EROSIVE PUSTULAR DERMATOSIS OF THE SCALP (EPDS) - A CASE SERIES AND SHORT REVIEW.

Erosive pustular dermatosis of the scalp (EPDS) is an uncommon and possibly underreported chronic inflammatory skin disease within the spectrum of neutrophilic disorders. Although it has been reported in all ages, elderly people are more common affected. The surrounding skin often shows symptoms of chronic actinic damage. Histopathology is rather unspecific. The pustules and lakes of pus are sterile. Treatment includes anti-septic, anti-inflammatory topical therapy, in more severe cases oral steroids. Rarely systemic antibiosis or surgery are necessary. EPDS is an important differential diagnosis of non-melanoma skin cancer, bullous autoimmune disease, and soft tissue infections by bacteria or fungi. When untreated, scarring alopecia develops. We report on or own case series and present a narrative review on published cases since 2010.

UPPER ARM CONTOURING - A NARRATIVE REVIEW.

Disfigurement of upper arms is a common esthetic problem. All soft tissues contribute with skin and subcutaneous adipose tissue as the major targets of medical intervention. This narrative review describes the complex pathogenesis of upper arm ptosis and its classification. Surgical and non-surgical methods to improve upper arm contour are discussed. With the broad spectrum of available treatments, a tailored approach is possible to address the individual patient's needs.

JUXTA-ARTICULAR ADIPOSIS DOLOROSA IN LIPEDEMA PATIENTS.

Both lipedema and juxta-articular adiposis dolorsa are painful disorders of subcutaneous adipose tissue. We investigated 297 female patients with lipedema treated at our department for the presence of juxta-articular adiposis dolorsa. Occurrence of both disorders was identified in 4.4% of lipedema patients. The common presence of both disorders was observed only in more advanced lipedema (grade II and III). Juxta-articular adiposis dolorosa of the knees is seen exclusively on the inner knees, and it presents neither bruising nor creases or hypothermia. Choices of surgical treatment are either microcannula liposuction or dermolipectomy. Recurrences have not been observed.

PIGMENTED NODULAR CYSTIC HIDRADENOMA OF THE ANKLE.

Solid-cystic hidradenoma is a benign cutaneous tumor that is most commonly found in the head, neck, trunk, and upper extremity regions of patients in the middle to older aged groups. Presentation on lower extremities and in particular on the foot is uncommon. Nodular hidradenomas represent a dermatological pitfall, being difficult to differentiate from basal cell carcinoma and melanoma. We report on a 53-year-old male patient with a pigmented nodular hidradenoma on his ankle that was surgically removed. We discuss histopathology and differential diagnosis of this eccrine tumor of skin. This is the second reported case in the English literature.

LONG-PULSED ND:YAG LASER TO TREAT TELANGIECTASIA OF THE NOSE: A COMPREHENSIVE 5-YEAR SINGLE CENTER STUDY.

Telangiectases of the nose are of esthetic concern and treatment is warranted. The study provides the results of 5 years of treatment of telangiectases of the nose region with the long-pulsed Nd:YAG 1,064 nm laser. A retrospective analysis was conducted in patients of Fitzpatrick skin type II-V. Exclusion criteria were patients with a previous history of treatment of the nose region, pregnant or lactating patients or patients with unrealistic expectations regarding the treatment risks, limitations and results. Standardized photographs were obtained before each session and at least 2 months after the last treatment session. A long-pulsed Nd:YAG 1,064 nm laser was used with a spot size of 2.5mm, fluence of 100 - 175 J/cm2, pulse duration of up to 135ms and repetition rate of 2-4 Hz. The follow-up ranged from 2 months to 5 years. The number of laser sessions varied from 1 to 5 monthly. Assessment was made by comparing pre-treatment and post-treatment photographs by two independent specialists and also by the patients' own assessment. All patients presented improvement of the vascular alterations. Evaluation of independent specialists as well as the evaluation of the patients themselves showed a high degree of satisfaction with the treatment. The treatment presented only few transitory side effects. Treatment of telangiectasia on the nose skin with the long-pulsed Nd:YAG 1,064 nm laser demonstrated to be safe and effective even in darker pigmented skin. The major limitation of this study is its retrospective nature.

[Complications after laser treatment of facial vascular lesions]. / Komplikationen nach Laserbehandlung vaskulärer Veränderungen des Gesichts.

Laser technology represents a major advance in the treatment of vascular changes. Excellent knowledge combined with technological advances in new laser sources form the basis of this safe and effective option in many acquired or congenital vascular changes on the face. With regard to the different laser sources, the pulsed dye laser (PDL) has the best efficacy-to-safety ratio. This type of laser remains the gold standard for vascular lesions. Neodymium-doped yttrium aluminium garnet (Nd: YAG) lasers and diode lasers, among others, as well as intensed pulsed light (IPL), play an important role in addressing vascular changes in the face. Good knowledge of the laser approach to vascular lesions and technological progress have led to safety features that seek to minimize side effects. These advances mainly include the introduction of cooled tips, cooling devices and cooling systems, changes in pulse duration, and the introduction of different wavelengths, among others. However, undesirable side effects can still occur. Although these are mostly discrete and resolve spontaneously, some complications can be serious and difficult to manage. Therefore, the prevention and early management of complications are all the more important in the treatment of vascular changes on the face.

Approach to skin malignancies in COVID-19 pandemic days.

COVID-19 pandemic emerged as a condition that changed our entire life and led us to develop new perspectives on diseases. Cancers are generally additional risk factors for COVID-19, and this has implications also for skin cancer patients. Those patients require special attention, due to situations such as an increased risk of infection as a result of visiting the hospital for treatment. It is imperative that the diagnosis and treatment of patients who have a cancer that progresses rapidly, such as malignant melanoma, high-risk squamous cell carcinoma and a high risk of metastasis, are delayed. Due to the relatively long-lasting nature of basal cell carcinoma and, as almost no metastasis would be expected, its treatment may be postponed, except for those that occur in areas such as the eyes and mouth. Diagnosis and treatment of skin cancers is a process that requires many procedures. Throughout this process, physicians should take appropriate precautions that are sufficient to protect both the patient and themselves in the best way without leading to any delay in the procedures.

IMPROVEMENT OF HYPERTROPHIC SCARS WITH INTRALESION INJECTIONS OF HYALURONIDASE.

In contrast to intra-urine wounds, extra-uterine wounds will heal with a scar. A number of conservative and surgical methods have been developed, aiming at improving unsightly and hypertrophic scars. The authors report on their experience with intralesional injection of the enzyme hyaluronidase to improve hypertrophic scars. Hyaluronidase produces low-molecular weight fragments during digestion of high-molecular weight hyaluronic acid. These fragments are known to stimulate angiogenesis and to activate mesenchymal stem cells. The manuscript presents a clinical review of series of patients with hypertrophic scars, mainly resulted from tumor resection, who were treated by this technique.

GIANT PEDUNCULATED TUMORS OF SKIN.

The clinical appearance of a skin tumor is of major importance for clinical diagnosis of both benign and malignant neoplasias. Pedunculated growth pattern is unusual to exceptionally rare, depending on a tumor type. A necessary prerequisite for pedunculated growth is a well vascularized stem. We provide a review on large and giant pedunculated tumors of skin to serve as an additional guidance for the clinicians to avoid diagnostic errors and mistreatment. The knowledge of unusual growth pattern of cutaneous neoplasia is an essential not only in outpatient care, but also in care of hospital-admitted patients.

LOCALIZED CUTANEOUS NON-TOXIC DIPHTHERIA (CASE REPORT).

The authors report on a clinical case of 91-year-old female patient presented with a two-year history of an enlarging forehead lesion with exudation and bleeding, suspicious of squamous cell carcinoma. Histology ruled out the suspected diagnosis, however the microbiology culture and polymerase chain reaction assay identified non-toxic Corynebacterium diphtheriae. Therefore the diagnosis of localized cutaneous diphtheria was confirmed. The patient was treated with penicillin regimen V 3 x 1 mio IU/ day for 10 days in complex with topical povidone-iodine. The chosen treatment achieved complete healing of the ulcer and no relapse has been reported during the 9-month follow-up. Cutaneous non-healing chronic ulcers can be caused by diphtheroid corynebacteria. Immediate diagnosis is important to exclude toxic variants, which need patient isolation and treatment of persons in close contact.

HYPERCALCEMIA DUE TO POLYMETHYLMETHACRYLATE INJECTIONS? (LITERATURE REVIEW AND CASE REPORTS).

Hypercalcemia is a common feature of malignancy, bone metabolic conditions and granulomatous disorders. In the latter, hypercalcemia is usually calcitriol-related. As eventual association of silicone and polymethylmethacrylate (PMMA) injections with granulomatous disease and hypercalcemia the condition has become an issue of recent interest. Authors report on two cases of calcitriol-related hypercalcemia where PMMA injections had been previously administered. The association, even though intriguing, requires additional confirmation by follow-up studies.

CALCIUM HYDROXYLAPATITE MICROSPHERES - BIOCOMPATIBILITY AND CLINICAL EFFECTS.

Soft tissue fillers are used in aesthetic medicine for volumizing and for contouring. Calcium hydroxylapatite (CaHA) is a fully biodegradable biostimulatory filler. The study presents results of in vitro biocompatibility and cytotoxicity investigations performed on CaHA and illustrates its clinical effects. We used a human cell culture model for in vitro studies with HaCaT keratinocytes and human dermal fibroblasts, known to be a sensitive cell type for biocompatibility and cytotoxicity. Cells were exposed to different concentrations of CaHA (Radiesse®). Cell proliferation was calculated by luminometric adenosine triphosphate (ATP) measurement using the ATPLiteTM-M Assay. Possible cytotoxic effects were detected by the calorimetric Cytotoxicity Detection Kit. Clinical data were obtained from our own treatment files. CaHA did neither inhibit cell proliferation nor cause cytotoxicity. Clinical data suggest an excellent tolerability and long-term efficacy superior to hyaluronic acid-based fillers. CaHA is a versatile and well-tolerated biodegradable and biostimulatory filler.

CUTANEOUS POLYPOID MELANOMA OF HEAD AND NECK.

Cutaneous polypoid melanoma is an uncommon subtype of malignant melanoma. The clinical behavior of this subtype has been described as aggressive. Tumors can be sessile or pedunculated. The typical patient is a younger adult. Authors have analyzed the case histories of patients with polypoid melanomas of the head and neck region treated at our clinic from 2001 to 2018. We identified 3 female patients with tumors of the neck and cheek. In contrast to other reports, all patients were older than 80-years of age. None of them had a metastatic spread at the time of diagnosis. Treatment was delayed Mohs surgery. Polypoid melanomas of the head and neck region can occur in elderly patients without an aggressive course. In those patients a number of differential diagnoses have to be considered including Merkel cell carcinoma, metatypical basal cell carcinoma, squamous cell carcinoma and tumor metastases.

BASAL CELL CARCINOMA OF THE FOOT - TWO CASE REPORTS AND LITERATURE REVIEW.

Basal cell carcinoma (BCC) is considered the most common skin cancer in men. BCC of the foot, however, is very rare, and may occur on dorsal surface of the foot, foot sole or nail apparatus. Diagnosis is often delayed due to the location at an unusual site. We report on two patients: a 61-year-old female with an ulcerated BCC of the sole and dorsum of the foot on a leg with Klippel-Trénaunay syndrome and a 61-year-old male with an ulcerated BCC of the foot sole. Histologic tumor types were either metatypic or mixed solid and morphea-like with partial glandular infiltration. Perineural invasion was evident in both patients indicating the aggressive tumor behavior in the particular region. Authors also provide a review of the literature with a focus on the years 2000 through 2017.

UNILATERAL FRONTALIS MUSCLE PARALYSIS: MANAGEMENT WITH BOTULINUM TOXIN A (CASE REPORTS).

Unilateral frontalis muscle palsy is a debilitating disease with a heterogeneous etiology. Congenital or acquired unilateral paralysis of the frontalis muscle causes ipsilateral brow ptosis and contralateral hypermobility of the non-paralytic frontalis muscle, resulting in a bizarre asymmetry and emotional embarrassment. We present five patients with unilateral frontal muscle paralysis, two males and three females, aged between 32 and 68, treated with botulinum toxin A injection to the contralateral (non-affected) side. A total dose between 10 to 30 U botulinum toxin A (onabotulinum or incobotulinum toxin A) successfully improve symmetry and facial esthetics without any adverse events. Botulinum toxin A is an alternative to facial palsy surgery but may also be used as an adjunct after the surgical procedure to optimize the outcome.

KERATOACANTHOMA OF THE UPPER LIP: REVIEW OF THE LITERATURE AND REPORT OF CASE WITH CENTRAL UPPER LIP RECONSTRUCTION.

Keratoakanthoma (KA) is a common non-melanoma skin tumor of sun-exposed skin. Recently it has been classified as a highly differentiated squamous cell carcinoma, based on the evidence of local destruction, tissue invasion and malignant transformation with metastatic spread described in the medical literature. Lower lip KA is not uncommon on lower lip, and quite rare on upper lip. The authors present a case of 78-year-old Caucasian male patient with a rapidly growing keratotic tumor of the central region of upper lip. After complete surgical excision, single-stage reconstruction of the defect was performed by modified Goldstein's bilateral advancement myocutaneous vermilion flap. The histologic examination confirmed KA with excision margins within healthy tissue. Healing was unremarkable and functional and esthetic outcomes were very good. KA of the upper lip is a rare tumor that warrants complete surgical excision. Reconstruction of the central part of the upper lip is a challenge, but bilateral advancement myocutaneous vermilion flap resulted in good outcome.

PHOTODYNAMIC TREATMENT WITH NANOEMULSIFIED 5-AMINOLEVULINIC ACID AND NARROW BAND RED LIGHT FOR FIELD CANCERIZATION DUE TO OCCUPATIONAL EXPOSURE TO ULTRAVIOLET LIGHT IRRADIATION.

Actinic keratosis (AK) is a premalignant epithelial disease that develops on skin chronically exposed to ultraviolet-light. For outdoor workers, AK is an occupational hazard with a potential for malignant transformation into squamous cell carcinoma. Various topical treatments are used to treat AK's. Photodynamic therapy (PDT) promises the highest cure rates. We performed a prospective single center trial evaluating effects of PDT treatment for field cancerization due to occupational exposure to ultraviolet light irradiation in patients unresponsive to the treatment regimen with topical diclofenac gel. For PDT, a nanoemulsified 5-aminolevulinic acid (5-ALA) formulation was combined with narrow band red light irradiation with a peak wavelength of 635 nm and a total light intensity of 37 J/cm2. Clearance rate and adverse events were recorded. Thirty patients with a mean age of 77±10.5 years (26 males and 4 females) were included in the trial. They received between one and nine PDT sessions. Mean pain during PDT was scored at 6.8±2.8 using the visual analogue scale. Patients exhibited a mild immediate erythema after PDT. Among the patients, who tolerated PDT, a complete clearance was achieved in 93.3%, and >90% clearance - in 6.7%. Pain management was performed by cold-air analgesia. In conclusion, PDT with nanoemulsified 5-ALA and narrow band red light irradiation is an effective and safe treatment for occupational field cancerization without systemic toxicity. Adherence to this treatment is much better than to topical treatment.