Eruptive Halo Naevi: A Possible Indicator of Malignant Disease in a Case Series of Post-Adolescent Patients.

Halo naevi are considered benign. They occur in children and adolescents. Eruptive multiple halo naevi are infrequently seen in adults. The first patient in this case series had previously had melanoma. Positron emission tomography-computed tomography (PET-CT) showed a papillary thyroid carcinoma. Subsequent adult patients underwent an examination programme similar to melanoma patients with unknown primary, including PET scanning. Sixteen patients were followed over a 6-year period. In total there were 2 papillary thyroid cancers, 1 neuroendocrine lung tumour, 1 patient had had lung metastases from a thin melanoma 7 years previously, 3 patients had primary cutaneous melanoma (1 had had halo naevi since excision of 2 melanomas 15 years previously) and 1 had melanoma metastasis with unknown primary. The incidence of melanoma was 955 times higher than expected (standardized incidence rate). The benefits of PET scanning must be validated in a controlled trial prior to implementation into clinical practice.

[Kerion Celsi on the vulva in a 15-year-old girl].

This is a case report of a 15-year-old girl, who developed kerion Celsi on the vulva after contact with a pet rodent. The skin was extremely painful, highly red, severely inflamed and oozing, mimicking a bacterial abscess. The patient's general condition was barely affected. PCR identified Trichophyton mentagrophytes, successfully treated with terbinafin 250 mg for 12 weeks. The majority of incidents in 11 published cases were caused by T. mentagrophytes, sensitive to terbinafin. Knowledge of this rare inflammatory dermatophytosis may cause the surgeon to abstain from surgery and to "keep calm and kerion".

Targeted therapy for malignant melanoma.

Treatment of advanced melanoma has undergone a paradigm shift over the last 10-15 years. The frustrating results of studies on medical treatment ten years ago have been replaced by studies constantly improving survival in patients with advanced melanoma. Immune checkpoint inhibitors belong to one group of treatments and targeted therapy to another. Fifty percent of melanomas are BRAF mutation positive. Normally, the mitogen activated protein kinase or MAP kinase (Ras-BRAF-MEK-Erk chain) pathways translate external signals to intracellular growth and proliferation. In BRAF mutated melanoma cells, the mutated BRAF kinase is excessively active leading to autonomous proliferation and cancerous growth. This kinase can be blocked by BRAF-inhibitors. If given to BRAF negative melanoma patients, it may lead to disease progression because Ras is not inhibited in these cells. Development of Squamous cell carcinomas as a serious adverse event to BRAF inhibition may be caused by similar mechanisms in non BRAF mutated keratinocytes. A spontaneous and paradoxical loss of effect is seen with BRAF inhibitors due to various ways melanoma cells bypass BRAF. This is somewhat counteracted by the addition of a MEK1/2 inhibitor. Overall progression-free survival has increased from a median of two months for chemotherapy, via 7-8 months for BRAF inhibitor to 10-14 months for newer BRAF and MEK inhibitor combination therapy.

Actinic keratosis: a cross-sectional study of disease characteristics and treatment patterns in Danish dermatology clinics.

OBJECTIVES: The incidence of actinic keratosis (AK) is increasing, and several treatment options are available. The aim of this study was to describe clinical characteristics and treatment patterns in patients with AK treated by Danish dermatologists. METHODS: A multicenter, non-interventional, cross-sectional study was conducted. Three dermatology hospital departments and seven private dermatology clinics enrolled eligible AK patients consecutively during one week. RESULTS: A total of 312 patients were included. Non-melanoma skin cancer (NMSC) was previously reported in 51.0% of patients and currently suspected in 9.4% of AK-affected anatomical regions. Lesions of AK were located primarily on the face (38.6%), scalp (12.8%), and hands (11.2%). Actinic keratosis commonly presented with multiple AK lesions (38.6%) and field cancerization (38.5%). The treatments used most frequently were cryotherapy (57.7%) and photodynamic therapy (PDT) with methyl aminolevulinate (17.1%) and imiquimod (11.2%). The likelihood of receiving cryotherapy was higher for men (odds ratio [OR] 1.65, 95% confidence interval [CI] 1.10-2.47) and increased with age (2.2% per year, 0.4-4.0%). PDT represented the most frequently applied treatment for severe actinic damage and was more likely to be prescribed to women (OR 4.08, 95% CI 2.22-7.47) and young patients (OR 0.97 per year, 95% CI 0.95-0.99). The prevalence of severe actinic damage (17.3% versus 9.6%) and intake of immunosuppressive medication (29.0 versus 2.0) were higher among hospital patients compared with those treated in private practices (P < 0.0001). CONCLUSIONS: The majority of AK patients in Danish dermatology clinics have a history of skin cancer, and NMSC is suspected in almost 10% of AK-affected regions. Cryotherapy is the most frequently used treatment overall, except in instances of severe actinic damage, in which PDT is the first-choice treatment.

[Bullous reaction after application of a single dose ingenol mebutate]. / Bulløs reaktion efter applikation af en enkelt dosis ingenolmebutat

Picato (ingenol mebutate) was recently marketed for local treatment of actinic keratosis (AK). Compared to alternative creams and gels, Picato is a quick and efficient treatment, which is applied for only two to three days. A patient developed a bullous reaction to the gel after a single application. Picato 150 microg/g was applied in the evening to AK in the patient's forehead. The patient experienced a headache during the night, and the next morning big, thin-walled bullae had developed in the treated area.

Comparison of classical dermatoscopy and acrylic globe magnifier dermatoscopy.

Dermatoscopic asymmetry of melanocytic skin lesion is pivotal in most algorithms assessing the probability of melanoma. Larger lesions cannot be assessed by dermatoscopy and the Dermaphot in a single field of vision, but this can be performed using the acrylic globe magnifier. We examined the diagnostic accuracy of the acrylic globe magnifier and compared it with classical dermatoscopy. A total of 119 patients successively referred to our naevus clinics had Dermaphot and acrylic globe magnifier pictures taken. Lesions were excised and assessed by histopathology. Observers blinded to histopathology diagnoses, assessed dermatoscopic and acrylic globe magnifier photo-slides according to the dermoscopic risk stratification. The observed agreement over all categories between acrylic globe magnifier dermatoscopy and classical dermatoscopy was 94% and Cohen's kappa coefficient was 90% (95% confidence interval 83-97%). Sensitivity for melanoma, benign melanocytic naevi and basal cell carcinoma was 100%, 98% and 85%, respectively. Specificity was 95%, 94% and 100% for melanoma, naevi and basal cell carcinoma. Acrylic globe dermatoscopy enables a diagnostic accuracy similar to epiluminescence microscopy.

Poppyfield bleeding: a new dermatoscopic sign and its histopathological background.

Dermatoscopy increases the accuracy of diagnosis of melanoma. An atypical vascular pattern may be an indicator of cutaneous malignant melanoma (CMM). During dermatoscopy of certain CMMs numerous ruby droplets of blood appear when the dermatoscope is pressed firmly against the lesion. The aim of this paper was to examine the histopathological background for this observation. CMMs from 8 patients showing the poppyfield sign, i.e. squirts of ruby blood droplets, were paired with 8 CMMs of equal Breslow thickness not showing this sign. The 16 CMMs were placed in an unsystematic sequence and presented to two dermato-pathologists who assessed the lesions independently for confirmation of Breslow thickness, Clark level, ulceration and presence of dilated tumour vessels. There was no disagreement between the pathologists' assessments. Age of the patients and Breslow thickness of the cutaneous malignant melanoma were similar in the two groups. All 8 poppyfield CMMs had dilated tumour vessels compared with 25% (2/8) of the non-poppyfield CMMs (p< 0.007). Histological ulceration was observed in all poppyfield CMMs and none of the non-poppyfield CMMs (p< 0.001). The poppyfield bleeding sign is a dermatoscopic clue to dilated tumour vessels. It may be a dermatoscopic reflection of increased vascular density described in primary CMMs compared with adjacent skin and may also reflect the presence of primitive vessels in CMMs displaying increased fragility.

[Dynamic dermoscopy]. / Dynamisk dermoskopi.

Dermoscopy of early-stage melanoma can be challenging, and repeated examination at three-month intervals may disclose subtle changes. In patients with atypical nevus syndrome or more than 50 nevi, repetitive excision of benign lesions does not guarantee that melanomas will be identified at an early stage and exposes patients to potentially disfiguring surgery. We present the case of a high-risk patient where repeated dermoscopy of an in situ melanoma showed that part of the pigment network had coarsened, even though the lesion had not changed macroscopically.

Clinical assessment of infection in nonhealing ulcers analyzed by latent class analysis.

The distinction between bacterial colonization and infection relies on clinical judgement. Determining sensitivity and specificity of this judgement are problematic as no gold standard exists. Six specialists in wound management independently assessed 120 nonhealing chronic wounds. Sixty-five (54.2%) patients had venous ulcer, 18 (15%) arterial ulcers, 15 (12.5%) ulcerative pyoderma gangraenosum, 12 (10%) neuropathic or pressure ulcers, six (5%) vasculitis ulcers, and four patients had ulcers caused by a primary or metastatic cancer disease. Unrestricted latent class analysis was used for determining sensitivity and specificity in the observer's assessment of hypergranulation, redness, and overall impression of infection. Interrater agreement among observers was determined by restricted latent class analysis. The observers used the diagnoses (redness, hypergranulation, and overall impression of infection with different frequencies (p<0.001, Cochrane's Q test). A two latent class model fitted data. Sensitivity for hypergranulation ranged from 3 to 82%, for redness from 34 to 91% and for overall impression of infection from 37 to 90%. None of the observers were interchangeable. These results indicate that clinical assessment of chronic wounds for the presence of infection are difficult tasks accompanied by great variability and low reliability.

[Imiquimod treatment of lentigo maligna to dermoscopic and histologic clearance]. / Imiquimodbehandling af lentigo maligna til dermoskopisk og histologisk tumorsvind.

Imiquimod is an immune system-modifying drug that switches the immune system to a Th1 response, enabling it to defeat virus-infected and neoplastic cells. We report on a 94-year-old woman with a large lentigo maligna (LM) on her cheek whom we treated with imiquimod 5% cream. Dermoscopy was used to identify the most suspect areas of the lesion for biopsy and in follow-up. By week 19 the lesion was cleared, and no remnants of the lesion were seen by dermoscopy or histology. Published LM cases treated with imiquimod are reviewed.