Method of Assessing Skin Cancerization and KeratosesTM (MASCK™): development and photographic validation in multiple anatomical sites of a novel assessment tool intended for clinical evaluation of patients with extensive skin field cancerization.

BACKGROUND: A range of 'field-directed' treatments is available for the management of extensive skin field cancerization (ESFC), but to date, the only validated objective quantitative tools are limited to assessment of actinic keratoses (AKs) affecting the head. AIMS: To develop a versatile quantitative instrument for objective clinical assessment of ESFC and perform initial internal validation across multiple anatomical zones. METHODS: The study comprised instrument development, pilot testing and instrument refinement and two rounds of reliability and inter-rater validation testing. The study was noninterventional and used a convenience sample of de-identified patient photographs selected based on preset criteria. An expert panel developed the instrument and scoring system via a modified Delphi voting process. A sample of 16 healthcare professionals from multiple specialties undertook the pilot testing, and a panel of seven dermatologists were involved in validation testing. Validation was determined by assessment of overall inter-rater agreement using Gwet chance-corrected agreement coefficients (ACs). RESULTS: The instrument produced, called the Method for Assessing Skin Cancer and Keratoses™ (MASCK™), comprises the Skin Field Cancerization Index (SFCIndex), derived from area of skin involvement and AKs (number and thickness), a global assessment score and a cancer-in-zone score, and uses Likert scales for quantitative scoring. The SFCIndex is a composite score comprising the number and thickness of AKs multiplied by area of skin involvement. ACs for the SFCIndex components, the overall SFCIndex score and the global assessment score were > 0.80 (rated 'almost perfect') while the AC for the cancer-in-zone metric was lower (0.33, rated 'fair'). Internal consistency was demonstrated via positive correlation between the overall SFCIndex score and the global assessment score. CONCLUSIONS: Our study found near-perfect agreement in inter-rater reliability when using MASCK to assess the severity of ESFC in multiple anatomical sites. Further validation of this novel instrument is planned to specifically assess its reliability, utility and feasibility in clinical practice.

Atopic dermatitis in adults: An Australian management consensus.

BACKGROUND/OBJECTIVES: Atopic dermatitis (AD) has significant negative impact on health-related quality of life, mood, sleep, work productivity and everyday activities. Research into the use of new drugs in the management of AD continues to develop, and international updates and recommendations have been published. However, questions remain in the Australian setting. This consensus aims to provide evidence-based insights and practical advice on the management of adult AD in Australia. METHODS: A panel (five dermatologists and one clinical immunologist) met to review the literature, critically examine clinical questions of relevance to Australian healthcare practitioners and develop a series of recommendation statements. A consensus panel, comprising the initial panel plus nine additional members, used a 2-round Delphi voting process to determine a set of final guidance statements. CONSENSUS: ≥75% agreement in the range 7-9. RESULTS: Round 1 voting comprised 66 guidance statements. Of these, consensus was reached on 26, which were retained, and five were removed. The remainder (35) were modified and one new guidance statement was added for inclusion in round 2 voting. After round 2, consensus was reached on 35, which were retained, and one was removed (considered redundant). The 61 guidance statements upon which consensus was reached were then used to support a series of core consensus recommendations and a management flow chart. CONCLUSIONS: Expert consensus recommendations providing practical guidance of clinical relevance to specialists and primary care physicians in Australia have been developed. Dissemination of this guidance and evaluation of its impact on patient outcomes remain to be undertaken.

In-Transit Metastasis From Squamous Cell Carcinoma.

BACKGROUND: In-transit metastasis from cutaneous squamous cell carcinoma (SCC) is an uncommon form of metastasis through lymphatics and occurs more commonly in immunosuppressed patients. OBJECTIVE: To identify cases of in-transit SCC and determine patient characteristics, tumor features, management, and prognosis. METHODS AND MATERIALS: A multicenter case series treated by Australian and New Zealand clinicians. RESULTS: In 31 patients, median age was 72 years (range 52-99) and 68% were immunocompetent. Tumors occurred on the head and neck in 94% of cases, with 71% of all tumors occurring on the scalp, forehead, or temple. The median time to presentation with in-transit SCC from treatment of the initial tumor was 5 months. Management included surgery (94%), radiotherapy (77%), chemotherapy (10%), and reduction of immunosuppression (3%). Median follow-up was 12 months. Overall survival at 3 and 5 years were 27% and 13%, respectively. CONCLUSION: In-transit metastases are described in 31 patients, of whom the majority was immunocompetent. The scalp, forehead, and temple were the most common sites. New clinical and histological diagnostic criteria are proposed. Prognosis was poor with 5-year survival of 13%. Recommended management is a combination of surgery and adjuvant radiotherapy. Reduction of any iatrogenic immunosuppression should be considered.

The efficacy and safety of topical 5% 5-fluorouracil in renal transplant recipients for the treatment of actinic keratoses.

Actinic keratoses (AK) occur more commonly and behave more aggressively in renal transplant recipients (RTR). Topical 5% 5-fluorouracil (5-FU) cream is a commonly used agent whose efficacy and safety have never been exclusively studied in the RTR population before. Eight RTR were enrolled and 5% 5-FU cream applied to AK lesions on their face twice daily for 3 weeks. They were reviewed at 2 and 8 weeks, and 12 months post-commencement of treatment. Their AK were counted and their cumulative surface areas measured. Patients completed surveys monitoring adverse effects and tolerability. Complete (100%) and partial clearance (≥ 75%) rates were measured, as well as mean percentages of the reduction in AK surface area. Patients had complete clearance rates of 63 and 0% at 8 weeks and 12 months, respectively. All (100%) patients had partial clearance at week 8 and 71% had partial clearance at 12 months. Patients had on average 15 AK at week 0 and 1 and 3 at 8 weeks and 12 months, respectively. The mean AK clearance rate was 98% at week 8 and 79% at 12 months. Common side-effects were erythema, itch and flaking or scaling, mostly mild in severity. 5-FU appears to be an efficacious and safe treatment for AK in RTR.

Acroangiodermatitis in a lower leg amputee related to suction socket use.

Acroangiodermatitis is a rare condition with numerous causes typically presenting as purple macules on the lower extremities. Although benign, it can mimic the presentation of more serious underlying conditions such as Kaposi's sarcoma. We present a case of acroangiodermatitis in the stump of an amputee related to suction socket use in order to raise awareness of an unusual setting for this vascular proliferation.

More than just dry skin.

Harriet is worried about her husband George. You don't see George very often but he certainly looks different. Apart from the changes described by Harriet, George has put on a lot of weight (from 97 to 112 kg since his last 'weigh in' 14 months ago). George is in his early 40s and in the past has been an active, quickly moving man despite his size (height 194 cm). Now he seems listless and lethargic.

'Great tan but I feel awful'. Diagnosis: Autoimmune primary hypoadrenalism.

'Everyone says I look great but I feel awful. I've lost weight, I feel sick all the time, I don't have any energy and I struggle just to get through the day'. Andrew is lean and tanned, but he has lost 8 kg since his last visit 3 months ago. He seems a bit flat in mood and listless in manner. He doesn't have a temperature, his blood pressure (BP) is 105/65, and examination of his chest and abdomen is normal. When the results of Andrew's tests come back the following day you are surprised to see abnormalities in his electrolytes.

Is it insulin allergy?

'I'm allergic to that insulin you gave me. The injections sting and leave marks that last more than a week'. When Joe pulls up his shirt you can see the marks.

Pigmented and thickened axillary folds.

Andrew, 45 years of age, presents with a 12 month history of dark, thickened skin in both axillae. He is concerned about the appearance and would like to know how to treat it. He is moderately obese, with a body mass index (BMI)of 31.2 kg (BMI = weight [kg] + height(2) [m(2)]) but is otherwise well and on no medication. There is no family history of any similar skin disorder.

Skin and Cushing syndrome.

'I feel like a traffic light stuck on red. My friends ask me if I'm having hot flushes but this isn't flushes, it's permanent and I'm still having periods.' Carol is describing her facial appearance. She is 42 years of age, has had trouble controlling her weight all her life and has gained 10 kg over the past 2-3 years.

Diabetes and the skin - onychomycosis.

Case history - Oliver: Oliver is aged 70 years, has had type 2 diabetes for 18 years, and has been treated with insulin for 4 years. He presents after two episodes of cellulitis of his right lower leg and forefoot, which have cleared on antibiotics. There are no residual skin changes on his leg and forefoot other than some postinflammatory pigmentation.

Endocrinology and the skin.

CASE STUDY: 'I've got these ugly red blotches on my legs and they are getting worse?' Lisa, 32 years of age, is an accountant who always presents herself meticulously. You can understand why she doesn't like the raised red brown blotches on her shins. The lesions are raised, indurated with follicular accentuation. They are an uneven red-brown colour that doesn't fade with pressure, nor does the tissue pit. Lisa seems more upset and agitated than you expected. When you ask if she's under stress at work she breaks down in tears and says she feels 'agitated and on edge all the time and can't sit still for a minute'.

Acute skin irritant effects of cyanobacteria (blue-green algae) in healthy volunteers.

OBJECTIVE: To assess the skin irritant potential of a range of laboratory grown cyanobacterial species using skin-patch testing on human volunteers. METHODS: Cell suspensions and extracts of cyanobacterial cultures of Microcystis aeruginosa (non-toxic strain), Anabaena circinalis and Nodularia spumigena were applied to 64 volunteers in one trial, and Microcystis aeruginosa (toxic strain), Apanocapsa incerta and Cylindrospermopsis raciborskii were applied to 50 volunteers in a second trial. Six cell concentrations of each organism in the range from less than 5000 to greater than 200,000 cells/mL were applied in random order using adhesive skin patches (Finn Chambers). In addition, the applications included two treatments of each cyanobacterial species, involving whole and lysed cells, and positive (sodium lauryl sulphate) and negative (culture media) controls. Patches were removed after 24 hours and assessment of erythema was made by a dermatologist blinded to the species, cell type and concentration. RESULTS: On average, between 20% and 24% of individuals with 95% confidence interval +/-8% reacted across the concentration range tested for these cyanobacterial species. The reaction rates were lower (11% to 15%) among the subset of subjects not reacting to negative controls. The reaction was mostly mild, and in all cases was resolved without treatment. This was the case for both whole and lysed cells with little difference in reaction rates between these two treatments. There was also no dose-response across the concentration range for any of the cyanobacterial species tested. CONCLUSION: A small proportion of healthy people (around 20%) may develop a skin reaction to cyanobacteria in the course of normal water recreation, but the reaction is mild and resolved without treatment.

Acitretin for chemoprevention of non-melanoma skin cancers in renal transplant recipients.

A prospective, open randomized crossover trial was conducted to evaluate the efficacy of acitretin for chemoprevention of squamous cell carcinomas and basal cell carcinomas in renal allograft recipients. Analysis was performed according to the intention-to treat principle. Twenty-three patients with previous history of non-melanoma skin cancer enrolled into the study and were randomly allocated into two groups. They crossed over at the end of 1 year. Eleven (47.8%) patients completed the 2-year trial. Twelve (52.2%) patients withdrew from the trial. Nine of these withdrew because of side-effects of acitretin. The majority of the patients who continued with the acitretin could tolerate 25 mg of acitretin daily or on alternate days. The number of squamous cell carcinomas (SCC) observed in patients while on acitretin was significantly lower than that in the drug-free period (P = 0.002). A similar trend was observed in patients with basal cell carcinomas, but this was not significant and the numbers were small. Side-effects were a major limiting factor. A severe rebound increase in SCC occurred in one patient after the acitretin was ceased.

A prospective study of the use of cryosurgery for the treatment of actinic keratoses.

BACKGROUND: Actinic keratoses are the most common actinic lesions on Caucasian skin. Cryosurgery with liquid nitrogen is commonly used to treat actinic keratoses, but there have been few studies examining the true rate of cure in everyday dermatologic practice. AIM: To determine prospectively the true efficacy of cryosurgery as a treatment for actinic keratoses in everyday dermatologic practice. METHODS: A prospective, multicentered study (a subsidiary study of a photodynamic therapy trial) was performed. Patients with untreated actinic keratoses greater than 5 mm in diameter on the face and scalp were recruited. Eligible lesions received a single freeze-thaw cycle with liquid nitrogen given via a spray device and were reviewed 3 months thereafter. Each center used their preferred freeze time. The only treatment criterion was complete freezing of actinic keratoses and a 1-mm rim of normal skin. Treated lesions were assessed as complete response or noncomplete response. The influence of the duration of freeze, cosmetic outcomes, and adverse events were examined. RESULTS: Ninety adult patients from the community with 421 eligible actinic keratoses were recruited. The overall individual complete response rate was 67.2%[SEM = +/-3.5%; 95% confidence interval (CI) = 60.4-74.1%]. Complete response was 39% for freeze times of less than 5 s, 69% for freeze times greater than 5 s, and 83% for freeze times greater than 20 s. Cosmetic outcomes were good to excellent in 94% of complete response lesions. The main adverse events were pain, stinging, and burning during treatment, and hypopigmentation after healing. CONCLUSIONS: Cryosurgery is an effective treatment for actinic keratoses. The true complete response rate is significantly lower than that previously reported. The freeze duration influences successful treatment. Adverse events are mild and well tolerated.