[What's new in instrumental dermatology?] / Quoi de neuf en dermatologie instrumentale ?

This "What's new in instrumental dermatology" dedicated skin surgeryis based upon a 2015-2017 literature analysis. The excision of skin cancers is an important part of surgical dermatology. Will artificial intelligence and new drug be able to face the increasing need for therapy? Wrong-site surgery is due to multiple factors. Photographs of biopsy site and short time between biopsy and surgery decrease postponement of surgery and wrong-site surgery. Noninvasive imaging technologies are improving and help to delineate skin tumors and increase the probability of complete tumor removal. They are beginning to be an essential tool for skin surgery. The 2005 recommendations for the management of melanoma stages I to III have been updated in 2016. The Slow-Mohs technique is the better way to treat dermatofibrosarcoma protuberans whose sub-clinical invasion is often asymmetric and unpredictable. Wide local excision for the treatment of severe hidradenitis suppurativa improves the quality of life and decreases recurrence rate. Cutaneous surgery is considered as safe procedures with a low risk of complications. Postoperative bleedings are the most frequent. Anti-thrombotics enhance the risk, but must not be stopped or bridged, except the novel oral anticoagulants which can be interrupted 24h before surgery and started again a few hours after. The risk of surgical site infections is low in dermatologic surgery. Most recommended measures to prevent them have been extrapolated from other types of surgery and the level of evidence is low. The reconstruction of skin defect must be adapted on size and location. A birhombic transposition flap is reliable in case of a defect too large to be repaired by a single flap. Full-thickness skin graft is a safe option to repair defect on the external ear.

[How to optimize scarring in dermatologic surgery?] / Optimisation de la cicatrisation en chirurgie dermatologique et gestions des aléas.

Scarring is the response elicited by the skin surface to injury and loss of tissue material. Wound healing takes place through a complex natural repair system consisting of vascular, inflammatory and proliferative phenomena, followed by a remodelling and cell apoptosis phase. This incredible repair system is inevitable, but sometimes unpredictable due to individual differences based on multiple factors. The scar is the objective criterion of a skin surgery, both for the patient and the dermsurgeon. It is therefore crucial to establish with the patient during the preoperative consultation, the size and positioning of the expected scar, taking into account the oncologic, anatomic and surgical constraints. Scars can ideally blend into normal skin, but may also give rise to various abnormalities. We can manage and prevent these abnormalities by mastering initial inflammation, that may induce hyperpigmentation and hypertrophy. Early massage using cortocosteroid topic or anti-inflammatory moisturizers may be effective. Random individual scarring may be minimized by a dynamic personalized accompanying scarring.

[Mohs micrographic surgery in two children with dermatofibrosarcoma protuberans]. / Chirurgie micrographique de Mohs dans le dermatofibrosarcome de Darier-Ferrand de l'enfant.

Dermatofibrosarcoma protuberans is a rare low-grade malignant tumor. The pseudopodia structure of the tumor requires 3-5 cm surgical margins. Mohs micrographic surgery (MMC) can reduce these margins to 1.3 cm while controlling all the histological excision margins. Children seem to be a good indication for this technique because it reduces the amount of skin removed. We report 2 cases of pediatric DFS treated with CMM to illustrate the usefulness of this technique in pediatrics. Two girls, aged 12 and 13 years, had a dermatofibrosarcoma located on the breast and sternum, respectively. CMM was proposed. One operative session was needed with direct closure in a second phase. MMS is a useful surgical technique for childhood tumors. If dermatofibrosarcoma is a very good indication in children, other skin tumors could benefit from this approach.

Skin responses to topical dehydroepiandrosterone: implications in antiageing treatment?

BACKGROUND: Although low dehydroepiandrosterone (DHEA) is suspected to have a role in skin ageing, little information is available on the mechanisms potentially involved. OBJECTIVES: To obtain information on androgen receptor (AR) and procollagen expression in ageing skin during DHEA treatment. METHODS: A placebo-controlled, randomized, prospective study was performed with 75 postmenopausal women aged 60-65 years. The women were treated twice daily for 13 weeks with 3·0 mL of placebo or 0·1%, 0·3%, 1% or 2% DHEA cream applied on the face, arms, back of hands, upper chest and right thigh where 2-mm biopsies were collected before and after treatment. RESULTS: Although the overall structure of the epidermis was not significantly affected at the light microscopy level, AR expression examined by immunocytochemistry was markedly increased by DHEA treatment. In the dermis, the expression levels of procollagen 1 and 3 mRNA estimated by in situ hybridization were increased by DHEA treatment. In addition, the expression of heat shock protein (HSP) 47, a molecule believed to have chaperone-like functions potentially affecting procollagen biosynthesis, was also found by immunocytochemistry evaluation to be increased, especially at the two highest DHEA doses. CONCLUSION: These data suggest the possibility that topical DHEA could be used as an efficient and physiological antiageing skin agent.

[The cost of Mohs micrographic surgery for basal cell carcinoma. The Ambroise Paré hospital's experience (Boulogne, France)]. / Coût de la chirurgie micrographique de Mohs dans les carcinomes basocellulaires. L'expérience de l'hôpital Ambroise Paré (Boulogne, France).

OBJECTIVE: Mohs'micrographic surgery is generally considered as the best procedure for the treatment of difficult basal cell carcinomas. It is supposed to be costly, but an economic evaluation, with a cost-outcome analysis, is necessary to estimate the actual contribution of this procedure in skin cancer treatment, in comparison with the reference procedure, i.e. traditional surgical excision. Our aim was to evaluate the actual cost of Mohs'surgery applied on basal cell carcinoma treatment in France. METHODS: The charts of 97 patients treated by Mohs'surgery between january 1997 and july 2001 in a teaching hospital near Paris (Ambroise Paré hospital, Boulogne), where Mohs'surgery is exclusively performed in France, were reviewed. Direct costs were derived from resource utilization of staff and material required for Mohs'surgery, estimated by a micro-costing method. Indirect costs and total costs were then calculated. RESULTS: When adding surgery and pathology facility costs, mean direct and total costs per basal cell carcinoma were 776.0 (range: 538.4-1273.9), and 1014.6 Euros (range: 777-1512.4), respectively. When including costs of diagnosis, the average total cost per procedure was 1084.3 Euros. DISCUSSION: These costs appear higher than those obtained with other methods of valuation of hospital costs used in France, but they are slightly lower than those found in the literature. The next stage will be to estimate, in the same way, the cost of traditional surgical excision for the same type of lesions, and to calculate the incremental cost-effectiveness ratio between the two procedures, with rate of recurrence at five years as the effectiveness outcome.

[Treatment of dermatofibroma protuberans with fixed Mohs' micrographic surgery]. / Dermatofibrosarcome de Darier Ferrand: traitement par chirurgie micrographique de Mohs avec inclusion en paraffine.

INTRODUCTION: Dermatofibrosarcoma protuberans is a tumor of intermediate malignancy characterized by its aggressive local growth due to pseudopodium-like outgrowths and marked propensity to recur after surgical excision. To achieve complete cure with conventional surgery, surgical margins up to 5 cm are required, leading to wide scars. Mohs' micrographic surgery is used for the removal of certain malignant tumors, both ensuring complete excision by examination of all margins as well as minimizing normal tissue loss. However, differentiating minimal residual tumor from normal skin can be difficult on the frozen sections used in Mohs' micrographic surgery. Our aim was to develop a procedure of Mohs' micrographic surgery in conjunction with rush formalin-fixed, paraffin-embedded tangential sections. PATIENTS AND METHODS: Ten consecutive cases have been prospectively treated since 1998. Under local anesthesia, the tumor was first excised including lateral margin of 1 cm and a deep margin including the underlying muscle aponevrosis. A 2 to 3 mm thick horizontal section of the surgical bed was then removed, rush formalin-fixed, paraffin-embedded, tangentially sectioned, hematin-eosin stained, and eventually stained with an anti-CD34 monoclonal antibody. While waiting for pathology results, the surgical bed was not definitively closed. If excision was incomplete, an oriented complementary excision was performed. RESULTS: Excision was complete after the first stage in 7 patients and incomplete only deeply in 3. Lateral surgical margins were reduced to 1.3 cm in all patients, facilitating wound closure: direct suture (5 patients), controlled wound healing (3 patients) or flap coverage (2 patients). No recurrence has been observed after a mean follow-up of 26 months. DISCUSSION: The use of Mohs' micrographic surgery in conjunction with rush formalin-fixed, paraffin-embedded tangential sections reduce surgical margins in dermatofibrosarcoma protuberans. This procedure would be interesting in difficult sites, such as the genitalia, the breast, or the periarticular regions. Other cases, and longer follow-up are however necessary to validate this promising technique.

[Mohs' micrographic surgery: history, principles, critical analysis of its efficacy and indications]. / Historique, principes, analyse critique de l'efficacité et indications de la chirurgie micrographique de Mohs.

OBJECTIVES: To systematically review the literature for studies reporting on the role of Mohs' micrographic (MMS) surgery in the treatment of skin tumors. To show how it is performed in France. DESIGN: We reviewed with a quality grid all studies indexed in MEDLINE before 2003/01/01 and published in English or French. Data were extracted by two independent reviewers. MAIN OUTCOME MEASURES: Quality of clinical studies, recurrence rates, number of patients lost to follow-up. RESULTS: No randomized study was found among the 493 references found. Studies of lower quality, on procedures similar to MMS, or previous systematic reviews were therefore selected. In tumors such as basal (BCC) or spinous (SCC) cell carcinoma, microcystic adnexal carcinoma, dermatofibrosarcoma protuberans, and Merkel cell carcinoma, MMS commonly induced lower recurrence rates than figures reported for conventional treatments and/or reduced surgical margins. Studies on melanoma were of low quality. CONCLUSIONS: Although no evidence-based guidelines could be developed, MMS should be used mainly for larger, morphea, micronodular or infiltrative-type, or recurrent BCCs located in danger zones, but also (sometimes with a slightly modified procedure) in microcystic adnexal carcinomas, dermatofibrosarcoma protuberans, Merkel cell carcinoma, and in aggressive forms of SCC. Randomized, controlled studies should be performed.

[Diagnostic and therapeutic problems in a severe case of hyperparathyroidism with renal insufficiency]. / Les difficultés diagnostiques et thérapeutiques dans un cas d'hyperparathyroïdie sévère avec insuffisance rénale.

It may sometimes be difficult to distinguish primary from secondary hyperparathyroidism when advanced renal failure coexists. We report here the case of a patient with end-stage renal failure who had severe hyperparathyroidism. Cervical exploration revealed only the presence of four parathyroid glands normal in size and histological appearance which were removed. Because the existence of severe hyperparathyroidism had been firmly established based on biochemical and radiological evidence, the diagnosis of primary hyperparathyroidism due to an ectopic adenoma became obvious. Digital angiography and computerized tomography were then carried out. The results of angiography were inconclusive but computerized tomography revealed and precisely localized a mediastinal adenoma which was subsequently removed via sternotomy. The existence of a hypoparathyroid state was confirmed over the following two months. Reimplantation of parathyroid fragments which had been cryopreserved during the first operation, was then performed with success.