Skin changes in the elderly people--how strong is the influence of the UV radiation on skin aging?

Just like every other part of the organism, the skin ages as a result of the passage of time. That process is called chronologic or intrinsic aging. However, skin is also exposed to external insults, such as UV radiation, which is the most influential extrinsic factor in skin aging, causing so called photoaging or extrinsic skin aging. Photoaging is a cumulative process which depends on the degree of UV exposure and the skin type. It is much more visible in individuals with skin types I and II and, less prominent in dark-skinned population. Chronic sun exposure can result in numerous changes in human skin, particularly on the face, nape, and arms. Keratinocytes, melanocytes, fibroblasts, and endothelial cells are altered by UV radiation. Therefore, changes in photoaging include wrinkling, elastosis, actinic keratoses, irregular pigmentation, telangiectases, and the development of malignant skin tumours. In the last decades, important progress has been made in understanding molecular mechanisms of photoaging. It is a complex process in which UV radiation has effects on numerous molecular processes that damage the skin, especially connective tissue of the skin. These processes include cell surface receptors, certain signal transduction pathways, transcription factors and, various enzymes involved in the synthesis and degradation of the dermal elements. Initial process in the activation of this process is UV-induced generation of the reactive oxygen species, which can also directly damage cell's DNA, membrane and proteins. Most of alterations found on the photoaged skin had formerly been considered to be caused by UVB wavelengths. However, a number of recent studies have demonstrated that UVA can also cause burning, elastosis, and skin cancer.

Multiple primary melanoma: epidemiological and prognostic implications; analysis of 36 cases.

Patients who are already diagnosed with cutaneous melanoma are at increased risk of developing another primary melanoma. The occurrence of multiple primary melanoma is a rare phenomenon, varying in frequency, with an estimated incidence ranging from 0.2% to 8.6%. The authors are presenting data on the patients with multiple primary melanoma from the Croatian Referral Melanoma Centre. The clinical, histological and epidemiological characteristics of 36 (3.6%) patients, identified from 991 patients with histologically confirmed melanoma, are analyzed in this study. Twenty-eight of the patients (78%) had two primary melanomas, six had three melanomas (16.7%) and two (5,6%) had four melanomas. Diagnosis was established synchronously in 11 patients (30%) and, in the rest of the patients, time interval between the diagnosis of the first and second melanoma varied from 1 month to the longest interval of 16 years. However, the majority of subsequent melanomas were removed within 2 years of the initial operation. The mean Breslow's thickness of the first melanoma was significantly higher than the mean Breslow's thickness of the second primary melanoma. The proportion of in situ to invasive melanomas was greater for the second melanomas compared with the first melanomas. Therefore, we emphasize the importance of regular follow-up as well as the education in regular self--skin examinations in melanoma patients in order to detect subsequent primary melanomas in the early phase.

The role of apoptosis in the pathogenesis of malignant melanoma.

Malignant melanoma genesis is a very complex process that involves a sequence of pathogenetic cellular events. Mutation of various genes and numerous other cellular mechanisms play an important role in the course of malignant melanocyte alteration and their malignant transformation from naevi into melanoma. Apoptosis is an active, genetically controlled process of programmed cell death, which leads to cell destruction and cell death without involvement of surrounding cells or inflammatory response. In this process, disrupted mechanisms of cell regulation and apoptosis take place in malignant melanoma cells, thus leading to their uncontrolled proliferation and melanocyte growth. Apoptosis is a process that involves two major pathways, the intrinsic and extrinsic apoptotic pathway, which interlace at certain points and ultimately result in apoptosis. It can be said that molecular events regulating cell survival, normal growth arrest, apoptosis and cell differentiation, contribute to the overall pathogenesis of malignant cell growth. It is presumed that in the future, understanding of molecular aberrations and cellular processes, such as cell signaling, cell cycle regulation and cell apoptosis, will be essential for better patient monitoring and rational design of effective treatment.

Perifolliculitis capitis abscedens et suffodiens in a caucasian: diagnostic and therapeutic challenge.

Perifolliculitis capitis abscedens et suffodiens or dissecting cellulitis of the scalp is a rare, chronic destructive folliculitis of the scalp, characterized by painful nodules, purulent drainage, sinus tracts, keloid formation and cicatricial alopecia. The cause of the disease is unknown, but it is similar in many features to hidradenitis suppurativa and acne conglobata. In our case report, the patient's dermatologic appearance included one slightly erythematous, infiltrated alopecic area with draining lesions in the right parietal part of the scalp with a few alopecic areas in other parts of the scalp. The identification of the infectious agent, repeated swabs and KOH examination/or fungal cultures and tissue sampling for histopathologic analysis were necessary to confirm the diagnosis of perifolliculitis capitis abscedens et suffodiens. The patient received systemic antibiotics (azithromycin and amoxicillin-clavulanate) and oral antimycotic therapy (fluconazole), followed by a long period of oral isotretinoin with local skin care, which led to resolution and thus inhibited the evolution to scarring and nodular stage of the disease. Thus, such combined approach could be useful for other patients with these dermatologic problems.

Most common clinical presentations of cutaneous mastocytosis.

The term mastocytosis is referred to as an array of uncommon, usually sporadic, heterogeneous clinical illnesses that result from the hyperplasia of tissue mast cells. It comprises many different clinical manifestations varying from indolent cutaneous forms to systemic and malignant conditions. The characteristic presentation of mastocytosis consists of cutaneous manifestations: either a solitary mastocytoma, urticaria pigmentosa, or less commonly, diffuse cutaneous mastocytosis. Urticaria pigmentosa is the most common manifestation of cutaneous mastocytosis that manifests as a generalized eruption of round or oval erythematous macules, papules and plaques with variable amounts of brown pigment, usually on the trunk, but may also occur in all regions of the body including face and mucous membranes. Pruritus, dermographism and Darier's sign are additional features of these eruptions. Mastocytosis may also be manifested as mastocytoma, a rare, benign, pediatric tumor that results from hyperplasia of mast cells in papillary dermis in the first few weeks of life. The clinical course of mastocytosis is variable. The prognosis for the majority of pediatric patients with urticaria pigmentosa is extremely good, and over half of cases clear completely by adolescence, while those with aggressive systemic mastocytosis or mast cell leukemia show a progressive course, usually with a fatal outcome.

Oral lesions in patients with lichen planus.

Forty patients with lichen planus admitted to University Department of Dermatology and Venereology, Sestre milosrdnice University Hospital in Zagreb during the 2004-2006 period were assigned to this retrospective study. In these 40 patients (27 female and 13 male), lichen planus was diagnosed on the basis of clinical presentation, laboratory findings and histopathologic analysis. The results obtained indicated an increased prevalence of lichen planus in middle-aged patients (40% of patients were aged 40-60), with a significant female predominance (67.5% vs. 32.5%). The majority of patients with lichen planus presented with both cutaneous and oral lesions (62.5%), one third of cases had only cutaneous lesions (35%), and only one patient had isolated oral lesions (2.5%). The initial symptoms in patients with lichen planus usually manifested on the skin (82.5%), in oral cavity (5%), or both simultaneously. Oral lesions usually developed on buccal mucosa (88.5%) in the form of Wickham's striae. All patients were administered topical therapy (corticosteroids, keratolytics), while 55% of patients were given both systemic and topical therapy (corticosteroids, retinoids). Phototherapy was used in 27.5% of patients. The management of patients with oral lichen planus lesions requires multidisciplinary approach including dermatologists and oral pathologists, general practitioners, as well as ENT specialists, internal medicine specialists, and others.

Oral lesions in patients with pemphigus vulgaris and bullous pemphigoid.

Thirty three patients admitted to the University Department of Dermatology and Venereology, Sestre milosrdnice University Hospital, were included in the study. The purpose of the study was to compare data on age and gender, habits, lesion localization, onset of symptoms and therapy between patients with pemphigus vulgaris and those suffering from bullous pemphigoid. Based on clinical presentation, histopathologic analysis, direct and indirect immunofluorescence, Tzanck smear and desmogleins, 15 cases of pemphigus vulgaris and 18 cases of bullous pemphigoid were diagnosed. The results obtained indicated an increased prevalence of pemphigus vulgaris in middle-aged patients (46.6% of patients were aged between 50 and 70), while bullous pemphigoid predominantly affected elderly individuals (83.3% of patients were older than 70). Pemphigus vulgaris showed a female predominance (female 66.6% vs. male 33.4%), while no sex difference was recorded for bullous pemphigoid. Patients with both diseases presented with cutaneous and/or oral lesions. The majority of patients with pemphigus vulgaris had skin lesions with oral manifestations (86.6%), whereas in 40% of cases oral lesions were preceded by the cutaneous ones. Mucosal erosions were found in only 16.6% of patients with bullous pemphigoid. The majority of patients were administered systemic and topical corticosteroid therapy with adjuvant systemic immunosuppressant therapy. Timely recognition of pemphigus vulgaris and bullous pemphigoid and appropriate treatment are important for the prognosis of these autoimmune bullous disorders.

Variations in clinical presentation of basal cell carcinoma.

Basal cell carcinoma (basalioma, BCC) is the most common skin cancer and the most common human malignancy in general, with a continuously increasing incidence. In most cases, BCC develops on chronically sun-exposed skin in elderly people, most commonly in the head and neck region. Besides chronic UV radiation, other risk factors for the development of BCC include sun bed use, family history of skin cancer, skin type 1 and 2, a tendency to freckle in childhood, immunosuppression, previous radiotherapy, and chronic exposure to certain toxic substances such as inorganic arsenic. There are numerous variations in clinical presentation of BCC, such as nodular BCC, ulcerating BCC, pigmented BCC, sclerosing BCC, superficial BCC, and fibroepithelioma of Pinkus. Each varies in terms of clinical presentation, histopathology and aggressive behavior. Treatment modalities for BCC include surgical excision, cryosurgery, curettage, electrodessication, radiotherapy, photodynamic therapy, topical cytostatics, and immunomodulators. If left untreated or inadequately treated, BCC may become invasive and locally destructive, although it very rarely metastasizes. Due to the extremely high incidence of BCC, medical professionals should be familiar with its manifold clinical presentations.