Pilonidal sinus disease: an intergluteal localization of hidradenitis suppurativa/acne inversa: a cross-sectional study among 2465 patients.

BACKGROUND: Hidradenitis suppurativa (HS), also referred to as acne inversa, is a debilitating skin disease characterized by inflammatory nodules, chronic abscesses and tunnels (fistulae and sinuses). The association with pilonidal sinus disease (PSD) is frequently reported but not well documented. OBJECTIVES: To determine the prevalence and characteristics of inflammatory skin lesions located in the intergluteal fold (IGF) of patients with HS. METHODS: This was an international multicentre retrospective cross-sectional study based on data collection from a large cohort of patients with HS with and without histopathology. Results From a total of 2465 patients with HS included in the study, 661 (27%) reported lesions in the IGF. These patients were significantly more often smokers and had more severe HS. Of the 238 patients with an available clinical diagnosis, intergluteal-HS (IG-HS) was diagnosed in 52 patients (22%) and PSD was diagnosed in 186 patients (78%). IG-HS was associated with the localization of HS in the proximity of the IGF, including the buttocks, genitals and the anus. There was a possibility of misclassification bias in this study as a clinical/image-based diagnosis or histopathology of the IGF lesions was not always available. CONCLUSIONS: The high prevalence of PSD suggests a strong link between both entities. Therefore, it may be useful to identify common pathophysiological mechanisms and develop common therapeutic strategies. What's already known about this topic? The occurrence of pilonidal sinus disease has not been clearly reported among patients with hidradenitis suppurativa/acne inversa. What does this study add? This is the first study that investigated the prevalence of pilonidal sinus disease among a large cohort of patients and identified the patient characteristics. Risk factors that might help to improve the management of patients were identified.

Assessing physicians' preferences on skin cancer treatment in Europe.

BACKGROUND: A wide variety of both surgical and nonsurgical therapies is currently available for patients with skin cancer. OBJECTIVES: This part of the EPIDERM (European Prevention Initiative for Dermatological Malignancies) project is aimed at the evaluation of the treatment preferences for skin cancer in eight countries of the European Union. METHODS: A multicentre hospital-based case-control study was carried out at dermatology departments in Finland, Germany, Greece, Italy, Malta, Poland, Scotland and Spain. Patients with skin cancer (basal cell carcinoma, actinic keratosis, squamous cell carcinoma, cutaneous malignant melanoma and Bowen disease) were consecutively enrolled between July 2008 and July 2010. Information on the study variables (sex, age, country, tumour type, anatomical location and treatment) was obtained from questionnaires designed by the EPIDERM project. RESULTS: In total, 1708 patients with skin cancer were included. Surgery was the first treatment option in 76·5% of the patients (P = 0·001). Actinic keratosis was the only tumour type in which nonsurgical treatment was more frequent than surgery (91·4%). Tumours on the head were less likely to be surgically excised than those at other locations (odds ratio 0·25, P = 0·001). Simple excision or curettage was the most common surgical procedure (65·4%), followed by graft and flaps (22·4%). Cryotherapy was the most common nonsurgical option (52·4%), followed by imiquimod (18·0%), photodynamic therapy (PDT; 12·0%), 5-fluorouracil (5-FU; 5·7%), and diclofenac with hyaluronic acid (4·0%). CONCLUSIONS: Surgery remains the first-choice treatment of skin cancer. Regarding nonsurgical treatments, the conservative treatments available (imiquimod, 5-FU, PDT and diclofenac gel) have not yet exceeded the use of ablative options such as cryotherapy despite their accepted benefit of treating field cancerization.

Known and potential new risk factors for skin cancer in European populations: a multicentre case-control study.

BACKGROUND: During recent years numerous studies have suggested that personal and environmental factors might influence cancer development. OBJECTIVES: To investigate environmental and personal characteristics associated with skin cancer risk. METHODS: A multicentre hospital-based case-control study was performed in Finland, Germany, Greece, Italy, Malta, Poland, Scotland and Spain, including 409 patients with squamous cell carcinoma (SCC), 602 with basal cell carcinoma (BCC) and 360 with cutaneous malignant melanoma (CMM) and 1550 control persons. Exposures were assessed by questionnaires that were partly self-administered, partly completed by dermatologists. Unconditional logistic regression modelling was used to assess associations including the influence of certain drugs and food items on skin cancer risk. RESULTS: The usual associations were observed for sun exposure and pigmentation characteristics, with chronic sun exposure being most strongly associated with SCC risk, and naevi and atypical naevi with CMM risk. Use of ciprofloxacin was associated with a decreased risk of BCC [odds ratio (OR) 0·33] and use of thiazide diuretics was associated with an increased risk of SCC (OR 1·66). Ciprofloxacin was also associated with SCC (OR 0·34) and thiazines with BCC (OR 2·04), but these associations lost significance after correction for multiple testing. Consumption of pomegranate, rich in antioxidants, was associated with decreased BCC and SCC risk, also after correcting for multiple testing. Recent experience of stressful events was associated with increased risk, particularly of CMM. CONCLUSIONS: In this large case-control study from across Europe the expected associations were observed for known risk factors. Some new potential protective factors and potential risk factors were identified for consumption of certain food items, medication use and stress, which deserve further investigation in future studies.

Risk factors for actinic keratosis in eight European centres: a case-control study.

BACKGROUND: There are limited data regarding the association of actinic keratosis (AK) and other types of nonmelanoma skin cancer (NMSC); studies investigating possible correlation of AK with melanocytic naevi are even scarcer. To our knowledge, there are no data examining the risk of AK in people using specific medications. OBJECTIVE: To investigate constitutional and exposure risk factors leading to AK and the coexistence of AK with NMSC and melanoma. METHODS: A multicentre hospital-based case-control study was performed in Finland, Germany, Greece, Italy, Malta, Poland, Scotland and Spain, including 343 patients with actinic keratosis (AK), 409 with squamous cell carcinoma (SCC), 602 with basal cell carcinoma (BCC), 360 with invasive melanoma and 119 with in situ melanoma, and 686 control subjects. Exposures were assessed by questionnaires that were partly self-administered and partly filled out by dermatologists. Unconditional logistic regression modelling was used to assess associations including the influence of phenotypic characteristics, presence of naevi, sun-exposure habits and certain drugs on AK risk. RESULTS: Differences in hair and eye coloration variably influenced the risk for AK, with red hair signifying a seven times higher risk [odds ratio (OR) 6·9, 95% confidence interval (CI) 4·34-11·00), and brown - compared with blue - eyes, about a 40% reduced risk (OR 0·61, 95% CI 0·13-0·92). The darker the skin phototype, the lower the risk for AK, with phototype IV exhibiting nine times less risk of developing AK. Some and many freckles on the arms were associated with an OR of 1·8 (95% CI 1·08-2·81) and 3·0 (95% CI 1·10-3·54), respectively, while overall number of naevi and high educational level were inversely associated with AK. Sun exposure, thiazide diuretics and cardiac drugs had a higher risk for AK. SCC was the most frequent (58%) skin neoplasm coexisting with AKs, followed by BCC (30%), melanoma in situ (12%) and invasive melanoma (6%). CONCLUSION: In this large case-control study from across Europe the expected associations were confirmed for known risk factors. Some possible new risk factors, including cardiac and diuretic drugs, were identified, creating a new field for further investigation in future studies.

The patient journey: a report of skin cancer care across Europe.

BACKGROUND: There are poorly documented variations in the journey a skin cancer patient will follow from diagnosis to treatment in the European Union. OBJECTIVES: To investigate the possible difficulties or obstacles that a person with a skin malignancy in the European Union may have to overcome in order to receive adequate medical screening and care for his/her condition. In addition, we wished to explore differences in European health systems, which may lead to health inequalities and health inequities within Europe. METHODS: Ten European countries took part in this investigation (in alphabetical order): Finland, Germany, Greece, Italy, Malta, Poland, Romania, Spain, the Netherlands and the U.K. The individual participants undertook local and national enquiries within their own country and completed a questionnaire. RESULTS: This exercise has identified important differences in the management of a skin cancer patient, reflecting major disparities in health care between European countries. CONCLUSIONS: Further investigation of health disparities and efforts to address health inequalities should lead to improvements in European health care quality and reduction in morbidity from skin cancer.

Depicting the analyses of the first National Maltese Childhood BMI study.

INTRODUCTION: Obesity is a chronic disease that often commences in childhood. Several publications have shown that a quarter to a third of Maltese children are overweight or obese. Malta will be the first country to measure height and weight (and hence Body Mass Index) for all school children in order to quantify the extent of the problem. METHODS: This study would include 46,000 children in 150 schools. This would be the first time that any country measured its entire childhood cohort, as opposed to sampling. Hence, it was decided to attempt to facilitate data collection and analysis with the use of bespoke spreadsheets. RESULTS: This paper will demonstrate how standard Microsoft Excel was used to accomplish this, greatly speeding up the data analysis process. CONCLUSION: Software should be prepared in advance in anticipation of large amounts of data that need to be analysed and summarised. Particular care must be taken in order to prepare the requisite graphs and tables in advance so as to process the data once and present it in a suitable format for consumption and evaluation.

Skin phototypes of a Maltese sample population.

BACKGROUND AND AIM: Skin phototyping is a clinical classification system based on a patient's historical reporting of the acute skin response to sunlight. We carried out a simple study to estimate the skin phototypes of the Maltese people in order to acquire more information on the relative risk of the general Maltese population to sun burning and to the more chronic effects of sun exposure, including photoaging and skin cancers. METHOD: A consultant dermatologist and dermatology trainees determined the skin phototype of patients seen with skin infections or skin tags at dermatology outpatients in Malta by carrying out a short interview. RESULTS: Data were collected on 756 patients. The commonest reported skin phototype in both sexes was type III (48.0% overall; 52.4% in males, 43.8% in females); this was followed by type IV in males (30.4%) and type II in females (32.3%). Only 1.2% of the total was of skin type I. CONCLUSION: Approximately one half of the Maltese population is at moderate risk of sun damage; about one quarter is at low risk; and the other quarter is at high risk, the latter group needing more thorough sun avoidance and better surveillance for skin tumours. Social desirability can influence responses to such questionnaires and might have contributed to the difference between males and females noted in our study.

A profile of invasive cutaneous malignant melanoma in Malta: 1993-2002.

BACKGROUND: The incidence of malignant melanoma of the skin has risen in every part of the world where reliable cancer registration data are found. OBJECTIVE: Our study aims to describe the changing incidence of and survival from invasive cutaneous malignant melanoma in Malta, by analysing the data from the 211 cases that were registered at the Malta National Cancer Registry between 1993 and 2002. RESULTS: The age standardized incidence rates for invasive cutaneous malignant melanoma rose from 3.7 per 100,000 population per year for males and 5.1 for females in the first 5-year period, to 8.0 per 100,000 population per year for males and 5.9 for females in the second 5-year period. In both sexes, numbers of thin (< or = 1.0 mm) invasive melanomas increased significantly between 1993 and 2002; males also registered a significant increase in intermediate-thickness (1.01-4.0 mm) melanomas. The increase in numbers of thin and intermediate-thickness melanomas between the two 5-year periods was greatest in patients aged 60 years and over. The overall absolute 5-year survival rate for the first period was 74% and for the second period 92%. CONCLUSION: Numbers of reported cases of invasive cutaneous malignant melanoma in Malta have more than doubled during the 10-year study period. This is mostly due to a marked rise in the diagnosis of thin melanomas in both sexes, occurring mainly in patients aged 60 years and over. As thin melanomas are of low metastasizing potential, this has resulted in an increase in survival between the two 5-year study periods.

Allergic reactions to glyceryl trinitrate and isosorbide dinitrate demonstrating cross-sensitivity.

Glyceryl trinitrate (nitroglycerin) has been in use for relief of angina for over a hundred years, but allergic reactions to it or to other organic nitrates rarely feature in the medical literature. Most of the case reports describe reactions to transdermally applied nitroglycerin. We report a case of a localized allergic reaction to nitroglycerin transdermal patches that developed when these were worn for the first time after 7 days of uneventful treatment with intravenous isosorbide dinitrate. The reaction evolved into a severe and generalized maculopapular rash with facial swelling when intravenous isosorbide dinitrate was re-administered 10 days later. Subsequent patch testing with a transdermal nitroglycerin patch and a placebo nitroglycerin-free patch provoked a reaction to the nitroglycerin patch but not to the placebo, thus excluding allergy to other constituents of the nitroglycerin patch.

Sun awareness in Maltese secondary school students.

BACKGROUND: Studies indicate that reducing exposure to ultraviolet light during childhood and adolescence decreases the risk of skin cancer. From a young age, children need to be educated about the sun's harmful effects on the skin and how best to protect themselves. OBJECTIVE: To help in the design of school-based interventions to raise sun awareness, a school survey was carried out to identify students' stereotypes and misconceptions. STUDY DESIGN: A total of 965 students attending Maltese secondary schools in forms 1, 2 and 3 were surveyed in May 2002, using a structured questionnaire designed to examine students' sun-related attitudes and knowledge. RESULTS: A high level of sun awareness among students was demonstrated, with high scores on knowledge of the effects of the sun on the skin, knowledge of skin cancer and knowledge of sun protection. Girls were clearly more knowledgeable than boys. However, of all the students surveyed, 55% thought that a suntan made them look better and 70% thought that their friends would desire a tan. These views were commoner among the older students. Skin type and hair or eye colour had no bearing on attitudes towards tanning or sun-related knowledge. The commonest misconceptions were that 'the sun is bad for your skin only when you get sunburnt' and that 'you cannot get too much sun on a cloudy day'. Deliberate suntanning was more frequently reported by girls than by boys and by students in the higher forms. CONCLUSION: Attitude change lags behind knowledge. Future school sun awareness interventions need to take into account gender and age differences in students' attitudes and perspectives. They should aim at motivating attitude change and preventive behaviour through consistent and repeated sun-education messages that are supported by a sun-conscious school environment.

Sun awareness and sun protection practices in Malta.

BACKGROUND: Concern regarding the rising incidence of melanoma and non-melanoma skin cancers in Malta has led to the organization of annual campaigns since the early 1990s. These aim to inform the public of the dangers of sun exposure and to promote sun protection. OBJECTIVE: To help guide future campaigns, a survey was carried out to evaluate current sun protection measures among the Maltese people and to assess their level of knowledge regarding harmful effects of the sun on the skin. STUDY DESIGN: A total of 559 pedestrians were interviewed in the main street of the capital city of Malta in the summer of 1999. RESULTS: Self-reported rates of regular sunscreen and hat use in adults exposed to the spring/summer sun between 10.00 h and 15.00 h were 51% and 32%, respectively, for leisure activities, and 25% and 37%, respectively, for outdoor work. Men reported using sunscreen less often than women during both leisure and work. The fairer-skinned outdoor workers actually reported making less use of a sunscreen and/or hat than their darker counterparts, and rates of sunscreen and/or hat use during leisure and work were not found to increase with the amount of time spent in the sun. Almost 75% of sunscreen users were using a sun protection factor of at least 15. Parents reported much higher rates of regular sunscreen and hat use by their young children than by themselves, with 87% of children under 12 years of age reported to be using sunscreen and 78% reported to be wearing a hat. The great majority knew that injudicious sun exposure is associated with skin cancer and skin ageing, but 48% were still regarding a suntan achieved without skin burning as 'healthy' The mass media was by far considered to be the main source of information for the general public regarding effects of the sun on the skin. CONCLUSIONS: The positive impact of past campaigns can be seen in the high reported rates of sun protection in children. However, much remains to be done with adults in order to change their attitude about a 'healthy suntan' and to convince them that it is worthwhile to protect themselves from the sun.