Basal cell carcinoma of the head region: therapeutical results of 350 lesions treated with Mohs micrographic surgery.

BACKGROUND: Basal cell carcinoma (BCC) is a non-melanocytic skin tumour with a high risk of recurrence after incomplete treatment, especially the aggressive subtypes (basosquamous, micronodular and morphea BCC). The percentage of recurrence also depends on the anatomical site of the tumour. Nose-cheek fold, paranasal fold, retroauricular fold and internal canthus are considered to be critical sites. OBJECTIVE: The aim of this study was to report on recurrence rates for BCC treated with Mohs micrographic surgery (MMS). MATERIAL AND METHODS: We retrospectively studied 350 BCCs of the head region treated with MMS. Results were analysed with chi-squared test and Fisher test and were considered significant when P value was ≤0.05. RESULTS: In our study, the percentage of BCC recurrence rate after MMS was of 3.4% for primary BCC and 4.9% for recurrent BCC; these were similar to the recurrence rates reported in the literature. CONCLUSIONS: Low recurrence rate can be achieved when treated with MMS; it is the treatment of choice for many BCC of the head. Aggressive histopathological subtypes, critical head sites and recurrence after incomplete excision are the most important indications for MMS.

Micrographic surgery (Tubingen torte technique) for the treatment of an invasive dermatofibrosarcoma protuberans with muscular involvement.

Dermatofibrosarcoma protuberans (DFSP) is an uncommon skin tumour characterized by a slow, infiltrative growth and marked tendency towards local recurrences. Wide surgical excision of 3-5 cm from the margins including the fascia is the recommended treatment. Mohs Micrographic Surgery has been shown to afford lower rates of recurrence. The Mohs-Tübingen technique is a variant indicated for very large excisions that allows a complete eradication of the tumour, preserving healthy tissues. We report the case of a 45 year-old man affected by DFSP of the right shoulder deeply infiltrating the muscles, referred to us for a recurrence after a large excision. We submitted the patient to Mohs-Tübingen surgery in collaboration with an orthopaedic surgeon due to the presence of muscular involvement of DFSP. Two surgical operations were necessary to obtain negative histology as the tumor was deeply infiltrating the prescapular muscles. After three years of follow-up, the patient did not have any recurrence and the normal mobility of the shoulder was preserved. Precocious diagnosis and adequate therapy are necessary for DFSP as not only the margins, but also the deep invasion of the tumor have to be carefully controlled.

Calcipotriol induces apoptosis in psoriatic keratinocytes.

In recent years, vitamin D3 analogues have become one of the most widely prescribed topical treatments for mild or moderate chronic plaque psoriasis. These molecules are effective and safe, but their exact mechanism of action is not completely understood. In vitro studies have shown that D3 analogues decrease proliferation and induce differentiation of keratinocytes, and have strong immunomodulating effects, but there are no conclusive data about apoptosis. The aim of this study was to evaluate differences in apoptotic response between lesional and perilesional keratinocytes of patients with psoriasis before and after treatment with calcipotriol, a synthetic vitamin D3 analogue. Keratinocytes were isolated from psoriatic plaques including lesional and perilesional skin, and cultured. Cells were treated with calcipotriol for 20 h and examined under confocal microscopy after staining with propidium iodide. The number of apoptotic cells after incubation with calcipotriol was significantly higher in lesional than in perilesional keratinocytes (P < 0.05) or non-treated psoriatic keratinocytes (P < 0.05). In conclusion, calcipotriol seems to induce apoptosis in psoriatic keratinocytes.

Once weekly administration of etanercept 50 mg is efficacious and well tolerated in patients with moderate-to-severe plaque psoriasis: a randomized controlled trial with open-label extension.

BACKGROUND: In previous studies, etanercept 25 mg twice weekly (BIW) or 50 mg BIW significantly reduced disease severity in patients with plaque psoriasis and demonstrated a favourable safety profile. OBJECTIVES: To assess the efficacy and safety of etanercept 50 mg administered once weekly (QW) compared with placebo in patients with moderate-to-severe plaque psoriasis over 24 weeks. METHODS: This study was conducted in two parts: (i) a 12-week, double-blind, placebo-controlled phase, in which patients received etanercept 50 mg QW or placebo QW; and (ii) a 12-week, open-label extension phase, in which all patients received etanercept 50 mg QW. Primary endpoint was a 75% or greater improvement from baseline in the Psoriasis Area and Severity Index (PASI 75) at week 12. Secondary endpoints included percentage PASI improvement and Physician's Global Assessment (PGA). RESULTS: One hundred and forty-two patients were analysed in the double-blind phase; 126 patients entered the open-label phase. At week 12, significantly more patients receiving etanercept 50 mg QW (37.5%) achieved PASI 75 response than patients receiving placebo (2.2%; P < 0.0001). At week 24, 71.1% in the etanercept-etanercept group and 44.4% in the placebo-etanercept group achieved PASI 75. Mean percentage of PASI improvement from baseline was 55.4% with etanercept vs. 9.4% worsening with placebo at week 12 (P < 0.0001), with 77.4% and 57.7% improvement in the etanercept-etanercept and placebo-etanercept groups at week 24. A PGA score of 0-1 (clear-almost clear) was achieved by 64% and 42% in the etanercept-etanercept and placebo-etanercept groups at week 24, respectively. Etanercept 50 mg QW was well tolerated. No deaths, serious infections, opportunistic infections (including tuberculosis), demyelinating disorders, malignancies or new safety signals were reported. CONCLUSIONS: Nearly three-quarters of patients with moderate-to-severe psoriasis receiving etanercept 50 mg QW achieved significant improvement in disease severity over 24 weeks. This study also showed a favourable tolerability and safety profile with etanercept 50 mg QW.

Is there an easier way to autograft skin in chronic leg ulcers? 'Minced micrografts', a new technique.

BACKGROUND: Chronic venous leg ulcers represent an urgent and increasing problem for public health. The use of skin autografts results in a greater therapeutic success in healing chronic ulcers. OBJECTIVE: A simple method of skin autografting that could permit a wider use of skin grafts in outpatients is needed. A new technique allowing skin autografting in a simple one-step process, without complex surgical procedures or expensive technical supplies, is presented. METHODS: A small, full-thickness skin specimen taken from the patient is finely minced and spread on his leg ulcer bed allowing to cover a surface many times wider than the sample itself. RESULTS: This method induces faster re-epithelization of chronic leg ulcers that failed to heal despite good conservative local therapy and give the possibility to repair very large ulcers with small fragments of skin. A clinical case is shown as an example out of 20 ulcers we recently treated. CONCLUSION: Our preliminary report shows that this technique results in a greater therapeutic success (18 of 20 cases) in healing chronic leg ulcers, a common pathology that often affects outpatients treated for very long periods at home or in the Dermatologist's office. In our experience, this new and successful reparative possibility makes 'mince grafting' a recommendable procedure.

Bath PUVA and psoriasis: is a milder treatment a worse treatment?

BACKGROUND/AIM: The guidelines of the British Photodermatology Group for topical treatment with psoralen and ultraviolet light (PUVA) recommend starting UVA doses between 0.2 and 0.5 J/cm(2), according to the phototype. Our purpose was to evaluate the therapeutic efficacy and tolerability of bath PUVA, with 8-methoxypsoralen (8-MOP), by using lower UVA doses, regardless of phototype. METHODS: We compared 2 groups of patients (group 1: n = 10, group 2: n = 20) with chronic plaque-type psoriasis. Group 1 was treated with the usual starting dose and dose progression; group 2 was treated by using a lower first dose, a slower dose progression and reaching a lower maximum dose. The Psoriasis Area and Severity Index (PASI) score was assessed at the initial stages, and every month until the end of the treatment. RESULTS: In group 1, the median baseline PASI score decreased from 15.2 to 4.5 (p < 0.005, Student's paired t test), while in group 2, it fell from 13.7 to 4.1 (p < 0.005). No statistical difference between the groups is detectable. Severe phototoxic reactions were observed only in 2 patients of group 1. Side effects were not observed in group 2. CONCLUSIONS: Our data indicate that an aggressive bath PUVA treatment is not substantially more effective in clearing chronic plaque-type psoriasis than a milder therapeutic approach.

[Dermatofibrosarcoma protuberans: surgical treatment using the Tübingen technique (31 cases)]. / Dermatofibrosarcome de Darier-Ferrand: traitement par la technique chirurgicale de Tübingen (31 cas).

BACKGROUND: Dermatofibrosarcoma protuberans is a rare cutaneous sarcoma that progresses slowly. Although it exhibits pronounced local aggressiveness, it rarely metastasises. The condition is difficult to treat on account of asymmetric and unpredictable growth as well as the frequency of relapse. Treatment is primarily surgical. PATIENTS AND METHODS: We report 31 cases of dermatofibrosarcoma protuberans operated at the Dermatology Clinic of Novara between 1997 and 2004 using the Tübingen technique. An immunohistochimical study was performed and screening was carried out for possible extension of the neoplasm into muscle. RESULTS: Muscular involvement was seen in 4 cases. No relapses were seen over a median survival period of 3 years and no patients were lost to follow-up. DISCUSSION: The Mohs technique is the surgical method of reference and allows tumour eradication with sparing of healthy tissue. The Tübingen method constitutes an alternative approach requiring fewer histological sections. The results obtained in our series were good and no relapses were seen over a median survival period of 3 years.

Thysanoptera dermatitis.

Thysanoptera dermatitis is caused by the bite of small (1-2 mm) insects (generally thrips). Thrips usually feed on the juices of vegetables but if they reach human skin they can suck the epidermal lymph after biting. The cutaneous lesions formed are small pink and itchy papules localized mainly on the trunk and the arms. Diagnosis is only possible by demonstrating that the insect is present inside one of the lesions of the skin. Thysanoptera dermatitis is often misdiagnosed as mosquito bites. Although self-resolving in a few days, Thysanoptera dermatitis should be known not only for the cultural and scientific training of the dermatologist but also to add more detailed diagnostic information to the generic diagnosis of 'entomodermatosis' and to confirm the benign evolution of the bites.

[Cutaneous spreading of a chordoma]. / Extension cutanée d'un chordome.

INTRODUCTION: Chordomas are rare extradural bone tumors arising from notochord remnants, the embryonic structure forming the original axis of the spine. They represent 0.1p. 100 of all intra-cranial tumors. The chordoma is a locally malignant cancer that tends to invade the surrounding tissues. Its localization in the skin is exceptional. OBSERVATION: A 56 year-old man developed a nut-sized vegetating nodule on the nasal groove. This lesion appeared a few months following surgery for a frontoglabellar relapse of a chordoma that had developed six years earlier at the base of the skull. DISCUSSION: We report this case because of the rareness of cutaneous involvement and the particular conditions in which it occurred. It may have been due to tumoral seeding during the previous surgical interventions.

Analysis of the microtopography of the skin by silicone replicas after repeated exposure to actinic radiation at high altitudes.

We investigated the superficial microtopography of the normal skin of 11 volunteers (not exposed to sunlight during the last 4 months), before and after sun exposure for 5 days at high altitudes of 2900-4559 m. The experiments were carried out on Mount Rosa in Italy, and cutaneous replicas using silicone resin were taken every day after 7 h of sun exposure. Casts were taken from the forehead, glabella, dorsum nasi, radial side (protected with a cream SPF 9.72) and ulnar side of the back of the hands, the only areas not protected. A total of 422 replicas were metallized with gold-palladium and observed under Zeiss 940A scanning electron microscope. The images were elaborated and analysed on computer with appropriate software supplying geometrical features of cutaneous surface using parameters proposed by Takahashi (1994). A Student's test for paired series was used to analyse the differences before and after 1-5 days of exposure giving uniform and significant data compared with controls. Using cutaneous replicas we demonstrated that repeated exposure of skin to sunlight in a short time elicits temporary defence mechanisms with increased obstruction of cutaneous pores, deepening of primary cutaneous furrows and shallowing of part of the secondary furrows; the two latter alterations are the consequence of reactive oedema.

Burow's triangle advancement flaps for excision of two closely approximated skin lesions.

The Burow's triangle advancement flap can be adapted to simultaneously remove two closely approximated cutaneous lesions. Possible technical variants and their limitations are discussed. Four clinical cases are presented. This technique gives good cosmetic results and reduces operating time.

A case of acute promyelocytic leukaemia with bullous, haemorrhagic and necrotic skin lesions.

Erythematous-oedematous-bullous skin lesions with necrotic vegetating and haemorrhagic evolution evocating atypical pemphigur or bullous reticulosis, revealed acute promyelocytic leukaemia. Histologically, vesicles and bullae were observed in the Malpighian layer and a dense infiltrate with atypical blasts in the dermis. Atypical promyelocytes (22%) were found in the bone marrow. The cytochemical features of promyelocytes, haemorrhage due to disseminated intravascular coagulation supported the diagnosis.