained Mohs surgeon and a board-certified dermatopathologist processed and examined these sections to determine the final histologic diagnosis of the tumor. RESULTS: Of the 29 subjects with biopsy-proven SCCIS, nine were found to harbor invasive SCC on final histology. Of the remaining lesions, seven had residual SCCIS, whereas the rest exhibited only actinic keratoses or scars. Approximately 31% of lesions showed evidence of invasive SCC. Correlating the clinical characteristics of the lesions with their corresponding final histologic diagnoses, the lesions harboring invasive SCC were more likely to demonstrate clinical signs of residual tumor (scales and papular changes) and be larger than 1.4 cm in diameter. LIMITATIONS: Our experience at a single institution in the northeastern United States may not be reflective of a wider population. There is also a possible referral bias, because only lesions with high clinical suspicion for invasive SCC were referred for MMS. CONCLUSION: Although biopsy-proven SCCIS is often treated with modalities that are best suited for superficial disease and do not involve a final pathologic confirmation of clearance (e.g., cryotherapy, electrodesiccation and curettage), this study demonstrated that up to 31% of biopsy-proven SCCIS lesions may harbor invasive SCC. Clinical signs of residual tumor and a diameter larger than 1.4 cm are statistically significant predictors of underlying invasive SCC. These data suggest that treatment modalities that include histologic control of tumor removal should also be strongly considered for the treatment of select biopsy-proven SCCIS meeting the above criteria.

Changes in skin tanning attitudes. Fashion articles and advertisements in the early 20th century.

Historical reviews suggest that tanning first became fashionable in the 1920s or 1930s. To quantitatively and qualitatively examine changes in tanning attitudes portrayed in the popular women's press during the early 20th century, we reviewed summer issues of Vogue and Harper's Bazaar for the years 1920, 1927, 1928, and 1929. We examined these issues for articles and advertisements promoting skin tanning or skin bleaching and protection. We found that articles and advertisements promoting the fashionable aspects of tanned skin were more numerous in 1928 and 1929 than in 1927 and 1920, whereas those promoting pale skin (by bleaching or protection) were less numerous. These findings demonstrate a clear shift in attitudes toward tanned skin during this period.

Lichenoid paraneoplastic pemphigus in the absence of detectable antibodies.

Paraneoplastic pemphigus (PNP) has been described as an antibody-mediated mucocutaneous disease occurring almost exclusively in patients with lymphocytic neoplasms. We describe 4 patients with the clinical features of the lichenoid variant of PNP in the absence of detectable autoantibodies. On the basis of these findings, we conclude that the spectrum of PNP likely includes patients with disease predominantly or exclusively mediated by cytotoxic T cells rather than autoantibodies. The pathophysiology and range of PNP disease are likely more complex than was initially believed.

Lymph node biopsy results for desmoplastic malignant melanoma.

Desmoplastic malignant melanoma (DMM) is a rare variant of melanoma with distinct histopathologic and clinical features. Compared with other melanomas, the desmoplastic variant demonstrates a greater frequency of local recurrence and a proclivity for tracking along nerves, but it poses a lower risk of distant metastases. Elective lymph node dissection and sentinel lymph node biopsy (SLNB) are commonly used tools for determining prognosis in thick melanomas. The role of these procedures for DMM remains unclear. This study was designed to characterize DMM and determine the frequency of histologically positive lymph nodes in patients with DMM. This retrospective chart review included patients with DMM treated by Johns Hopkins Hospital (JHH) physicians between 1998 and 2003. Among the 28 patients included in the study, 18 patients had biopsies performed on lymph nodes (15 SLNBs and 3 radical neck dissections). One patient had a sentinel lymph node with histology positive for DMM. All others had negative results from histology and S100 stains. This study suggests that the frequency of positive SLNBs in DMM may be substantially lower than that of other melanomas.

Cutaneous malignant melanoma.

Skin cancer has become the most common neoplasm in the United States. With early diagnosis and appropriate management, most skin cancers have an overall 5-year survival rate of 95%. Cutaneous malignant melanoma (CMM), however, has a significantly higher morbidity and mortality, resulting in 65% of all skin cancer deaths. Although the long-term survival rate for patients with metastatic melanoma is only 5%, early detection of CMM carries an excellent prognosis, with surgical excision often being curative. Primary care physicians can play a critical role in reducing morbidity and mortality from CMM by recognizing patients at risk, encouraging the adoption of risk-reducing behaviors, and becoming adept at identifying suspicious lesions.

Treatment of pemphigus vulgaris and pemphigus foliaceus with mycophenolate mofetil.

BACKGROUND: Mycophenolate mofetil is increasingly being used as a corticosteroid-sparing agent in immunosuppressive regimens. OBJECTIVE: To elucidate the effectiveness of mycophenolate as adjuvant therapy in the treatment of both pemphigus vulgaris and pemphigus foliaceus. DESIGN: Historical prospective study. SETTING: University hospital. PATIENTS: The study included 42 consecutive patients with pemphigus (31 with pemphigus vulgaris and 11 with pemphigus foliaceus) who had relapses during prednisone taper or had clinically significant adverse effects from previous drug therapy. RESULTS: Remission was achieved in 22 (71%) and 5 (45%) of patients with pemphigus vulgaris and pemphigus foliaceus, respectively. Partial remission was achieved in 1 (3%) and 4 (36%), respectively. The median time to achieve complete remission was 9 months (range, 1-13 months). The treatment was administered for a median of 22 months, and the median follow-up period was 22 months. Seventy-seven percent of patients had no adverse effect. Two patients had side effects severe enough to necessitate discontinuation of treatment, one because of symptomatic but reversible neutropenia and the other because of nausea. CONCLUSION: Mycophenolate is an effective and safe adjuvant in the treatment of both pemphigus vulgaris and pemphigus foliaceus.

Adalimumab therapy for recalcitrant pyoderma gangrenosum.

OBJECTIVE: To describe a patient with treatment-refractory pyoderma gangrenosum and the outcome of a novel therapeutic approach. METHODS: Case report and review of the literature. RESULTS: A patient with inflammatory bowel disease developed severe pyoderma gangrenosum while receiving treatment with the chimeric anti-TNF-alpha antibody infliximab. Despite subsequent trials of numerous immunosuppressive and immunomodulatory medications, the dermatologic disease progressed. The patient's ulcers finally resolved when treatment with adalimumab, a fully humanized monoclonal antibody specific for TNF-alpha, was initiated. CONCLUSIONS: We report a novel application of the TNF-alpha inhibitor, adalimumab, in the treatment of pyoderma gangrenosum.

Mycobacterium marinum with different responses to second-generation tetracyclines.

BACKGROUND: Persistent cutaneous infections with Mycobacterium marinum can follow exposure of injured skin to contaminated water or fish, and can be treated with second-generation tetracyclines in addition to other antimicrobials. Due to the rarity of this infection, there are few data comparing the different treatment alternatives. METHODS: We report a patient with culture-proven M. marinum who was treated with two different second-generation tetracyclines. RESULTS: Our patient failed a 4-week trial of doxycycline, but responded rapidly to minocycline. CONCLUSION: This case suggests that, despite a similar mechanism, pharmacokinetics, and even sensitivity, these two agents may differ in their effectiveness against strains of M. marinum.

Downregulation of NDUFA1 and other oxidative phosphorylation-related genes is a consistent feature of basal cell carcinoma.

Basal cell carcinoma (BCC) is the most common cutaneous malignancy that, like other tumours, possesses a heterogeneous genetic composition. In order to select genes with consistent changes in expression among these tumours, we analysed BCC microarray expression data by using a novel approach, termed correlative analysis of microarrays (CAM). CAM is a nested, non-parametric method designed to qualitatively select candidates based on their individual, similar effects upon an array-wide closeness measure. We applied the CAM method to expression data generated by two-channel cDNA microarray experiments, where 21 BCC and patient-matched normal skin specimens were examined. Fifteen candidate genes were selected, with six overexpressed and nine underexpressed in BCC vs. normal skin. Five of the nine consistently downregulated genes in the tumour samples are involved in mitochondrial function and the oxidative phosphorylation (OXPHOS) pathway. One of these genes was the 7.5-kDa subunit, NADH dehydrogenase (ubiquinone) alpha subcomplex-1 (NDUFA1), an accessory component of OXPHOS complex-I that is essential for respiratory activity. These findings support the hypothesis that irregularities in mitochondrial function are involved in neoplasia. Suppression of NDUFA1 expression could represent a key pathogenic mechanism in the development of BCC.

Oral cyclophosphamide for treatment of pemphigus vulgaris and foliaceus.

BACKGROUND: Cyclophosphamide is an alkylating adjuvant used in refractory cases of pemphigus. OBJECTIVE: We sought to evaluate the effectiveness and safety of oral cyclophosphamide in the treatment of patients with pemphigus vulgaris (PV) and pemphigus foliaceus (PF) with refractory disease. PATIENTS: We studied 23 patients with pemphigus (20 with PV; 3 with PF) who failed to achieve clinical remissions with the use of prednisone and antimetabolites. RESULTS: Complete remission was achieved in 17 patients with PV and 2 with PF. A total of 3 patients with PV failed therapy. A partial remission was achieved in 1 patient with PF. The treatment was administered for a median duration of 17 months with a follow-up period of 27 months. The median time to complete remission was 8.5 months. A total of 9 patients who were severely affected received concomitant plasma exchange. Adverse reactions included 5 cases of hematuria, 6 nonlife-threatening infections, and the development of transitional cell carcinoma of the bladder 15 years after discontinuation of cyclophosphamide in 1 patient. No death was associated with cyclophosphamide treatment. CONCLUSION: Oral cyclophosphamide is an effective adjuvant in the treatment of severe and refractory PV and PF, but requires close monitoring.

Differences and similarities among expert opinions on the diagnosis and treatment of pemphigus vulgaris.

BACKGROUND: As a result of a lack of large-scale controlled studies, the diagnosis and management of pemphigus vulgaris (PV) has been solely on the basis of expert opinion, rather than on empirical evidence. We have completed a survey of worldwide experts on the diagnostic and therapeutic approaches to PV. METHODS: We conducted a telephone-based survey of 24 physicians from academic, tertiary care centers worldwide with an average of 20 years experience treating pemphigus. Survey questions included referral patterns, diagnostic techniques, and therapeutic regimens. RESULTS: Of those surveyed, 50% receive referrals within 6 months after onset of symptoms, 17% within 1 year, and 8% within 3 years. Diagnosis is secured by 96% using skin biopsy specimen with direct immunofluorescence, and by indirect immunofluorescence alone for 4%. None of the participating physicians make the diagnosis of PV solely on clinical and histologic evidence. Of the physicians, 75% initially treat with prednisone and 25% use other agents or attempt to eliminate potential triggers. The physicians who initially used noncorticosteroid drugs did so with no relation to the nature or extent of the disease. Of those surveyed, 50% use prednisone doses of 1 mg/kg/d, 31% use 1 to 1.5 mg/kg/d, and 19% use 1.5 to 3 mg/kg/d. Azathioprine is used as an adjuvant by 44%, mycophenolate mofetil by 20%, cyclophosphamide by 16%, and methotrexate by 8%. Complete discontinuation of prednisone was the goal for 37% whereas others were satisfied with doses from 2.5 to 10 mg/d. CONCLUSION: Wide variation exists in diagnostic techniques and treatment of PV, even among the world's experts. The lag time from symptom onset to referral emphasizes the need for heightened awareness. There is clearly a need for consensus standards with regard to patient stratification and randomized controlled trials.