Oral submucous fibrosis: An overview of a challenging entity.

The oral cavity is considered to be a mirror of the body's health, as it reflects the manifestations of various systemic disorders. Most of the oral mucosa is derived embryologically from an invagination of ectoderm and thus, like other similar orifices, it may become involved in the disorders that are primarily associated with the skin. Oral submucous fibrosis is one of the commonest precancerous conditions of the oral mucosa involving any part of the oral cavity resulting in tissue scarring, dysphagia and trismus. It is a collagen-related disorder characterized by excessive fibrosis in the oral submucosa, hyalinization and degenerative changes in the muscles. This disease has become a challenging entity for dermatologists due to resemblance of its features to various mucocutaneous conditions. An improper diagnosis can lead to wrong treatment and additional complications. Dermatologists need to be aware of the characteristic features of this disease which can distinguish it from other similar conditions. This review aims to focus on the detailed aspects of oral submucous fibrosis including its historical background, etiological factors, pathogenesis, clinical features, differential diagnosis, investigations, management and future perspectives.

Skin diseases of the nose.

OBJECTIVES: The goal of this study was to review the main lesion types of the nasal skin and appropriate treatment strategies rather than to present a comprehensive list of all diseases that affect the skin that can involve the nose. METHODS: We reviewed the main nasal skin lesion types and available treatment strategies. Nasal skin lesions were classified as benign, premalignant, or malignant. RESULTS: Benign lesions of the nose include nonmalignant tumoral lesions (i.e., freckles, comedo, adenoma sebaceum [Pringle disease], hydrocystoma, fibrous papules, sebaceous hyperplasia, and rhinophyma), autoimmune and inflammatory conditions (i.e., pemphigus, sarcoidosis, systemic lupus erythematosus, facial eosinophilic granuloma, rosacea, herpes zoster infection, leishmaniasis, and leprosy), and vascular lesions (i.e., telangiectasis, hemangioma, and spider nevus). Premalignant lesions are actinic keratosis and keratoacanthoma; and malignant tumors are melanoma, basal cell carcinoma, and squamous cell carcinoma. Regardless of whether or not they are malignant, all facial lesions can yield significant cosmetic discomfort that should be evaluated carefully before commencing any curative or corrective intervention. In general, benign lesions are treated with dermabrasive modalities, such as trichloroacetic acid, phenol, salicylate, and laser ablation. Electrocautery, cryosurgery, and surgical excision are also used, although these methods may result in scar formation, which can sometimes be more problematic than the original lesion itself. CONCLUSION: Any disease that affects the skin, especially those diseases that are triggered by ultraviolet exposure, can involve the face and nose. Cosmetic defects due both to the lesion itself and the intervention must be discussed with the patient, preferably in the presence of a first-degree relative, before commencement of treatment. As a result of heterogeneity of skin lesions of the nose, appropriate education of general practitioners as well as otorhinolaryngologists is mandatory.

Leucoplasia verrucosa proliferativa: a propósito de un caso clínico / Proliferative verrucous leukoplakia: a clinical case

La Leucoplasia Verrucosa Proliferativa (LVP) es una placa blanca, verrucosa, exofítica, de crecimiento lento, que no se desprende al raspado y que tiende a comprometer diversos sitios de la mucosa oral. Es resistente al tratamiento independiente de la terapia adoptada y presenta una alta tasa de recidiva posterior al tratamiento quirúrgico. Desde 1985, cuando fue descrita por primera vez por Hansen, hasta le fecha, se ha mantenido como una entidad patológica compleja. Reportamos un caso de una paciente de sexo femenino de 72 años de edad que consulta por una lesión blanca, verrucosa, asintomática, que no se desprende al raspado, en el borde y vientre lingual y piso de boca. Se realizaron 2 biopsias incisionales del borde lateral de la lengua. Al examen microscópico se observó en ambas biopsias un grueso revestimiento epitelial acantósico, con marcada hiperparaqueratosis, una membrana basal nítida y cambios displásicos mínimos. Al mes de realizadas las biopsias la lesión presentó recidiva, manteniendo las mismas características clínicas encontradas inicialmente. Considerando la evolución, comportamiento biológico y las características histopatológicas, la lesión se diagnosticó como una LVP. Hasta la fecha, no hay protocolo de tratamiento establecido para estas lesiones. En este caso en particular, tomando en cuenta la extensión de la lesión, los sitios comprometidos, las escasas atipias presentes al examen histopatológico, la edad y escaso nivel socioeconómico de la paciente, se decidió no realizar la remoción quirúrgica de la lesión y mantenerla en control clínico cada 3 meses. Después de varios controles realizados durante un periodo de 3 años, se observó que la lesión mantuvo sus características clínicas iniciales. Esto confirma que haber optado por un tratamiento conservador, en este caso en particular de LVP, fue la decisión correcta...

The proliferative verrucous leukoplakia (PVL) is a white plate, wart-like, exophytic , slow growth , which does not follow the scaling that tends to compromise various oral mucosal sites . It is resistent to independent therapy and has a high rate of recurrence after surgical treatment. Since 1985, when it was first described by Hansen, and to date it has remained a complex pathological disorder. We report a case of a 72-year-old female patient who complains of a white, verrucous and asymptomatic lesion. The lesion does not detach by scraping the edge, lingual belly or mouth floor. Two Incisional biopsies were performed on lateral border of the tongue. Upon microscopic examination of both biopsies, thick epithelial lining, with marked hyperparakeratosis, a basement membrane, and minimal dysplasia alterations were observed. One month following biopsies of the lesion were performed, lesion relapsed and maintained the same clinical features found initially. Considering the evolution, biological behavior and histopathological features, the lesion is diagnosed as an PVL. To date, there is no established treatment protocol for these injuries. In this particular case, taking into account the extent of the injury, compromised sites, the few atypia present histopathological examination, age and low socioeconomic level of the patient, it was decided not to perform surgical removal of the lesion and maintain clinical monitoring every 3 months. Following several examinations carried out over a three-year period, it was observed that the injury kept initial clinical features. This confirms that having opted for conservative treatment, in this particular case of PVL, was the right decision...

Acitretin in dermatology.

Acitretin, a synthetic retinoid has gradually replaced etretinate in today's dermatologic practice because of its more favorable pharmacokinetics. Acitretin over the past 20 years has proven useful in a number of difficult-to-treat hyperkeratotic and inflammatory dermatoses and nonmelanoma skin cancers. It is effective both as monotherapy and in combination with other drugs for hyperkeratotic disorders. It is considered to be an established second line treatment for psoriasis and exerts its effect mainly due to its antikeratinizing, antiinflammatory, and antiproliferative effect. Its antineoplastic properties make it a useful agent for cancer prophylaxis. Evidence-based efficacy, side-effect profile, and approach to the use of acitretin would be discussed in this review. In addition to its approved uses, the various off label uses will also be highlighted in this section. Since its use is limited by its teratogenic potential and other adverse effects, including mucocutaneous effects and hepatotoxicity, this review would summarize the contraindications and precautions to be exercised before prescribing acitretin.

Leucoplasia verrugosa proliferativa / Proliferative verrucous leukoplakia

Una leucoplasia es según la definición de la Organización Mundial de la Salud (OMS) una placa blanca de la mucosa bucal, de cuestionableriesgo, habiéndose excluido otras enfermedades conocidas o desórdenes que no tienen aumentado el riesgo de transformación encáncer. Su diagnóstico se realiza por exclusión de otras enfermedades con aspecto clínico similar, pero que no acarrean riesgo aumentadode cáncer. Es el desorden potencialmente maligno que sufre transformación con mayor frecuencia, con rango de transformación entreel 0,13 y el 17.5%Una variante rara de la leucoplasia, es la leucoplasia verrugosa proliferativa (LVP), descripta por primera vez en 1985 por Hansen etal. Anterior a esa fecha era conocida como papilomatosis florida. La LVP, fue clasificada por la OMS en 2005 como un desorden potencialmente maligno (OMS 2005) por presentar una alta probabilidad de transformarse en un carcinoma espinocelular o un carcinomaverrugoso. Esto indica un comportamiento biológico agresivo.En la mayoría de los casos el diagnóstico de LVP es retrospectivo, lo que enlentece su tratamiento. Su etiología es incierta, pudiendo estar relacionada con el virus del papiloma humano (VPH), con el virus de Epstein-Barr, o con infecciones por cándida, pero aún no hasido posible establecer una correlación definitiva. Sigue considerándosele como lesión de etiología desconocida.

A leukoplakia is, as defined by the World Health Organization (WHO), a white plate of the oral mucosa, of questionable risk having excluded other known diseases or disorders that have no increased risk of cancer transformation. The diagnosis is made by excludingother diseases with similar clinical appearance but carry no increased risk of cancer. It is the potentially malignant disorder that most often suffers transformation within a range between 0.13 and 17.5%. A rare variant of leukoplakia is the proliferative verrucous leukoplakia (PVL) first described in 1985 by Hansen et al. Previously it wasknown as florid papillomatosis. WHO in 2005 classified the PVL as a potentially malignant disorder (WHO 2005) for presenting a high probability of becoming a squamous cell carcinoma (squamous) or warty carcinoma; this indicates an aggressive biological behavior.In most cases the diagnosis of PVL is retrospective, slowing the treatment. Its etiology is uncertain and may be related to human papillomavirus (HPV), the Epstein-Barr virus or even yeast infections, but has not been possible yet to establish a definitive correlation. Still it is considered an injury of unknown etiology.

Topical photodynamic therapy with methylaminolevulinate for the treatment of actinic keratosis and reduction of photodamage in organ transplant recipients: a case-series of 16 patients.

BACKGROUND: Organ transplant recipients (OTR) are at high risk of developing cutaneous neoplasms. Topical photodynamic therapy (PDT) has been used for the treatment of actinic keratosis (AK) in OTR. AIMS: The objective was to evaluate the efficacy of PDT with methylaminolevulinate (MAL) in the treatment of facial AK in OTR. As a secondary objective, we wanted to evaluate the usefulness of topical PDT in the reduction of photodamage in OTR. METHODS: A prospective, single center, single arm study was made. 16 OTR were included. Topical PDT was applied for 1 or 2 cycles depending on the patient's characteristics. An evaluation of AK was made at visits pre-treatment, at 12 weeks and at 24 weeks. Photodamage was measured with multispectral image technique (SkinCare). RESULTS: A complete response rate of 100% was achieved for AK in all patients; it persisted without change at 12 and 24 weeks of follow-up. 62.5% of patients improved their photodamage as measured by SkinCare®, but this result was not statistically significant (P = 0.12). All patients had high level of satisfaction at the end of the therapy. CONCLUSIONS: MAL-PDT is an effective therapy for the treatment of AK in OTRs. It can reduce photodamage in this group of patients, but these results were not statistically significant.

Pseudoepitheliomatous, keratotic, and micaceous balanitis presenting as cutaneous horn in an adult male.

Pseudoepitheliomatous, keratotic, and micaceous balanitis is an extremely rare condition occurring over the glans in elderly characterized by silvery white plaque with mica-like crust, which can undergo malignant transformation. Herein we present a case of pseudoepitheliomatous, keratotic, and micaceous balanitis occurring in an adult male presenting as a cutaneous horn.

Efficacy of 3% diclofenac gel for the treatment of actinic keratoses: a randomized, double-blind, placebo controlled study.

BACKGROUND: Actinic keratoses (AKs) are premalignant skin lesions caused by excessive sun exposure. AIMS: To explore the therapeutic efficacy of 3% diclofenac in 2.5% hyaluronan gel in the topical treatment of AK. METHODS: Sixty-four lesions in 20 patients were evaluated. They were randomized to receive either the active treatment, 3% diclofenac in 2.5% hyaluronan gel or placebo, which consisted of the inactive gel vehicle, hyaluronan for a period of three months. The collected data were analyzed by using Student t- tests. RESULTS: There was a reduction in the lesion size in 64.7% of diclofenac-treated lesions and 34.3% of control lesions during the three-month course of treatment. Only 9.3% of the lesions in the diclofenac group were completely cleared during three months of treatment. During the treatment, no significant side-effect was observed in both groups. CONCLUSION: Considering the malignant potential of actinic keratoses and the importance of clearing them to prevent their transformation to squamous cell carcinoma, the efficacy of diclofenac gel seen in our study seems to be low. This treatment may be useful for patients who do not tolerate other, more effective kinds of treatment for actinic keratoses.

Epidemiological and clinicopathological study of oral leukoplakia.

BACKGROUND: Oral white lesions that cannot be clinically or pathologically characterized by any specific disease are referred to as leukoplakia. Such lesions are well known for their propensity for malignant transformation to the extent of 10-20%. Exfoliative cytology is a simple and useful screening tool for detection of malignant or dysplastic changes in such lesions. AIMS: A clinico-epidemiological and cytological study of oral leukoplakia was undertaken to detect their malignant potential and value of cytology in diagnosis. METHODS: This 2 year duration multicentre study was undertaken on all patients presenting with oral white lesions to the out patient department of the two institutions. Those cases in which a specific cause (infective, systemic disease or specific disease entity) for the white lesions were elicited were excluded from the study. The group with idiopathic white lesions was included in the study and was subjected to periodic exfoliative cytological study at three monthly intervals to detect any malignant change. Patients presenting less than two times for follow up were excluded from the final analysis of the study. RESULTS: Out of total 2920 patients studied, 89.53% showed benign, 9.93% showed dysplastic and, 0.72% showed malignant cells on exfoliative cytological study. All the dysplastic and malignant lesions were subjected to histopathological study by incisional biopsy. Among the dysplastic lesions 13.79% proved benign and the rest true dysplastic. Among the cytologically malignant group 4.76% showed dysplasia and the rest true malignant lesions. CONCLUSION: Persistent leukoplakia has a potential for malignant transformation and exfoliative cytology could be a simple method for early detection of dysplastic and malignant changes.