The impact of incomplete clinical information and initial biopsy technique on the histopathological diagnosis of cutaneous melanoma.

BACKGROUND/OBJECTIVES: Increased rates of histopathological misdiagnosis of melanoma have been associated with incisional punch more so than shave biopsy when compared with complete excisional biopsy. It is unknown how the increasing utilisation of shave biopsy may impact melanoma diagnosis. The extent to which the provision of clinical information to the pathologist may improve diagnostic accuracy remains unclear. This study assessed the impact of both initial biopsy technique and provision of adequate clinical information to pathologists on the accuracy of histopathological diagnosis of melanoma and disease progression. METHODS: We conducted a retrospective cohort with nested case-control study of all histopathological false-negative and false-positive melanoma diagnoses from January 2014 to May 2019 from the Victorian Melanoma Service electronic database. Cases were assessed for the initial biopsy type, provision of clinical information on pathology request forms and disease progression associated with false-negative diagnosis. RESULTS: Partial shave biopsy had higher odds of false-negative (OR 5.19, 95% CI 2.89-9.32; P < 0.001) and false-positive diagnoses (OR 1.95, 95% CI 1.45-2.63; P < 0.001) of melanoma when compared with elliptical excisional biopsy. These odds ratios were comparable with those found with incisional punch biopsy. Providing the suspected clinical diagnosis to pathologists also reduced the odds of false-negative diagnosis with melanoma progression by 3.8-fold (P = 0.02). CONCLUSION: The choice of initial biopsy technique and providing the suspected clinical diagnosis to pathologists are important for correct histopathological diagnosis of cutaneous melanoma and prevention of further disease progression.

Nodular melanoma: a distinct clinical entity and the largest contributor to melanoma deaths in Victoria, Australia.

BACKGROUND: There is a growing body of evidence that nodular melanoma (NM), because of its association with increased growth rate and thickness at diagnosis, accounts for a substantial proportion of melanoma deaths. OBJECTIVE: We sought to assess the contribution of NM to melanoma deaths in comparison with other tumor subtypes. METHODS: Four cohorts were established comprising 5775 cases of invasive primary cutaneous melanoma reported to the Victorian Cancer Registry during 1989, 1994, 1999, and 2004. Original pathology reports were reviewed. Age-standardized melanoma incidence rates were compared from 1989 to 2004 with annual percentage change using Poisson regression. RESULTS: The incidence of thick tumors (>4 mm) increased by 3.8% (95% confidence interval 1.4 to 6.2) and 2.5% (95% confidence interval -0.5 to 5.5) per year for male and female patients, respectively. The median thickness of NM at diagnosis was 2.6 mm compared with 0.6 mm for superficial spreading melanoma. A third of patients who died from melanoma during the follow-up period had thick tumors (>4 mm), most of which were nodular subtype (61%). NM accounted for 14% of invasive melanomas, but was responsible for 43% of melanoma deaths in a total of 57,461 person-years of follow-up. By comparison, superficial spreading melanoma contributed 56% of invasive melanoma but only 30% of deaths. LIMITATIONS: Pathology review was limited to reports only. Mortality information relied mostly on death certificate information. CONCLUSION: The incidence of thick melanomas continues to increase. Nodular melanoma is clinically distinct and the predominant contributor to melanoma-related deaths, representing a public health challenge in reducing skin cancer mortality.

Hairdressers presenting to an occupational dermatology clinic in Melbourne, Australia.

BACKGROUND: Hairdressers constitute one of the largest occupational groups attending our occupational dermatology clinic in Melbourne, Australia. OBJECTIVES: To perform a retrospective review of the clinical assessments of hairdressers and trainee hairdressers attending our clinic, including patch testing results. PATIENTS/MATERIALS/METHODS: We used our clinic database to identify trainee and qualified hairdressers who had attended our occupational dermatology clinic between January 1993 and December 2010. RESULTS: One hundred and sixty-four hairdressers and hairdressing apprentices were identified. One hundred and fifty-seven had a diagnosis of occupational contact dermatitis (OCD), with allergic contact dermatitis being the primary diagnosis in 71% and irritant contact dermatitis in 20%. Involvement of more than one body part was suggestive of allergic contact dermatitis (p = 0.05). Sixty-five per cent of participants were found to have more than one factor contributing to their OCD. Allergic contact dermatitis was more common in apprentices than in qualified hairdressers. Ammonium persulfate, p-phenylenediamine, toluene-2,5-diamine and glyceryl monothioglycolate were the most common occupational allergens. Nickel allergy was seen in 31% of hairdressers, but considered to be occupationally relevant in only 3%. CONCLUSIONS: Multiple sensitizations and multiple factors contributing to OCD in hairdressers are common. More needs to be done to prevent the development of OCD in hairdressers in our geographical region.

Drug rash with eosinophilia and systemic symptoms secondary to sulfasalazine.

A severe cutaneous eruption in an unwell patient can be a major cause of physician anxiety. With numerous differential diagnoses, an early accurate diagnosis can be challenging. infectious causes are the most important to exclude in a timely manner and drug rash and eosinophilia with systemic symptoms (DRESS) is another differential diagnosis that should be considered in children. This hypersensitivity reaction is associated with multisystem involvement. Children with underlying chronic diseases may have impairment of normal metabolic pathways and are also often on multiple medications. Therefore, drugs should always be considered in the aetiopathology of any new symptoms and signs. This case report informs readers of the association of sulfasalazine and DRESS in an 11-year-old with inflammatory bowel disease and discusses its pathogenesis and treatment. Increased awareness of this disorder will hopefully lead to increased reporting and consequently illuminate the syndrome more clearly and help guide its prevention and treatment.

Nickel allergy presenting as mobile phone contact dermatitis.

A 39-year-old man presented with a 6-month history of a treatment-resistant facial dermatitis. The patient regularly used his mobile phone, predominantly on the left cheek. Patch testing confirmed the clinical suspicion of mobile phone contact dermatitis from nickel contained in the phone casing. Although infrequently reported, with the trend towards metallic mobile phone casings and the high incidence of nickel sensitization in the community, the incidence of mobile phone contact dermatitis is likely to increase.

Methotrexate is a safe and effective treatment for paediatric discoid (nummular) eczema: a case series of 25 children.

We present a case series of 25 paediatric patients with refractory discoid eczema treated with methotrexate. Patients were commenced on either 5 mg or 10 mg of methotrexate per week. Sixteen patients (64%) completely cleared their eczema after an average of 10.5 months of methotrexate therapy. A further three patients (12%) have responded well and are almost clear at the time of writing. Methotrexate was well tolerated by the majority of patients and no serious adverse events were observed. Methotrexate should be considered in moderate to severe paediatric discoid eczema that has failed to respond to conventional therapies.

Successful treatment of lymphomatoid papulosis with photodynamic therapy.

A 40-year-old woman presented with a prolonged history of recurrent crops of erythematous papules and nodules on her abdomen, arms and legs. Histological examination of a cutaneous biopsy revealed Type A lymphomatoid papulosis. Over a 3-year period, some of the patient's lesions had proven to be resistant to treatment with topical and intralesional corticosteroids and systemic agents including methotrexate, tetracycline and nicotinamide. These resistant lesions were treated with two sessions of methyl aminolevulinate photodynamic therapy given 1 week apart. Review 11 months post-photodynamic therapy demonstrated complete clinical clearance at the treatment site. While photodynamic therapy is considered a standard non-surgical treatment option for non-melanoma skin cancers and has been described in a number of non-oncological indications, this is the first report of its use in lymphomatoid papulosis.

Complications of ERCP for choledocholithiasis in a sickle cell cohort.

BACKGROUND: Patients with sickle cell disease (SCD) demand special attention during clinical interventions because they are predisposed to acute chest syndrome (ACS), vaso-occlusive crises, intra-vascular haemolysis and immune paresis. Although SCD is endemic in the Caribbean, there has been no report on endoscopic retrograde cholangio-pancreatography (ERCP) outcomes in these patients from this region. STUDY: The records of patients with SCD who underwent ERCP between 1 January 2005 and 1 June 2010 were analysed retrospectively. Parameters assessed included patient demographics, procedural details, ERCP-related and SCD-related morbidity. Data were analysed using SPSS version 12.0. RESULTS: Fifty-four patients with SCD were subjected to ERCP during the study period. There were 37 women and 17 men at a mean age of 28 years (SD +/-12.05). There was 29% (16) overall morbidity, with 10 (18.5%) SCD-related complications and six (11.1%) ERCP-specific complications. More common complications were: pancreatitis (9.3%); cholangitis (1.9%); ACS (9.3%); pneumonia (3.7%); and painful crises (5.6%). There was one death (1.9%) due to multiple organ failure secondary to severe pancreatitis. CONCLUSIONS: This study suggests that the SCD cohort requires special perioperative attention to minimise the inordinately high morbidity, many of which are SCD-related. We propose a perioperative management protocol that may minimise morbidity in these patients.

Socioeconomic deprivation independently predicts symptomatic painful diabetic neuropathy in type 1 diabetes.

INTRODUCTION: Painful peripheral neuropathy in people with type 1 diabetes is a disabling and costly complication. A greater understanding of predisposing factors and prescribing may facilitate more effective resource allocation. METHODS: The Townsend index of deprivation (numerically higher for greater disadvantage) was examined in the pseudonymised records of 1621 (684 females) individuals with type 1 diabetes and related to prevalence of drug treated severe diabetes related neuropathic pain. RESULTS: Treatment for neuropathic pain was initiated in 280 patients, who were older at 57.1 vs 45.6 years and had greater BMI (29.8 vs 27.8kg/m(2); p<0.0001). HbA1C was similar between groups, whilst eGFR was lower in the neuropathic pain group. Amitriptyline was the most commonly prescribed agent (46.8% of total prescriptions). Duloxetine (60mg daily) was prescribed in 9.3% of cases. There were significant differences between the groups for the Townsend index, with a greater proportion (34.3% vs 21.7%) of patients with treated neuropathic pain having a score of ≥1 (X(2)=19.9, p<0.001). Multivariate logistic regression analyses indicated that each unit increment in Townsend index was associated with a 11% increased odds of requiring neuropathic pain treatment [odds ratio (95% CI) 1.11 (1.05-1.17), p<0.001]. This was independent of age: 1.04 (1.02-1.05), BMI: 1.03 (1.01-1.05), HbA1C: 1.15 (1.05-1.24), male gender: 0.74 (0.55-0.98), systolic BP and eGFR. Inclusion of depression and mixed anxiety/depressive disorder did not change the risk estimates. CONCLUSION: Amitriptyline was the most commonly used agent for treatment of diabetes related neuropathic pain with Duloxetine much less used. A higher level of socioeconomic deprivation may predispose to severe neuropathic pain in diabetes. Differential allocation of resources may benefit this group.

Unilateral limited scleroderma-like changes following formation of an arteriovenous fistula.

A 55-year-old man presented with a 1-year history of progressive skin thickening involving the right hand associated with Raynaud's phenomenon, sclerodactyly and painful cutaneous ulcers. An arteriovenous fistula for haemodialysis had been formed on the same arm 2 years previously. There were no symptoms or signs of systemic sclerosis or involvement of the contralateral arm. The limb was clinically ischaemic, attributed to a vascular steal phenomenon from the arteriovenous fistula, superimposed on occlusive arterial disease. A revascularization procedure was performed, which resulted in substantial improvement in the sclerodactyly, Raynaud's phenomenon and hand function. Tissue hypoxia is believed to be a contributing factor in the pathogenesis of scleroderma, and this case demonstrates scleroderma-like changes in the setting of limb ischaemia.

Allergic contact dermatitis to panthenol and cocamidopropyl PG dimonium chloride phosphate in a facial hydrating lotion.

Dexpanthenol is the alcohol corresponding to pantothenic acid (the water-soluble vitamin B(5)). Although it is a common ingredient in many pharmaceuticals and cosmetics, contact allergy is relatively uncommon. Cocamidopropyl PG dimonium chloride phosphate is a phospholipid complex derived from pure coconut oil, and contact allergy is rare. We report a case of allergic contact dermatitis to panthenol and cocamidopropyl PG dimonium chloride phosphate in a facial hydrating lotion.

Prevalence of atopy in a population of hairdressing students and practising hairdressers in Melbourne, Australia.

Hairdressers are one of the largest groups affected by occupational contact dermatitis. In this population-based study, 193 trainee hairdressers and 184 practising hairdressers each completed a questionnaire and had their hands examined. Participants were asked about past or present atopy including eczema, asthma or hayfever, which occurred in 59.2%, and were individually correlated with a history of occupational skin problems. Almost 60% of hairdressers and trainees had experienced changes on their hands since commencing hairdressing, while 29% had evidence of abnormal skin on examination on the day of participation. Atopic individuals, who plan to work in a career such as hairdressing with known high rates of occupational contact dermatitis, should be advised to care for and protect their skin from the outset to prevent the development of this condition. There has been little awareness of this issue in Australia, despite longstanding knowledge of the association of hairdressing and contact dermatitis.

Knowledge of skin hazards and the use of gloves by Australian hairdressing students and practising hairdressers.

Occupational contact dermatitis is common amongst hairdressers. In this population-based study, 193 trainee hairdressers and 184 practising hairdressers completed a questionnaire detailing their knowledge of skin hazards, the skills they practised and the frequency of glove use. Knowledge of skin hazards was poor in both groups. While up to 70% of participants correctly identified hairdressing chemicals as potential skin hazards, less than 15% correctly identified the role of wet work. Only a small proportion recognized that hairdressing chemicals could cause allergy. Contrary to findings elsewhere, less-experienced hairdressers often handled chemicals, particularly hair dyes containing p-phenylene diamine. The use of gloves was inadequate, particularly when performing work at the basin, which both junior and senior hairdressers did on a regular basis. Recommended strategies for the prevention of hand dermatitis in hairdressers include improved student education, appropriate glove use and the application of after-work moisturizing creams.

Severe toxic epidermal necrolysis precipitated by amphetamine use.

A 48-year-old man presented with a maculopapular truncal rash 9 days following intravenous amphetamine use. He subsequently developed widespread bullae over his trunk and upper limbs. Treatment was initially commenced with intravenous hydrocortisone. A diagnosis of toxic epidermal necrolysis was made and the treatment was changed to intravenous immunoglobulin at a lower dose than requested. At the height of the reaction, there was 90% body surface area involvement with tri-mucosal involvement. His response to the intravenous immunoglobulin was poor and was complicated by infection with methicillin-resistant Staphylococcus aureus, Candida albicans and Pseudomonas aeruginosa. Gradual re-epithelialization took place over the next 6 weeks.

Clinical utility of magnetic resonance imaging and the preoperative identification of low risk endometrial cancer.

BACKGROUND: Magnetic resonance imaging (MRI) is reported to offer the best imaging of local disease in endometrial cancer. We audited MRI scans to identify their clinical utility, particularly in the preoperative identification of 'low risk' endometrial cancer (grade one or two endometrioid tumours confined to the inner half of the myometrium). AIM: To correlate histological and MRI findings and to establish our ability to preoperatively identify women with 'low risk' tumours. STUDY DESIGN: A retrospective audit of MRI scans in women with a new diagnosis of endometrial cancer from July 1998 to November 2002. Radiology and pathology reports and surgical staging data were extracted. Independently a team of radiologists reviewed MRI films and the findings were compared to pathology. RESULTS: Thirty-nine patients were included. Only 10% of original reports contained all the clinically relevant information. On review, the sensitivity for the detection of myometrial invasion was 90%, specificity 71%, positive predictive value (PPV) 93% and negative predictive value (NPV) 63%. For the detection of deep invasion, sensitivity was 56%, specificity 77%, PPV 64% and NPV 71%. All women with grade one or two tumours having no invasion or grade one having superficial invasion detected on MRI had pathological 'low risk' disease. CONCLUSIONS: Magnetic resonance imaging scans as reported offered limited clinical benefit. Attention needs to be given to MRI sequencing and reporting protocols. If the review results can be confirmed by prospective studies, MRI offers significant clinical utility in the identification of low risk patients and their surgical treatment planning.