Optical transfer diagnosis differentiating benign and malignant pigmented lesions in a simulated primary care practice.

BACKGROUND: The detection of melanoma poses a substantial challenge, particularly for primary care providers (PCPs) who may have limited training in discriminating between suspicious and benign melanocytic lesions. The noninvasive optical transfer diagnosis (OTD) method was designed to be used by PCPs in their decision-making process. OBJECTIVES: To assess the potential of the OTD method by developing, training and validating an OTD indication algorithm for automated discrimination between benign melanocytic lesions and malignant lesions, based on a set of 712 lesions. METHODS: The authors performed in vivoOTD capture and subsequent analysis of 712 pigmented lesions. Of the lesions, 415 were clinically and dermoscopically benign and 297 were dermoscopically suspicious or equivocal. After image capture, all suspicious or equivocal lesions were biopsied and examined histopathologically. RESULTS: Of the 297 suspicious or equivocal lesions, histopathological findings revealed 80 to be malignant (64 melanomas, 13 basal cell carcinomas and 3 squamous cell carcinomas). OTD misdiagnosed one of the 80 malignant lesions as benign (sensitivity, 99%). OTD specificity was 93% for the dermoscopically benign lesions, 73% for all lesions included in the study and 36% for the clinically suspicious but histopathologically benign lesions. CONCLUSIONS: High sensitivity and specificity, as provided by OTD in this preliminary study, would help PCPs reduce the number of referrals for dermatology consultation, excision or biopsy. Further studies are planned for screening patients in a primary care setting, with comparisons of OTD results with biopsy or dermoscopy results.

False-negative rate of intraoperative frozen section margin analysis for complex head and neck nonmelanoma skin cancer excisions.

INTRODUCTION: Intraoperative frozen section analysis (IFSA) is traditionally performed for complex and high-risk non-melanoma skin cancer (NMSC) resections, particularly when surgery under a general anaesthetic and a complex reconstruction is required, and where Mohs micrographic surgery (MMS) is not available. METHODS: A retrospective audit of 253 cases between 1999 and 2009 was undertaken, investigating the accuracy and efficacy of IFSA for the treatment of NMSC in our tertiary skin tumour unit based in a university hospital setting. RESULTS: The combined incomplete and very narrow (<1 mm) excision margin rates were 28.7% and 27.5% for basal cell and squamous cell carcinoma, respectively. Unrepresentative sampling of the excision margins intraoperatively was the overwhelming cause of error (94%). CONCLUSION: After a thorough audit of our data, IFSA has been abandoned for the treatment of NMSC in our unit. MMS is practised intraoperatively, even in advanced cases. We believe that IFSA no longer has any role in our complex, multidisciplinary skin cancer practice.

Seasonal variation in high-risk phenotypes of cutaneous malignant melanoma diagnosed in Eastern England: An observational study.

BACKGROUND: Despite seasonal variation in malignant melanoma diagnosis being well described, data on the annual variation in high-risk melanomas are scarce. OBJECTIVES: We set out to investigate the relationship between seasonality, the incidence of melanoma, and the distribution of melanoma characteristics, including Breslow thickness, ulceration, mitotic rate, lymphovascular and perineural invasion, and the presence of microsatellites. METHODS: Primary cutaneous malignant melanomas diagnosed between 2011 and 2019 in Eastern England were identified from our prospectively maintained melanoma database (n = 2199). These were analysed by year and season of diagnosis, patient demographics, and melanoma characteristics. RESULTS: There was a variation in rates of melanoma diagnosis across the year, with Summer having the highest incidence (p < 0.0001). There was a significant trend towards more male than female diagnosis in Winter (p = 0.0354). There were no significant seasonal trends in Breslow thickness, ulceration, tumour infiltrating lymphocytes, or mitotic rate. Multivariate analysis showed that microsatellites were more likely to be diagnosed in the Winter (OR=2.00 (1.19-3.43), p = 0.010), lymphovascular invasion significantly more likely to be diagnosed in Autumn (OR=1.78 (1.16-2.76), p = 0.009), and perineural invasion was more likely to be diagnosed in the Summer (OR=0.44 (0.23-0.79), p = 0.007). CONCLUSIONS: These data confirm that high-risk phenotypes are associated with increasing Breslow thickness and mitotic rate. However, season variability as an independent risk factor for the phenotypes is a novel finding.

A randomized, double-blind, negatively controlled pilot study to determine whether the use of emollients or calcipotriol alters the sensitivity of the skin to ultraviolet radiation during phototherapy with narrowband ultraviolet B.

BACKGROUND: There is contradictory evidence suggesting that emollients increase, decrease or have no effect on minimal erythema dose (MED) or minimal phototoxic dose values prior to phototherapy. Few studies have looked at the in vivo use of emollients or calcipotriol prior to narrowband ultraviolet (UV) B (NB-UVB) treatment. OBJECTIVES: To investigate whether emollients or calcipotriol alter MED readings of skin on the back of healthy subjects prior to NB-UVB irradiation. METHODS: Topical agents were applied to the backs of 20 healthy volunteers for 30 min prior to MED testing. These agents were aqueous cream, 50:50 white soft paraffin and liquid paraffin, Diprobase(®) (Schering-Plough, Welwyn Garden City, U.K.), Epaderm(®) (Medlock, Oldham, U.K.) and calcipotriol ointment and cream. A control MED strip was used with no topical agent applied prior to testing. MED readings were recoded as integer steps between 1 and 9 (one is lowest MED dose for skin type; eight is highest; nine is no response, i.e. a higher MED). RESULTS: The median MED was between step 5 and 6 for all treatments and control. There was no significant difference at the 5% level between control and each topical agent. The study was powered to detect a median difference of approximately 0·4-0·6 steps. CONCLUSIONS: This has important implications at a practical level when advising patients not to apply creams prior to treatment with NB-UVB. Studies where agents are applied immediately prior to phototherapy have been more likely to show that emollients block transmission of UV radiation. If they are applied at least 30 min prior to treatment, they have no effect.

Severe lower limb cellulitis is best diagnosed by dermatologists and managed with shared care between primary and secondary care.

BACKGROUND: Cellulitis is responsible for over 400,000 bed days per year in the English National Health Service (NHS) at the cost of £96 million. OBJECTIVES: An audit following transfer of care of lower limb cellulitis managed in secondary care from general physicians to dermatologists. METHODS: Review of patient details and work diaries from the first 40 months of implementation of the new model of care. RESULTS: Of 635 patients referred with lower limb cellulitis 33% had other diagnoses which did not require admission. Four hundred and seven of 425 patients with cellulitis were managed entirely as outpatients, many at home. Twenty-eight per cent of patients with cellulitis had an underlying skin disease identified and treated, which is likely to have reduced the risk of recurrent cellulitis, leg ulceration and lymphoedema. Only 18 of 635 patients referred with lower limb cellulitis required hospital admission for conventional treatment. CONCLUSIONS: This new way of managing suspected lower limb cellulitis offered substantial savings for the NHS, and benefits of early and accurate diagnosis with correct home treatment for patients.

A comparison of the stimulatory effects of cytokines on normal and psoriatic keratinocytes in vitro.

Keratinocytes from normal and psoriatic skin were tested for their in vitro proliferative response to a range of concentrations of rIL-6, rTGF alpha, rIL-8 and rGM-CSF using a serum-free culture system. With one exception, all normal cultures (11/12) were stimulated by 1000 ng/ml IL-6 (P < 0.001). Six out of ten psoriatic keratinocyte cultures were also stimulated at this concentration, but this just failed to reach significance (P = 0.05). As a group, the response by psoriatic keratinocytes to IL-6 was significantly less than that of normal keratinocytes (P = 0.02). TGF alpha at 1 ng/ml induced proliferation in approximately 60% of both normal (8/12, P < 0.05) and psoriatic (6/10, P < 0.01) keratinocyte cultures; there was no significant difference between the responses of the two groups to this cytokine. In addition, small numbers of both normal and psoriatic cultures responded to TGF alpha over a concentration range of 0.1 to 100 ng/ml. Approximately half of the normal and psoriatic cultures were stimulated by 10-1000 ng/ml IL-8. However, the effect was not significant for the group at any of the concentrations tested. GM-CSF had minimal to no effect on most of the normal and psoriatic cultures tested. This study showed that psoriatic keratinocytes are equally responsive to the stimulatory effects of TGF alpha and IL-8, but are less susceptible to IL-6 compared to keratinocytes from normal skin. These findings are consistent with a role for these cytokines in the maintenance of a hyperproliferative epidermis in psoriasis.

Induction of cutaneous lymphocyte-associated antigen expression by group A streptococcal antigens in psoriasis.

The cutaneous lymphocyte-associated antigen (CLA) has been proposed as a homing receptor for the selective migration of memory T cells into the skin. To investigate the effect of group A streptococci (GAS) on the migration of T cells in psoriasis, CLA expression was assessed by double-staining for CD3 and the HECA-452 epitope on peripheral blood T cells from 13 patients with psoriasis, 10 patients with other inflammatory skin diseases and 12 normal controls before and after 7 days culture with a GAS sonicate, Candida albicans (control antigen) or medium. In addition, CLA+, and CLA-, CD3+ CD45RO+ subsets were isolated from individuals in each group and V beta 2 expression and proliferation to GAS studied. Mean CLA expression by freshly isolated T cells was almost identical in the three groups. After culture with GAS, T cells from the psoriatic patients and control showed a significant increase in mean percentage CLA+ expression compared to medium (P < 0.002, P < 0.05, respectively). This induction was inhibited by the addition of anti-IL-12 antibody. However, in psoriatic patients, but not in controls, the GAS-induced increase was significantly greater than that of C. albicans (P < 0.002) and was accompanied by a decrease in T cells positive for the peripheral lymph node homing receptor, L-selectin (P < 0.05). The percentage of V beta 2+ T cells was markedly higher in the CLA+ than in the CLA- T-cell subset in psoriatic patients (P < 0.01) and controls; both subsets proliferated to GAS, in each group. These findings suggest a differential modulation of specific tissue homing receptors on T cells by GAS in psoriasis.

Cytokine expression in psoriatic skin lesions during PUVA therapy.

To determine whether an improvement in skin lesions as a result of PUVA therapy may be correlated with changes in cytokine patterns, RT-PCR amplification was used to compare the levels of IL-2, IL-6, IL-8, IL-10, TNF-alpha and IFN-gamma cytokine mRNA expression in serial biopsies from three chronic plaque psoriatic patients. In each case, 3-mm punch biopsies were taken from lesional skin before and during 2-28 days of treatment with PUVA. Total mRNA was extracted from each biopsy, cDNA synthesized, and then amplified by 35 cycles of PCR using cytokine-specific primers. The specificity of the PCR products was confirmed by the Southern blot technique. Substantial levels of specific mRNA for each of the cytokines studied was present in the lesions prior to treatment. In two of the three patients who responded well to PUVA, a reduction in all the cytokines including IL-10 was observed compared with baseline levels. In contrast, PUVA proved to be ineffective in clearing the psoriasis of the third patient whose skin lesions worsened during the course of treatment. This was accompanied by an increase in IFN-gamma but not of the other cytokines investigated, above the pretreatment level. This study showed an association between PUVA-induced resolution and decreases in the levels of various cytokines highly expressed in psoriatic lesions.

Acne in schoolchildren: no longer a concern for dermatologists.

OBJECTIVE: To determine the prevalence and severity of acne among schoolchildren in Glasgow. DESIGN: Secondary schools in Glasgow were divided by postcode into five socioeconomic cluster groups. Different numbers of schools were selected at random from the five groups to ensure proportional representation. One class from each registration year of the chosen schools was selected at random and the whole class recruited into the study. SETTING: 15 Secondary schools in Glasgow. SUBJECTS: 2014 Randomly selected schoolchildren aged 12-17 (5% of total secondary school roll). INTERVENTIONS: None. END POINT: Assessment of facial acne by two independent examiners by a recognised acne scoring system. MEASUREMENTS AND MAIN RESULTS: The prevalence of acne in boys increased from 40% (75/189) at age 12 to 95% (108/114) at age 16, and in girls it increased from 61% (114/187) at age 12 to 83% (136/164) at age 16. On a scale of 0 to 10 only 18 boys (1.8%) and three girls (0.3%) had grades of acne of 1.0 or greater; most of the pupils had grade 0.05-0.375 (minimal) acne. Nine per cent of boys (88/973) and 14% of girls (145/1041) had visited their general practitioner specifically for advice on and treatment for acne; only five pupils (0.3%) had been referred to a dermatologist. CONCLUSIONS: Both the prevalence and severity of acne have decreased over the past 20 years. This has probably been due to improvement of treatment for acne by primary care doctors and the greater availability and use of over the counter preparations for acne.

Setting up an effective and efficient sentinel node biopsy service for malignant melanoma within the NHS.

Sentinel lymph node biopsy provides prognostic information for melanoma patients, and the Department of Health states that it should be available across the country by 2012. We review the setting up of a melanoma sentinel lymph node biopsy service with specific consideration to resources, service implications and patient outcomes. In total, 164 patients underwent sentinel lymph node biopsy for melanoma from August 2008 until March 2010. The median time for sentinel lymph node excision was 26 min. The median total operative time, which includes melanoma excision and sentinel node biopsy was 65 min, compared with 22 min for excision of the melanoma performed during the previous 19 months. The complication rate was 8.5%, with only 1.2% requiring operative treatment. After the initial outlay for two gamma probes, it was possible to deliver a cost neutral service within the National Tariff. Despite a significant increase in demand for the service in the second half of the study period, and 106% increase in the number of regional lymphadenectomies, only 1 patient (0.6%) breached the 'Going Further on Cancer Waits' target. In conclusion, a sentinel lymph node biopsy service for malignant melanoma can be effectively delivered within the majority of UK plastic surgery departments.