[Assessment of tele-expertise among elderly subjects in retirement homes]. / Une expérience de télé-expertise en établissement d'hébergement de personnes âgées dépendantes (EHPAD).

BACKGROUND: Chronic wounds (leg ulcers, pressure ulcers, diabetic foot ulcers, etc.) constitute a real public health problem and engender high economic and human costs. Due to the declining physical and mental conditions of our elderly subjects and their rural environment, we created a computer program to assist with chronic wound management in elderly subjects living in retirement homes and to reduce the amount of ambulance transportation. MATERIALS AND METHODS: Each participating establishment was provided with a digital camera and its own secure e-mail address in order to allow photographs to be sent anonymously. Patients with chronic wounds entailing treatment difficulties were included. Details were recorded of the number of tele-expertise consultations given, the chronic wound type, the number of hospitalizations or medical consultations, and the number of ambulance trips avoided. The project was evaluated at 1 year. RESULTS: Of the 40 establishments invited to take part, 22 agreed to do so but only the first 10 respondents were accepted for participation in the pilot feasibility study. Funding ("Health and social prize" provided by the Haute-Vienne region Social Security Office - CPAM) was used to purchase the cameras. Beginning on 15 April 2010, 10 establishments for the elderly sent photographs of 34 patients presenting 26 chronic wounds and tele-expertise was provided for 10 pressure ulcers, two diabetic feet and 14 leg ulcers. CONCLUSION: Over a two-year period, this program helped avoid 20 trips for patients and enabled rapid hospitalization of nine patients by the university hospital by optimizing chronic wound management for patients residing in establishments for the elderly.

[Historic malignant tumour: 27 observations]. / Tumeur maligne historique: 27 cas.

BACKGROUND: When used in the French medical literature to describe a pathological state, the word "historic" normally refers to tumours of startling appearance because of their size. It is difficult to understand how a patient can allow such tumours to continue to grow. We attempt to define this concept. PATIENTS AND METHODS: Two dermatologists carried out a retrospective, independent and comparative selection of photographs taken between 1978 and 2008 of malignant cutaneous tumours of unusual size given the histological diagnosis. Socio-professional, demographic, clinical, histological psychological data, and details of treatment history and progress were collected. RESULTS: Twenty-seven patients (11 M, 16 F) of mean age 74 years (34-99 years) presented a "historic" tumour. Twelve patients lived in rural regions. Five patients were company executives. The average duration of development of the "historic" tumours was 4.5 years (6-420 months). The tumours were classed histologically as epidermoid carcinomas (nine) and melanomas (seven). The mean size was 13 cm (6-30 cm). Psychiatric problems, membership of sects or dementia were noted for 13 patients. Treatment consisted of chemotherapy, radiotherapy or, less frequently, surgery. Eighteen patients died on average 13 months after diagnosis. DISCUSSION: "Historic" malignant tumour (also described in the literature as "giant" tumour) is a real-life fact. No studies have been made of a series of such patients. Despite histological diagnosis, the size was associated with slow tumoral progress and/or late treatment, chiefly accounted for by psychiatric disorders. Socio-professional data indicate that "historic" tumours are equally common in urban and rural areas.

[Photodynamic therapy for the treatment of extramammary Paget's disease]. / Traitement de la maladie de Paget extramammaire par photothérapie dynamique topique.

BACKGROUND: The usual treatment for extramammary Paget's disease (EMPD) is surgery, but this approach may have grave functional and physical consequences, as well as high recurrence rates. Topical photodynamic therapy (PDT) offers an optional approach for EMPD; it has a high complete response rate and there is no dose restriction. The aim of this study was to evaluate the efficacy and safety of PDT in the treatment of EMPD. PATIENTS AND METHODS: This series of patients was seen at a single centre between 1 December 2005 and 31 December 2010. All patients with histologically confirmed EMPD were included. Patients received two courses of PDT 21 days apart: 3 hours after topical application of methyl aminolevulinic acid emulsion, they underwent illumination with red light (570-670 nm) at a dose of 37 J/cm(2) for 10 minutes. In the event of relapse, a further cycle was given at week 6. RESULTS: Eight patients (seven female, one male) of a mean age of 69 years were included. After two series of two illuminations, seven patients were in complete clinical remission at 3 months and one patient was in partial remission. Five patients were still in complete clinical remission at 6 months. All patients had relapsed after a mean 8.4 months (4-14 months). The limiting factor appears to be pain occurring during illumination. Patients reported satisfaction with the disappearance of symptoms and a notable improvement in quality of life. DISCUSSION: The complete clinical response rate to PDT at month 6, after two series of two illuminations, was equivalent to that for surgery. Although the recurrence rate was high, this treatment may be repeated without functional or physical consequences. PDT resulted in disappearance of pain and improved quality of life.

High prevalence and risk factors of thromboembolism in stage IV melanoma.

BACKGROUND: Patients with cancer are at a high risk of thromboembolism (TE), which contributes to morbidity and mortality. Several case reports of thromboembolic events have been reported in patients with melanoma in the literature. OBJECTIVE: The aim of this study was to evaluate the prevalence of venous thromboembolism (VTE) in stage IV melanoma and determine risk factors, outcomes associated with the development of VTE and the number of haemorrhagic complications in patients under anti-coagulant treatment. PATIENTS AND METHODS: In this retrospective study, we included all consecutive patients with stage IV melanoma among 290 patients followed-up in the department of Dermatology each year between January 2005 and 31 December 2007. The diagnosis of VTE was confirmed by venous ultrasound, pulmonary perfusion-ventilation technetium scan and angiography. The primary outcome was to evaluate the number of TE diagnosed in stage IV melanoma patients. The secondary outcomes were to study the influence of TE on survival, its prevalence according to metastatic sites and to evaluate the number of haemorrhagic complications. RESULTS: Twenty-four VTE events were found [25.2% (CI: 16.5-34)]. Eighteen VTE were deep venous thrombosis in lower limbs associated with pulmonary embolism (PE) in 50% of cases. Twenty-five percent were asymptomatic and were revealed in the pulmonary scan performed for follow-up. Eight percent of VTE events revealed stage IV melanoma. Seventeen patients developed thrombosis at home after stopping heparin prophylaxis. Seven thrombotic events occurred during oral anti-coagulant therapy. CONCLUSION: We found as high a prevalence of VTE in stage IV melanoma as in lung and gastrointestinal cancers. All patients suffered thrombotic events when they were treated with chemotherapy and at home when they stopped heparin prophylaxis. Therefore, heparin prophylaxis should be maintained at home.

[Clinical characteristics, outcome of scleromyxoedema: a retrospective multicentre study]. / Caractéristiques cliniques et évolutives du scléromyxœdème : étude rétrospective multicentrique.

BACKGROUND: scleromyxoedema is characterized by dermal mucin deposition associated with a monoclonal gammopathy. This is a rare disease, mostly reported as isolated cases. There is limited data regarding the course and prognosis of the disease. The aim of this study was to determine the clinical characteristics and course of scleromyxoedema. PATIENTS AND METHODS: this was a retrospective study in patients from five French university hospitals between 1987 and 2007. Data were collected using a standardized questionnaire. The inclusion criteria were based on the disease diagnosis criteria proposed by Rongioletti and Rebora: (1) generalized, papular and sclerodermiform skin eruption, (2) mucin deposition in the dermis, fibroblastic proliferation and skin fibrosis, (3) presence of a monoclonal gammopathy, (4) absence of thyroid disease. RESULTS: eight patients were included. The mean age at disease onset was 51.5 years (range: 35-67). The mean time from primary symptoms and diagnosis was 41.6 months (range: 4-120). Seven patients had extra-cutaneous involvement: four with peripheral neuropathy and three with interstitial pneumonia. The mean follow-up time was 9 years. Four patients improved: two experienced partial remission and two complete remission. Complete remission was obtained under treatment with dexamethasone (one patient) and thalidomide (one patient). One patient presented a myeloma and one patient presented encephalopathy leading to death. DISCUSSION: our study shows the frequency of extra-cutaneous involvement and shows that complete remission occurs in some patients.

[Calciphylaxis treated by cinacalcet: a medical alternative to parathyroidectomy]. / Le traitement de la calciphylaxie par cinacalcet: une alternative médicale à la parathyroïdectomie.

Calciphylaxis is a rare necrotizing calcifying arteriolopathy, with a poor prognosis, for which there is currently no effective treatment. One of the major challenges of the therapy is normalizing the calcium-phosphate balance. Therefore, cinacalcet, which inhibit the production of parathormone by negative feedback, was considered a treatment option to control the evolution of calciphylaxis in a dialysed patient suffering from cholangiocarcinoma.

[The value of photodynamic therapy in the treatment of Bowen's disease]. / Intérêt de la photothérapie dynamique topique dans la prise en charge de la maladie de Bowen.

BACKGROUND: While the standard treatments for Bowen's disease (BD) (surgery, cryotherapy and antimitotic agents) are efficient, they are associated with extensive scarring. In this paper we confirm that photodynamic therapy using topical aminolevulinic acid provides effective treatment for this disease. PATIENTS AND METHODS: Twenty-two patients with a total of 38 cases of BD were included in this retrospective single-centre study between 2001 and 2006. They were treated with photodynamic therapy using topical aminolevulinic acid (Metvix. The study criteria consisted of patient age and gender, site and area of lesions, number of patients with multiple patches of BD and/or large lesions, tolerance of the treatment, clinical response and quality of wound healing at 3, 6 and 12 months. Annual follow-up was conducted for five years. The probability of remission up to 60 months after treatment was determined by means of survival analysis based on the variable-interval actuarial method. RESULTS: Seven men and 15 women of median age: 76 years (interquartile range: [69-82]) with 38 cases of Bowen's diseases were treated with photodynamic therapy. In terms of frequency, lesions were seen predominantly on the lower limbs (N=24) and face (N=10). Other lesions were seen on the trunk or back (N=4). The mean surface area of lesions was 8.62 cm2 (1-96 cm2). Eight patients were presenting multiple patches of BD (> or = three lesions), and large lesions were noted in 11 cases. The most common adverse effect was an immediate burning sensation, described by 32% of patients (n=7). Treatment was effective, with remission being achieved in all patients at 3 months of follow-up. Wound healing was optimal and without atrophy or cosmetic sequelae. The remission rate was 100% at 6 months, 95% at 12 months and 85% at 24 months. DISCUSSION: This open retrospective study confirmed the good efficacy of photodynamic therapy in the treatment of BD in terms of both clinical remission and cosmetic results. It enables easier treatment of large and/or multiple lesions than surgery. It is more suitable for elderly patients than either topical anticancer drugs, which require prolonged compliance, or surgery and cryotherapy, both of which result in slow-healing postoperative wounds. CONCLUSION: Since photodynamic therapy is a very costly therapeutic method, we feel that dynamic phototherapy should be used only for large and/or multifocal lesions or for lesions of the lower limbs in patients with chronic venous insufficiency.

[Radiation induced skin reactions]. / Réactions cutanées induites par la radiothérapie.

Radiotherapy is one of the most important treatment modality of cancers. Skin secondary effects are well known. Cutaneous complications are described. Physiopathogenic mechanisms are reported. Many preventative and treatment options have been used with varying degrees of evidence of success. Information of patients, further research studies and a multidisciplinary approach are necessary to increase the management of radiation induced skin reactions.

[Verrucous carcinoma of the lower limbs]. / Carcinomes verruqueux des membres inférieurs.

BACKGROUND: Verrucous carcinoma is a rare, low-grade, slow-growing, well-differentiated squamous cell carcinoma affecting the skin (particularly on the foot) and mucosa. The diagnosis is often delayed. We report a study of twelve cases of verrucous carcinoma of the lower limbs. PATIENTS AND METHODS: We retrospectively studied a series of 12 patients (8 women, 4 men) who developed verrucous carcinoma of the lower limbs between 1978 and 2005 and we analyzed their follow-up data. RESULTS: The mean age of patients was 78 years (66-97 years). Eleven patients exhibited verrucous carcinoma in a previous lesion comprising varicose ulcer (5 cases), mixed ulcer (3 cases), burn (2 cases) or traumatic lesion (1 case). The mean time from onset of lesions to diagnosis was 28 years. Nine patients showed locoregional extension (8 bone involvement, 3 lymph node involvement). No visceral metastasis was detected. Three patients received medical treatment that proved ineffective. Two received secondary surgical treatment. Nine patients underwent surgery (6 amputations, 3 local excisions). Four patients were lost to follow-up, 4 died, 3 showed no recurrence and 1 had a chronic unhealed wound after surgery. DISCUSSION: Verrucous carcinoma of the lower limbs is a disease of the elderly, affecting both men and women, and occurring mainly on chronic venous ulcerations. The clinical presentation is evocative although histopathological diagnosis is difficult, particularly in the event of superinfection. Repeated and deep biopsies are needed to avoid delay in diagnosis. Extension is chiefly locoregional and visceral involvement is rare. Medical treatment is ineffective and may even be harmful, with surgery the best option. Regular monitoring is necessary because of the risk of relapse, although verrucous carcinoma does not seem to directly affect patient survival.

[Primary cutaneous large B-cell lymphoma in chronic venous leg ulcer]. / Lymphome B primitif à grandes cellules CD20-, CD79a+ apparu sur un ulcère veineux chronique de jambe.

BACKGROUND: Large B-cell lymphoma of the leg in elderly subjects, of intermediate prognosis according to the new EORTC classification, may present as nodular or ulcerated forms. There has been relatively little study of the various etiological hypotheses advanced, including venous insufficiency. We report the case of an elderly man with chronic leg ulcer, recently undergoing modification, in which microscopy revealed large B-cell lymphoma (CD20-). PATIENTS AND METHODS: A 78 year-old man presented chronic ulcer of the right leg of mixed origin with severe venous insufficiency and arteritis. In the previous 2 months, 2 nodules appeared in the centre of the ulcer. Histological examination of a skin biopsy revealed the presence of large B-cell lymphoma and immunohistochemical analysis showed positive anti-CD79a+, CD20- antibody labeling of cells. Staging studies showed only locoregional invasion. Because of the positive CD20- labeling, ZEM chemotherapy (idarubicine, cyclophosphamide, prednisolone) was given, resulting in disappearance of the nodules after four months and preliminary epidermal healing of the ulcer. Several months later, severe infectious complications necessitated amputation. Examination of the excised sample showed no residual tumor. DISCUSSION: Many causal links have been proposed between large B-cell lymphoma of the leg and aetiologies such as infectious agents, Koebner phenomenon and chronic lymphedema, as well as various other vascular factors. A number of hypotheses were proposed in the present case. It may have been leg ulcer cutaneous B-cell lymphoma, or, more likely, development of lymphoma on a chronic mixed ulcer, with the respective roles of vascular disease, local immunosuppression and antigenic stimulation subject to debate.

[Abrupt onset of papulovesicular lesions: diagnostic features and outcome]. / Eruptions varioliformes aiguës: aspects diagnostiques et évolutifs.

INTRODUCTION: Abrupt onset of papular lesions, with ulcero necrotic evolution could refers to many dermatitis. Febrile ulceronecrotic Mucha-Habermann disease is an unusual severe form of pityriasis lichenoides and varioliform acuta (PLEVA) characterized with ulceronecrotic eruption potentially associated with high fever and systemic symptoms leading to death. Lymphomatoid papulosis is a recurrent papulonodular eruption with an initial presentation close to PLEVA. While this disorder usually has a benign course, about 10% of the patients develop lymphoproliferative disorders such as CD30+ lymphoma. EXEGESIS: The authors reported an acute form of PLEVA in a young man hospitalized in internal medicine unit with fever and ulcero-necrotic papulo-vesicular lesions. Treatment with tetracycline was successful. They also report a case of lymphomatoïd pustulosis that occurred in a 34 years old woman with an extensive nodulo-pustular eruption characterized by central necrosis and ulceration. Histopathological examination revealed CD30 lymphocytic infiltration leading to diagnosis. CONCLUSION: Theses two dermatosis, uncommon and clinically similar, are both characterized with an unpredictable evolution that to be known by internist.

[Pyogenic granuloma revealing fistula and deep infection: five cases]. / Botriomycomes révélant une fistule et un foyer infectieux profond: cinq cas.

BACKGROUND: Pyogenic granuloma, or botryomycosis, occurring after minor injury or scratching with a septic implement, is a rapidly growing benign inflammatory vascular tumour, often involving the skin or mucous membrane. We report 5 unusual cases of pyogenic granuloma revealing fistula tracking to foreign bodies such as a pace-maker or orthopaedic material, and deep infectious sites with fistula. METHODS: This retrospective study included 5 men of average age 72.2 years over a period of 22 years (between 1981 and 2003). Clinical images were recorded and a diagnosis of botryomycosis was confirmed in all patients by histological analysis. Four patients presented suppuration. The time from initial clinical signs to diagnosis, presence of traumatic events, screening for microscopic organisms, response to systemic antibiotic therapy, recurrence and clinical features of botriomycosis were analysed. RESULTS: All patients presented botryomycosis with fistula and suppuration revealing deep bone infection and in one patient, pace maker infection. Complete resolution of the lesions occurred after excision of foreign material and prolonged systemic antibiotic therapy. CONCLUSION: We report the first series of botryomycosis revealed by fistula and showing deep infectious disease. Pyogenic granuloma is a well-known but rarely reported dermatologic condition.

Aortic angiosarcoma clinically mimicking polyarteritis nodosa.

We report two patients in whom angiosarcoma of the aorta (ASA) with distal emboli and skin metastases was initially clinically misdiagnosed as polyarteritis nodosa (PAN). Both presented with features highly suggestive of systemic necrotizing vasculitis, including constitutional symptoms, orchitis (in one), leg pain with sensory neuropathy, livedo, focal areas of skin necrosis, painful cutaneous nodules demonstrating vasculitis or inconspicuous changes on biopsy, raised acute phase reactants, and transient improvement with systemic corticosteroids. Repeated skin biopsies revealed an atypical endovascular cell proliferation with strong reactivity for factor VIII. Magnetic resonance angiography (MRA) demonstrated an intra-luminal aortic tumour at the infra-renal level. In retrospect, the (PAN)-like features appeared to involve exclusively the lower part of the body in these patients.

Melanoma associated with subacute primitive fibrinolysis.

BACKGROUND: Surgery is the first treatment of a pigmented skin lesion when a melanoma is suspected. This excision is most of the time realized by the dermatologist as well as the second time surgery. Bleeding at the surgical site may have numerous aetiologies. Fibrinolysis is a rare but dramatic event. CASE REPORT: We report a case with delayed bleeding after excision of a melanoma. The patient was re-operated and a major haemorrhage followed so that a transfusion of blood and fresh frozen plasma was necessary. The biological investigations concluded to a subacute primitive fibrinolysis associated with the melanoma. The patient was first considered to have completely recovered when a blood-borne liver metastasis diffusion rapidly occurred. The patient deceased within a few months from a hepatic encephalopathy with hepatic metastases. DISCUSSION: We find only a few published cases of melanoma with fibrinolysis. Its association with other abnormalities, like a partial factor XIII deficiency, made these abnormalities even more difficult to identify. The relation between the subacute fibrinolysis, the melanoma and the liver infiltrative metastasis is difficult to establish.