Fistulising skin metastases in Crohn's disease: a case report and review of the literature.

BACKGROUND: Metastatic Crohn's disease is a rare disorder characterized by various granulomatous skin lesions that occur independently of gastrointestinal tract involvement. However, currently there is no standardized care or specific treatment. Therapeutic approaches include immunosuppressive agents, such as corticosteroids, azathioprine, and monoclonal antibodies targeting inflammatory cytokines like tumor necrosis factor (TNF). CASE PRESENTATION: We present a case of a 29-year-old western European woman with significant blind ending abdominal subcutaneous fistulas and abscesses, who sought evaluation in the dermatology department. Histological examination revealed multiple epithelioid cell granulomas. There was no evidence of infectious or rheumatologic diseases such as sarcoidosis. The tentative diagnosis was metastatic Crohn's disease, which was not related to an intestinal manifestation of the disease. The patient responded to infliximab but had to discontinue it due to an allergic reaction. Subsequent adalimumab treatment failed to induce clinical remission; thus, therapy was switched to ustekinumab, resulting in a positive response. Written informed consent for publication of their clinical details and clinical images was obtained from the patient. For our study more than 1600 publications were screened for cases of metastatic Crohn's disease on PubMed database. 59 case reports with 171 patients were included in the analysis and evaluated for localization, diagnostic and therapeutic approaches, and complications and were summarized in this review. CONCLUSION: The successful ustekinumab treatment of a patient with metastatic Crohn's disease underscores the potential of this minimally investigated therapeutic option, highlighting the need for future treatment guidelines given the increasing prevalence of such cases.

Fractional carbon dioxide laser resurfacing of skin grafts: long-term results of a prospective, randomized, split-scar, evaluator-blinded study.

BACKGROUND: Fractional ablative resurfacing is frequently used for treating atrophic and acne scars as well as for the early improvement of scars after surgery. No evidence-based clinical data on improving the appearance of skin grafts by fractional CO2 -laser resurfacing have been available so far. OBJECTIVES: The primary outcome parameter was the adaptation of the skin graft to the surrounding skin 2, 6, and 12 months after the second laser treatment. Secondary outcome parameters were melanin variation, skin roughness, resizing of the skin graft, and patient satisfaction with cosmetic results. METHODS: The randomized half of the skin graft was treated with the fractional CO2 -laser two times in a 4-week interval, whereby the first laser treatment was conducted 3-8 weeks after surgery. Two independent dermatologists assessed the adaptation of the treated area and the untreated control of the skin graft to the surrounding skin using follow-up pictures and an 11-point scale (0 representing no adaptation at all and 10 complete adaptation). RESULTS: Adaptation to the surrounding skin was significantly improved after laser therapy. The mean investigator ratings showed poor adaptation to the surrounding skin before the first treatment (treatment: 2.24 ± 1.00; control group: 1.95 ± 1.27; P < .001; n = 26) but significant improvement at the follow-up visits (8 weeks: treatment: 6.38 ± 1.47; control group 5.29 ± 1.27; P < .001; 6 months: treatment: 7.31 ± 1.24; control group 6.04 ± 0.91; 12 months: treatment: 7.6 ± 1.26; control group: 6.57 ± 1.02; n = 26). After fractional ablative laser treatment, appearance of the skin grafts was significantly improved for all time points. Profilometric analysis showed significantly reduced skin roughness 1 year after laser treatment compared to control (P = .003). Pigmentary irregularities were improved. Melanin distribution was significantly more uniform 1 year after laser treatment compared to control (P = .034). Patients were reasonably satisfied with both sides of the skin graft before treatment but more satisfied with the laser-treated side at the other time points (P < .001). CONCLUSIONS: Adaptation of the skin graft to the surrounding skin was significantly improved after ablative fractional skin resurfacing. Skin roughness and melanin variation were also improved. Patient satisfaction with the appearance of the skin graft was significantly higher after graft resurfacing. Thus, this treatment modality can be recommended for patients wishing to improve the appearance of their skin graft. Lasers Surg. Med. 50:1010-1016, 2018. © 2018 Wiley Periodicals, Inc.

Genetic alterations driving metastatic colony formation are acquired outside of the primary tumour in melanoma.

Mouse models indicate that metastatic dissemination occurs extremely early; however, the timing in human cancers is unknown. We therefore determined the time point of metastatic seeding relative to tumour thickness and genomic alterations in melanoma. Here, we find that lymphatic dissemination occurs shortly after dermal invasion of the primary lesion at a median thickness of ~0.5 mm and that typical driver changes, including BRAF mutation and gained or lost regions comprising genes like MET or CDKNA2, are acquired within the lymph node at the time of colony formation. These changes define a colonisation signature that was linked to xenograft formation in immunodeficient mice and death from melanoma. Thus, melanoma cells leave primary tumours early and evolve at different sites in parallel. We propose a model of metastatic melanoma dormancy, evolution and colonisation that will inform direct monitoring of adjuvant therapy targets.

Fractional carbon dioxide laser resurfacing of rhytides and photoaged skin--a prospective clinical study on patient expectation and satisfaction.

BACKGROUND: Fractional CO2 -laser resurfacing is increasingly used for treating rhytides and photoaged skin because of its favorable benefit-risk ratio. A key outcome measure and treatment goal in aesthetic laser therapy is patient satisfaction. However, few data are available on patient-reported outcomes after fractional ablative skin-resurfacing. OBJECTIVES: To compare patient expectations before and patient satisfaction after three fractional CO2 -laser treatments and to correlate objectively measured wrinkle reduction with patient satisfaction after treatment. METHODS: We investigated patient expectation and satisfaction using a 14-item questionnaire in 24 female patients. We assessed the skin-related quality of life and patient satisfaction with skin appearance. We profilometrically measured wrinkle size in four facial areas before and three months after treatment and investigated correlations between wrinkle reduction and patient satisfaction. RESULTS: The high patient expectations before treatment (ceiling effect) were actually slightly exceeded. The average score of 14 items delineating patient satisfaction with laser treatment was higher (4.64 ± 0.82; n = 24) than the respective expectations before treatment (4.43 ± 0.88; n = 24). Skin-related quality of life and patient satisfaction with skin appearance had significantly improved after the last treatment. Patients dissatisfied with their skin appearance before treatment (mean 2.1 ± 1.5; evaluated on a scale ranging from 0-6) were satisfied (mean 5.1 ± 1.2) (P < 0.001) with skin appearance at the follow-up. Patient satisfaction with skin appearance was not correlated to the profilometrically measured reduction of wrinkle size of any facial area. CONCLUSIONS: Our results show high patient satisfaction with ablative fractional skin resurfacing, also regarding improved self-esteem and self-satisfaction despite high pre-treatment expectations. Skin-specific quality of life had significantly improved. Thus, this treatment modality can be recommended for patients with photoaged skin wishing to improve skin appearance.

S1 guideline: microscopically controlled surgery (MCS).

When using procedures that enable complete examination of surgical margins (3D histology), microscopically controlled surgery (MCS) represents a safe and proven method to confirm R0 resection of infiltrating tumors, especially at problematic sites, while preserving the adjacent tissue. This allows for excellent or good aesthetic results that are superior (cryosurgery, short-range irradiation) or equivalent (PDT) to nonsurgical and less safe procedures (PDT).

Experience with non-ablative fractional photothermolysis with a dual-mode laser device (1,440/1,320 nm): no considerable clinical effect on hypertrophic/acne scars and facial wrinkles.

In the literature, non-ablative fractionated photothermolysis (nFP) is accredited with improvement of wrinkles and scars combined with a reduced downtime. The purpose of this work was to evaluate the impact of a combination laser (1,320/1,440 nm) for nFP on hypertrophic scars, acne scars, and facial wrinkles. Thirty-six patients suffering from hypertrophic scars (n = 7), acne scars (n = 9), and wrinkles (n = 20) were treated using a combination Nd:YAG laser [λ(em) = 1,320 and 1,440 nm, pulse duration: 3-ms single pulse, fluence: 8.0-9.0 J/cm(2) (1,320 nm); 2.0-2.5 J/cm(2) (1,440 nm)]. The appearance of the treated condition was evaluated in a retrospective study by two blinded investigators based on follow-up photographs and by patient self-assessment. The frequency of side-effects was also assessed. Both patients and blinded observers rated the treatment results for hypertrophic scars and acne scars as slight improvement, and for wrinkles as equal as compared to baseline. No serious side-effects were reported. The light device used did not lead to a considerable clinical improvement of hypertrophic scars, acne scars, or wrinkles in this study.

Split-face comparison of intense pulsed light with short- and long-pulsed dye lasers for the treatment of port-wine stains.

BACKGROUND: So far, pulsed dye lasers have been regarded as the gold standard in the treatment of port-wine stains (PWS). Recently, intense pulsed light (IPL) has been reported to achieve more pronounced fading in some patients. OBJECTIVES: To evaluate the efficacy and the side effects of IPL treatment of PWS in a direct comparison to the short-pulsed dye laser (SPDL) and the long-pulsed dye laser (LPDL). METHODS: Test spots (n = 158) were applied with IPL (λ(em) = 555-950 nm, pulse duration: 8-14 milliseconds (single pulse), fluence: 11-17.3 J/cm(2)), the SPDL (λ(em) = 585 nm, pulse duration: 0.45 milliseconds, fluence: 6 J/cm(2)), and the LPDL (λ(em) = 585/590/595/600 nm, pulse duration: 1.5 milliseconds, fluence: 12/14/16/18 J/cm(2)) in a side-by-side modus in untreated (n = 11) and previously treated (n = 14) patients with PWS. Lesion clearance was evaluated by three blinded investigators based on follow-up photographs 6 weeks after treatment. Incidence of side effects was assessed. RESULTS: In previously untreated PWS as well as in pretreated PWS, IPL treatments were rated significantly (P<0.05) better than treatments with the SPDL. In both groups, IPL and LPDL treatments did not differ significantly. Side effects were few in all settings. CONCLUSIONS: In PWS resistant to dye laser therapy, IPL showed additional lesion clearance. The use of IPL increases the therapeutic possibilities in PWS.

Microscopically controlled surgery (MCS).

To confirm a local R0 resection of tumors with infiltrative growth at problem sites and for sparing of tissue, microscopically controlled surgery represents a safe and proven method, particularly when there are no gaps between the tissue taken at the incision margins.

Confocal laser scanning microscopy--evaluation of native tissue sections in micrographic surgery.

Micrographic surgery is mainly used for excising basal cell carcinomas in high-risk body sites. The time-consuming process of frozen histopathology could be potentially accelerated by the application of ex vivo confocal laser scanning microscopy (CM). We examined the margins of 52 excised basal cell carcinomas by means of CM, and compared the results to conventional histological findings. For contrast enhancement, tissues were treated with 10% citric acid. The morphologic features of tumors seen in CM corresponded well to conventional light microscopy. Confocal assessment and light microscopical findings were consistent in 84.6%. If a tumor is clearly detectable by means of CM, the procedure of micrographic surgery can be accelerated. Negative confocal findings have yet to be confirmed by conventional microscopy. Applicability of CM is limited because of an inconsistent image quality that does not allow a reliable detection of small tumor nests. Further research into the handling of the samples and into specific contrast enhancement is necessary for CM to become a widely accepted procedure in micrographic surgery.

Progressive disseminated essential telangiectasia and erythrosis interfollicularis colli as examples for successful treatment with a high-intensity flashlamp.

BACKGROUND: Treatment of progressive disseminated essential telangiectasia and erythrosis interfollicularis colli by flashlamp pulsed dye laser frequently results in a mottled appearance and often leads to hypo- or hyperpigmentation after treatment. Furthermore, treatment is time-consuming due to the small spot size. OBJECTIVE: To report the successful removal of thin vessels in patients with the above-mentioned indications by an intense pulsed light (IPL) source. METHODS: Four patients with progressive disseminated telangiectasia on the extremities and 5 patients with erythrosis interfollicularis colli were treated with IPL. RESULTS: A clearance of up to 90% of the telangiectasias was achieved. CONCLUSION: The superficial, thin vessels of progressive disseminated essential telangiectasia and erythrosis interfollicularis colli can be successfully treated by IPL.

Gene expression profiling of melanocytes following Q-Switched Ruby laser irradiation.

BACKGROUND: The Q-switched Ruby laser (QSRL) is used for the treatment of pigmented lesions. The influence of QSRL treatment on gene expression of nontransformed primary melanocytes has not been addressed in vitro. OBJECTIVE: We investigated the gene expression profile of melanocytes following QSRL irradiation. METHODS: Primary melanocytes were irradiated with the QSRL (694 nm). Early and late transcriptional effects were analyzed using the Affymetrix gene array platform. RESULTS: Laser irradiation of melanocytes had minor effects on mRNA expression. We found only 31 out of 14,500 genes which were at least twofold up- or downregulated. The differential expression of heme oxygenase 1 and galanin in QSRL-treated melanocytes was additionally confirmed by real-time RT-PCR. Analysis of a selection of 36 genes which are known to be associated with malignant melanoma development and progression revealed no significantly aberrant expression in the QSRL-treated melanocytes. CONCLUSION: Our study shows that QSRL treatment of primary melanocytes in vitro does not cause major alterations of global gene expression and particularly of genes associated with malignant melanoma. However, since QSRL treatment may have different effects on gene expression of melanocytic cells in vivo, further studies are required to evaluate QSRL treatment of (nevo-) melanocytic lesions.

The venous nevus: a distinct vascular malformation suggesting mosaicism.

BACKGROUND: Venous malformations are common vascular anomalies which only occur sporadically. OBJECTIVE: We present a series of 25 patients with extratruncular venous malformations of the skin or the neighboring mucosa that are arranged in a segmental pattern. RESULTS: All lesions were sporadic and mostly unilateral. According to the extent of the vascular malformation, two subgroups were defined: large- to medium-sized and small localized lesions ('acrofacial distribution'). In large- or medium-sized lesions, we noted a strict midline separation of the disorder. Thus, we assume that this segmental arrangement reflects genetic mosaicism. CONCLUSIONS: This type of venous malformation originates from a postzygotic mutation that occurs at an early developmental stage. Hence, the type of vascular disorder present in our 25 patients seems to fulfil each criterion of the term 'nevus'. This vascular nevus should be distinguished from other forms of venous malformations such as the varicose veins associated with the Klippel-Trénaunay syndrome, the dermal nodules of the blue rubber bleb nevus syndrome and the vascular skin lesions of the Maffucci syndrome. Thus, we propose the new term 'venous nevus' or 'nevus venosus'.

A woman with a dangling digit.

Ainhum (dactylolysis spontanea) is a distinct clinical and radiological disorder of dark-skinned people characterized by a progressive development of a constricting band encircling the toe which usually results in spontaneous amputation. Ainhum mainly occurs in African natives, but in times of global migration and tourism, Ainhum is likely to be more often encountered outside Africa. Even though the clinical presentation can mimic more common entities such as arthritis and trauma, the correct diagnosis and treatment is easy if one knows this unusual entity.