Itraconazole in the treatment of tinea pedis and tinea manuum: comparison of two treatment schedules.

A multicentre, randomized, double-blind, parallel-group trial was conducted to compare the efficacy and safety of two dosages of itraconazole in the treatment of tinea pedis or manuum. Of the 135 patients recruited, 66 received itraconazole 400 mg daily for 1 week and 69 received itraconazole 100 mg daily for 4 weeks. In the evaluable patients observed-case analysis, mycological cure was seen in 63% of patients in the 400 mg/1 week group and in 75% in the 100 mg/4 weeks group at the end of a 6-week follow-up period (not significantly equivalent). In the evaluable patients worst-case analysis and the intention-to-treat analysis, mycological cure rates in the two groups were borderline significantly equivalent at the end of follow-up (range 51-57%). Clinical response was seen in 81% of evaluable patients in the 400 mg/1 week group and in 75% in the 100 mg/4 weeks group at the end of follow-up; equivalence testing showed the 400 mg/1 week regimen to be at least equivalent to the 100 mg/4 week regimen. Similar results were found in the intention-to-treat analysis, and tolerability ratings for the two treatment regimens were significantly equivalent. This trial has shown that itraconazole 400 mg/1 week and itraconazole 100 mg/4 weeks are both effective regimens for the treatment of tinea pedis or manuum. The two treatment schedules were equally well tolerated and safe.

Factors influencing participation among melanoma screening attenders.

We surveyed the demographic profile and motives prompting to participate among people attending voluntary melanoma screening clinics in Southern Limburg, the Netherlands, in June 1993. Precampaign public announcements addressed only melanoma and its precursor lesions. All attendees completed a detailed questionnaire addressing demographic particulars and specific fixed choice questions on their motivation to attend. There were 4,146 persons attending the screening clinics. Most attendees opted for examination of a specific lesion (71%). More females than males participated. Fear of having skin cancer was an important reason to participate (27%). Of all attenders, 16% had to be convinced by relatives or friends to attend the screens, and 33% would not have visited a physician on their own initiative when there had not been a free screening. Females were more concerned about skin cancer than males. The local and regional newspapers formed the most important precampaign publicity channel. Free melanoma screenings attract large numbers of people. Males are underrepresented. They are less aware of the risk profile of melanoma. Future screenings should target the male population.

Volunteer melanoma screenings. Follow-up, compliance, and outcome.

BACKGROUND: Follow-up information on free melanoma screening clinics is not readily available. OBJECTIVE AND METHODS: We studied the follow-up, compliance, and outcome of positive screenees after a screening campaign for melanoma in the Netherlands. RESULTS: Of the 4146 participants, 486 (11.7%) had a suspicious premalignant or malignant lesion warranting referral to his or her general physician indicating the proposed line of management. Participants with borderline lesions were not referred. Referral of borderline cases should have resulted in a considerable increase of the number of positive screenees (18.1%). All positive screenees but two gave permission for follow-up. Only 18 screenees (3.7%) were lost during follow-up. Moreover, one screenee with a presumed basal cell carcinoma and six screenees suspicious of having a premalignant lesion decided not to seek medical attention despite several reminders. The positive predictive value for melanoma was 17.2%, and for nonmelanoma skin cancers was 42.9%. CONCLUSION: A selective referral policy may reduce the generated costs of melanoma screenings substantially. Adequate follow-up of positive screenees is mandatory in order to determine the ultimate yield and usefulness of such campaigns.

Total skin examination during screening for malignant melanoma does not increase the detection rate.

Total skin examination during public screening for malignant melanoma is often advocated, but the benefit of this approach has not been established properly. We assessed the yield of examination of the entire skin, in addition to examination of intentionally shown skin lesions, in people attending melanoma screening clinics in southern Limburg, the Netherlands, in 1993. Of the 4146 attenders, 2910 (70%) showed a specific skin spot. Additional examination of the entire skin was offered to 1385 people. There were 1221 evaluable cases. Fourteen presumptive diagnoses of malignancies were encountered: seven malignant melanomas, all with low clinical suspicion, and seven basal cell carcinomas. Histology revealed three basal cell carcinomas. No malignant melanomas were confirmed by histology. It is concluded that additional total skin examination during screening for malignant melanoma is not worthwhile, except perhaps for persons presenting lesions that are suspicious of melanoma or dysplastic naevi.

Diphencyprone in the management of refractory palmoplantar and periungual warts: an open study.

BACKGROUND: Induction of delayed-type hypersensitivity has recently been introduced for resistant viral warts. The method is not painful and less destructive than most other modalities. OBJECTIVE: We assessed the efficacy of topical diphencyprone (diphenylcyclopropenone) treatment for recalcitrant warts. METHODS: From September 1988 to June 1995, 134 patients with periungual and/or palmoplantar warts were entered into the study. Eight weekly applications were delivered. RESULTS: The scheduled treatment course and follow-up were completed by 111 patients. There were 49 complete and 18 partial remissions. The rate of positive responders (60%) compares with the results published by other authors. CONCLUSION: Diphencyprone is an effective treatment for resistant warts, especially in palmoplantar and periungual locations.

An addition to the controversy on sunlight exposure and melanoma risk: a meta-analytical approach.

Case control studies on the association between sunlight exposure and melanoma risk show considerable differences in design; this could be responsible for the variation in study results. In an attempt to resolve the controversy between study results, the results of 25 publications on case control studies were evaluated using meta-analytical techniques. Comparison of odds ratios between subgroups of studies revealed that the range of odds ratios was far greater for hospital-based studies than for population-based studies. For the latter type of studies, the odds ratios were homogeneous and the pooled odds ratios were 1.57 (95% confidence interval [CI], 1.29-1.91) for intermittent sunlight exposure and 0.73 (95% CI, 0.60-0.89) for chronic exposure. However, among other problems, the lack of standardized measures for sunlight exposure warrants cautious interpretation of these results. It is concluded that evidence to support the intermittent sunlight theory is still far from complete.

False-negative findings in skin cancer and melanoma screening.

BACKGROUND: Few data are available on the accuracy of visual skin examination by dermatologists as a skin cancer and melanoma screening tool. OBJECTIVE: The purpose of this study was to assess the number of false-negative findings in a skin cancer-melanoma screening program. METHODS: We obtained follow-up information regarding 1551 persons with a negative screening result in a skin cancer-melanoma screening program in 1990. Follow-up was established by record linkage with two different population-based registries. RESULTS: Fifteen persons had new skin cancers. Three of their lesions had been present at the original screening and had probably been missed; 12 were genuinely new. No melanomas were among the missed cases. The calculated sensitivity of the screening was 93.3%, its specificity was 97.8%, its positive predictive value was 54.0%, and its negative predictive value was 99.8%. CONCLUSION: Visual examination by dermatologists as a screening tool for skin cancer and melanoma is appropriate.

Skin cancer screening focusing on melanoma yields more selective attendance.

BACKGROUND: Screening theoretically reduces death and morbidity from malignant melanoma. The rationale of screening for nonmelanoma skin cancer is more debatable, since mortality is very low. METHODS: We organized a screening campaign in Southern Limburg, the Netherlands, in 1993. Press releases and public announcements referred only to melanoma. The results were compared with similar campaigns in Arnhem and Eindhoven, the Netherlands, in 1990; these, however, addressed skin cancer in general. RESULTS: There were 4146 people attending the 1993 screenings, compared with 2463 in 1990. The proportion of screenees with lesions suggestive of melanoma increased from 1.1% in 1990 to 1.7% during the 1993 campaign (P = .04). The proportion of dysplastic nevi rose from 2.1% to 7.7% (P < .001). Nonmelanoma skin cancers were less often encountered (3.7% in 1990 vs 2.6% in 1993; P = .009). Actinic keratoses were also less numerous (6.3% vs 1.5%; P < .001). CONCLUSION: Screening concentrating on melanoma increases the rates of lesions suggestive of melanoma and dysplastic nevi, whereas the proportions of basal and squamous cell carcinomas and actinic keratoses decrease. These findings may have important implications with regard to the cost-effectiveness of skin cancer screening efforts.

Swimming and the risk of cutaneous melanoma.

Recreational exposure to the sun may not explain fully current trends in melanoma incidence. The hypothesis was examined whether carcinogens in water play a role in the development of cutaneous melanoma. In a case-control study, 128 melanoma patients and 168 patients with other types of malignancy completed a detailed questionnaire on aquatic leisure time activities. All relative risk estimates were adjusted for age, gender, educational level, pigmentation characteristics, and exposure to sun habits. Regular swimming during the summer months in swimming pools and in open waters such as rivers and seas before the age of 15 years, was associated with odds ratios of 2.20 (95% confidence interval (CI), 1.05-4.62) and 2.41 (95% CI, 1.04-5.58), respectively, compared with no swimming at all or swimming in relatively unpolluted waters, such as lakes and fens. Melanoma patients learned to swim at a younger age; compared with those who never learned to swim or who learned to swim after the age of 12 years, the odds ratio was 1.87 (95% CI, 0.91-3.78) for those who learned to swim at ages 9-12 years, and 2.22 (95% CI, 1.16-4.26) for those who learned to swim before 9 years of age. Compared with persons who had no swimming certificates, an odds ratio of 1.25 (95% CI, 0.71-2.23) was found for persons with one or two certificates, and an odds ratio of 2.96 (95% CI, 1.25-6.96) for persons with three or more certificates. The positive association between a history of swimming and melanoma risk suggests that carcinogenic agents in water, possibly chlorination by products, play a role in melanoma aetiology.

Report of a symposium on: diagnosis and treatment of cutaneous head and neck melanoma.

A series of presentations and discussions was held during a symposium on the diagnosis and treatment of cutaneous head and neck melanoma. The purpose of this meeting was to define certain guidelines on diagnosis and treatment of head and neck melanoma. The results of this symposium are summarized and condensed in this report. Recommendations are made for diagnostic strategies and for treatment. It is indicated that research efforts in immunology need to be expanded to develop rational immunotherapy.

Lack of selective attendance of participants at skin cancer/melanoma screening clinics.

BACKGROUND: Whether persons who come for skin cancer/melanoma screening are those at highest risk for the disease remains a debatable issue. OBJECTIVE: Our purpose was to evaluate the appropriateness of self-selection of persons attending screening clinics. METHODS: We studied the frequency of malignant and/or premalignant clinical diagnoses according to certain demographic characteristics as a measure of selective attendance among 2463 persons screened in the regions of Arnhem and Eindhoven in 1990. RESULTS: The referral rates for tentative malignant and/or premalignant diagnoses were more or less similar in men (11.8%) and women (9.6%); in persons with symptoms (11.6%) and those who were symptom free (9.3%); in attendants from the towns in which the screenings were held (11.4%) and those coming from distant communities (9.0%); and in persons who attended for specific skin lesions (10.7%) and those who opted for general skin examination (8.8%). The referral rate was 9.2% in persons younger than 70 years of age against 18.5% in those 70 years of age or older (p < 0.001). Most presumptive melanoma diagnoses (15 of 22) were recorded in persons 50 years of age or older. CONCLUSION: Our findings suggest that participants of free skin cancer/melanoma screening clinics, on average, are unable to estimate their own risk profile properly.

Effect of intermittent exposure to sunlight on melanoma risk among indoor workers and sun-sensitive individuals.

Intermittent exposure to sunlight is considered to be an important risk factor for melanoma, but the associations reported in most case-control studies are surprisingly weak. The aim of this study was to evaluate whether the incorporation of a subject's background exposure to the sun and pigmentation characteristics (which are assumed to influence a person's susceptibility to sunlight exposure) could produce stronger associations between sunlight exposure and the risk for melanoma. A population-based case-control study was performed in the mid-eastern part of the Netherlands. The study group comprised 141 patients with a histologically verified melanoma and 183 controls with other malignancies who were registered by the same cancer registry. Patients with a lentigo maligna melanoma or an acrolentiginous melanoma were excluded. Information was collected by interviews and physical examination. We categorized subjects as indoor or outdoor workers on the basis of occupational exposure to the sun. Pigmentation characteristics, which are known to be risk indicators for cutaneous melanoma, were summarized as one sun sensitivity score. We used this score to distinguish between sun-sensitive and sun-resistant persons. The odds ratios associated with sunbathing, vacations spent in sunny countries, and sunburns were higher among the indoor workers than among the outdoor workers. After stratification by the sun sensitivity score, the effect of sunbathing, participating in water sports (swimming excluded), vacations to sunny countries, and a history of sunburn was largest for the sun-sensitive persons. The data show a general trend toward higher relative risks among indoor workers and sun-sensitive individuals. The results of this study support the intermittent sunlight hypothesis.

Melanoma and occupation: results of a case-control study in The Netherlands.

Several studies have reported excesses of risk of melanoma in specific industries. Data from a case-control study in The Netherlands, including 140 cases with a cutaneous melanoma and 181 controls with other types of malignancy, were used to evaluate whether the reported associations with these specific industries could be reproduced. Adjustment for characteristics of pigmentation and exposure to sunlight was made. Increased risks of cutaneous melanoma were found for subjects who had ever worked in the electronics industry (odds ratio (OR) = 2.03, 95% confidence interval (95% CI) 0.63-6.62), in the metal industry (OR = 2.61, 95% CI 0.96-7.10), and in the transport and communication branch (OR = 1.92, 95% CI 0.84-4.35). These ORs were adjusted for age, sex, education, hair colour, tendency to burn, freckling, and exposure to sunlight. No increased risks were seen for workers in the chemical industry, the textile industry, and among health care workers. Analyses according to duration and latency of exposure did not give consistent results, but existing patterns may be obscured by the imprecision of the estimates.

General practitioners' workload after skin cancer/melanoma screening clinics in The Netherlands.

We studied the workload of the general practitioner after two skin cancer screening clinics in the Netherlands. Thirty-one physicians participated in the project. The numbers of patients presenting with benign and malignant skin lesions were recorded 2 weeks before and 6 weeks after the public campaigns. In the week immediately after the screening there was a small increase in the number of consultations for suspected skin cancer. Thereafter, the weekly number of malignant lesions decreased to precampaign levels. Subsequently to the campaigns the numbers of referrals for benign skin lesions decreased slightly. We conclude that the extra workload for the general practitioner generated by the screening campaigns has been negligible.

Fundamentals of skin cancer/melanoma screening campaigns.

There is increased world-wide concern about the rising incidence of melanoma and non-melanoma skin cancer. Screening theoretically reduces death and morbidity from skin cancer/melanoma. Visual examination of the skin is a rapid, safe and inexpensive screening tool. In this review the fundamentals of early disease detection before implementation of a public-health screening programme are critically analysed with reference to the skin cancer/melanoma, epidemic. It is concluded that skin cancer/melanoma fulfils, for the most part, the criteria enunciated by Wilson and Jungner in 1968. However, information about the effect of screening on reducing incidence and mortality is still lacking. Future research should focus on methods of improving compliance and on the costs and benefits of such screening programmes.