Cutaneous findings in patients with acromegaly and its relationship with concomitant endocrinopathies.

OBJECTIVES: Skin changes in acromegaly are often the first sign of the disease. The aim of this study was to describe the cutaneous findings in patients with acromegaly. In addition, a secondary aim was to investigate the possible association of these findings with remission status and concomitant endocrinopathies. DESIGN, PATIENTS, AND MEASUREMENTS: In this prospective multicenter study, 278 patients over the age of 18 years with acromegaly who were followed up in 14 different tertiary healthcare institutions were included. These patients, who were followed up by the Endocrinology Department, were then referred to a dermatologist for dermatological examination. The frequency of skin lesions was investigated by detailed dermatologic examination. Dermatological diagnosis is reached by clinical, dermatological and/or dermoscopic examination, and rarely skin punch biopsy examinations in suspicious cases. The possible association of the skin findings between remitted and nonremitted patients and with concomitant endocrinopathies were evaluated. RESULTS: The most common skin findings in patients with acromegaly in our study were skin tags (52.5%), cherry angiomas (47.4%), seborrhoea (37%), varicose veins (33%), acneiform lesions (28.8%), hyperhidrosis (26.9%) and hypertrichosis (18.3%). Hypertrichosis was significantly more prevalent in patients nonremitted (p: .001), while xerosis cutis was significantly more prevalent in patients remitted (p: .001). The frequency of diabetes mellitus and hypothyroidism was significantly higher in patients with varicose veins and seborrhoeic keratosis than those without. Additionally, the coexistence of hypothyroidism, hyperthyroidism and galactorrhea was significantly higher in patients with Cherry angioma than in those without Cherry angioma (p-values: .024, .034 and .027, respectively). The frequency of hypogonadism in those with xerosis cutis was significantly higher than in those without (p: .035). CONCLUSIONS: Cutaneous androgenization findings such as skin tag, seborrhoea, acne and acanthosis nigricans are common in patients with acromegaly. Clinicians should be aware that skin findings associated with insulin resistance may develop in these patients. It can be said that the remission state in acromegaly has no curative effect on cutaneous findings. Only patients in remission were less likely to have hypertrichosis. This may allow earlier review of the follow-up and treatment of acromegaly patients presenting with complaints of hypertrichosis. Additionally, it can be said that patients with skin findings such as cherry angioma may be predisposed to a second endocrinopathy, especially hypothyroidism. Including dermatology in a multidisciplinary perspective in acromegaly patient management would be beneficial to detect cutaneous findings earlier.

Can we manage the melanocytic lesions with peripheral globules according to the grade of dysplasia?

BACKGROUND/OBJECTIVES: Although excision of melanocytic nevi with high-grade dysplasia is recommended by the World Health Organization (WHO), clinical studies investigating the approach based on the grading dysplasia of melanocytic lesions with peripheral globules (PGs) are lacking. We investigated the grades of dysplasia and their distinguishable dermoscopic and clinical features to provide accurate data for managing these lesions. METHODS: We retrospectively classified histologically confirmed melanocytic lesions with PGs according to the 2018 WHO Classification of Skin Tumours criteria in a university hospital in Turkey. Dermoscopic features, lesions, and patient characteristics were recorded. RESULTS: Sixty-six lesions of 56 patients were included. After classification, 9.1% (n: 6) of lesions were melanomas, 39.4% (n: 26) were high-grade dysplastic nevi, and 50% (n: 33) were low-grade dysplastic nevi (n: 33, 50%). There was one nevus with no dysplasia (n: 1, 1.5%). Univariate analysis revealed that ≥31 years of age, irregular shape of peripheral globules, black colour, total colour count, and maximum diameter of the lesion were associated with high-grade dysplasia and melanoma. In the multivariate analyses, ≥31 years of age (OR = 3.80, 95% CI, 1.17-12.37), irregular shape of peripheral globules (OR = 3.90, 95% CI, 1.15-13.2), and total colour count (OR = 3.21, 95% CI, 1.2-8.5) were significant predictive factors for the lesions with high-grade dysplasia and melanomas. CONCLUSIONS: To avoid the underdiagnosis of both melanomas and high-grade dysplastic nevi with PGs, the irregular shape of peripheral globules and multiple colours after the third decade may be useful in making an excision decision. The risk increases every 1-year increase in age. Excision is suggested for all melanocytic lesions with PGs for patients 60 years or older because of the high risk of melanoma and melanocytic nevus with high-grade dysplasia.

Could RPMI-1640 Medium be Used in the Diagnosis and Isolation of Cutaneous Leishmaniasis Lacking NNN Medium?

Laboratory diagnosis of leishmaniasis is based on culture, microscopic examination, serological and molecular methods. The gold standard method is to see amastigotes in microscopic examination and to grow promastigotes in Novy, MacNeal, Nicolle (NNN) medium. NNN medium is frequently used for culture all over the world. In our study, it was aimed to investigate whether the use of RPMI-1640 medium is an appropriate method in cases where the gold standard NNN medium is not available for the diagnosis of cutaneous leishmaniasis (CL). Smears were prepared from the needle aspiration fluid sample from the patient who applied to Manisa Celal Bayar University Faculty of Medicine and had lesions suspicious of CL, and were stained with Giemsa for the presence of amastigotes. The samples taken were directly inoculated into RPMI-1640 broth and incubated at 26 °C for the presence of promastigotes. On consecutive days after incubation, it was checked for promastigote growth. Genotyping of the grown isolate was performed with primers and probes specific to the internal transcribed spacer-1 (ITS-1) gene region with the help of real-time polymerase chain reaction. The amastigote form was observed in the microscopic examination of the needle aspiration fluid sample smear preparations taken from the patient. On the other hand, promastigote growth was observed in RPMI-1640 broth from the 3rd day. In addition, the isolate obtained from the CL patient was determined to be Leishmania tropica as a result of the species determination made by genotyping. It is thought that this study is important in terms of suggesting an alternative medium for the diagnosis of leishmaniasis in laboratories where the gold standard NNN medium is easily accessible. RPMI-1640 medium, which is easily obtained and prepared in parasitology laboratories, can help in the diagnosis of the disease and treatment follow-up, Leishmania spp. isolation and drug resistance studies.

Chronic actinic damage of facial skin.

Chronic actinic damage of the skin manifests itself as extrinsic skin aging (photoaging) and photocarcinogenesis. During the last decade, substantial progress has been made in understanding cellular and molecular mechanisms of photoaging. DNA photodamage and ultraviolet-generated reactive oxygen species are the initial events that lead to most of the typical histologic and clinical manifestations of chronic photodamage of the skin. Chronic actinic damage affects all layers of the skin. Keratinocytes, melanocytes, fibroblasts, and endothelial cells are altered by ultraviolet radiation and can result in numerous changes in human skin, particularly the skin of fair-skinned individuals. These changes include actinic keratosis, thickening and wrinkling, elastosis, telengiectasia, solar comedones, diffuse or mottled hyperpigmentation, and skin cancers. There are many options in the treatment of changes caused by chronic actinic damage. The most effective measure of prevention of the photoaging and photocarcinogenesis is sun protection.

Cross validation of the Turkish version of dermatology life quality index.

BACKGROUND: The aim of this study was to test the linguistic validation of the Turkish version of the Dermatology Life Quality Index (DLQI) for Turkish speaking dermatology patients. METHODS: The DLQI is a 10-item dermatology specific index developed originally in English. The methodology of this study consists of four consecutive sections: Translation, cognitive debriefing, field testing and statistical analysis. Translation steps: (a) Two forward independent translations into Turkish, (b) reconciliation of these translations by a dermatologist, (c) backward translation of the consensus Turkish version by a bilingual person into its original language (English), (d) and comparing the original questionnaire with the backward translated one. Cognitive debriefing: Sessions were performed on five patients from each of the seven different dermatological diagnosis groups. Field testing: The final Turkish version on which the face validity was approved by specialists on a total of 79 inpatients/outpatients with various dermatological diagnoses treated at Celal Bayar University Hospital. STATISTICAL ANALYSIS: Internal consistency (using Cronbach a) and item-total score correlations (Pearson correlation) were used for reliability analysis. Validity analysis was carried out by construct testing (principal components factor analysis), convergent (Pearson correlation) and (discriminate Student's t-test and Mann-Whitney U-test) validity, and SF-36 was used in parallel with DLQI in order to test convergent validity. The data were analyzed by the SPSS version 10.0 (SPSS Inc., Chicago, IL, USA) statistical package. RESULTS: The mean age of the patients in the study was 30.77+/-15.91 years; the mean score of DLQI was 7.61+/-6.12. The median of item-total correlation coefficient was found to be 0.66, within a range of 0.48-0.81. The internal consistency of the index was found to be highly sufficient (alpha=0.85). The DLQI was found to be highly related to the physical domain of SF-36. Life quality score was found to be significantly low for the inpatients compared with outpatients (differential validity). CONCLUSION: It was found that the Turkish version of the DLQI was an acceptable index for dermatologists and dermatology patients and, moreover, to be valid and reliable in a cross-sectional level. The responsiveness of the Turkish version of the DLQI needs to be tested further on a variety of dermatological conditions with different severities.

Erythromelanosis follicularis faciei et colli associated with keratosis pilaris in two brothers.

Erythromelanosis follicularis faciei et colli is characterized by well-demarcated erythema, hyperpigmentation, and follicular papules. Since the original description, it has seldom been reported in the literature. We present two adolescent brothers who had this disorder associated with keratosis pilaris on the shoulders and the extensor surfaces of the arms. Dermatologic examination found brown-red pigmentation, erythema, and follicular papules on both maxillary, preauricular regions, and the cheeks. The lesions of the older brother were more prominent. Histopathologic examination of skin biopsy specimens taken from both brothers revealed hyperpigmentation of the basal layer, follicular plugging, dermal vascular dilatation and congestion, and perivascular inflammatory infiltration. We suggest that the coexistence of these two conditions in brothers implies a genetic inheritance and a possible relationship between the disorders.

Sunscreen use and sun protection practices in students and personnel of Celal Bayar University.

BACKGROUND/PURPOSE: The steady increase in the incidence of melanoma, non-melanoma cutaneous neoplasia and preneoplastic disorders has contributed to the demand for more effective protection from the sun. In this study, we aimed to determine the prevalence of sunscreen use and other sun protection behaviors in a large sample of students and personnel of Celal Bayar University, Manisa, Turkey. METHODS: The study group included 1018 participants of whom 607 work in the Celal Bayar University Hospital and 411 are students from the Medical Faculty and School for Health Professionals. All participants completed a questionnaire composed of 45 items about sun protection and other health behaviors, such as sports activity, use of cigarettes, alcohol and seat-belts. Sun protection factor (SPF) of sunscreen, avoiding sun exposure during peak hours, wearing clothing, a hat and sunglasses were studied. RESULTS: Of the 1018, 403 participants were male and 615 were female. While avoiding sun exposure during peak hours was the most popular preventive behavior for men (42.5%), wearing sunglasses was the most popular one for women (50.7%). Avoiding exposure was the second preventive behavior for women (42.1%). Use of sunscreen with SPF 15+ was the second popular protective measure for men (19.4%) and the third one for women (39.2%). There were no significant relationships between sun protection behaviors and obesity, use of cigarettes and alcohol. We also investigated behavioral changes with sunburn experience in the participants who had sunburn history. Among these behavioral changes, increased use of sunscreen and decreased sun exposure during peak hours with sunburn experience were significant. CONCLUSION: Our study demonstrated that the risk of sun exposure is largely unrecognized in Manisa, Turkey, and we have very incomplete information about protective measures. An efficient policy of education on the effective use of sun protection methods should be developed to prevent skin cancer.

Norfloxacin-induced toxic epidermal necrolysis.

OBJECTIVE: To report a case of toxic epidermal necrolysis (TEN) in a man who was treated with oral norfloxacin for prostatitis. CASE SUMMARY: A 40-year-old man presented with a severe skin reaction, which was diagnosed as TEN. He had received norfloxacin 800 mg/day over a 14-day period for prostatitis and, 10 days after finishing the treatment regimen, he developed cutaneous and mucous lesions typical of TEN. After a prolonged hospitalization and treatment with oral prednisolone therapy, fluid resuscitation, and wound dressing, the man recovered. DISCUSSION: TEN is an infrequent, yet often fatal, severe systemic and cutaneous disease that is most often an adverse drug reaction. There are few case reports of TEN induced by fluoroquinolones. A MEDLINE search (1966-February 2005) revealed no reports of toxic epidermal necrolysis, but one incidence of Stevens-Johnson syndrome due to norfloxacin therapy. An objective causality assessment suggests that TEN was probably related to norfloxacin in this patient. CONCLUSIONS: To our knowledge, this is the first case of TEN associated with the use of oral norfloxacin. We hope that this case report creates awareness that norfloxacin-induced TEN is possible.

Bullous pemphigoid associated with prostate adenocarcinoma.

Bullous pemphigoid is a common autoimmune skin disease characterized by the presence of subepidermal blisters. It has been associated with underlying neoplasia in isolated reports. A 78-year-old man with generalized blisters was diagnosed as bullous pemphigoid on clinical, histopathological and direct immunofluorescence grounds. His free and total prostate specific antigen (PSA) levels were high and histopathological examination of a prostate specimen revealed prostate adenocarcinoma. We present this rare case to discuss the possible association between bullous pemphigoid and prostate adenocarcinoma.

A comparison of dermoscopic features among lentigo senilis/initial seborrheic keratosis, seborrheic keratosis, lentigo maligna and lentigo maligna melanoma on the face.

Clinical differentiation of facial lentigo senilis/initial seborrheic keratosis (LS/ISK), seborrheic keratosis (SK), lentigo maligna (LM), and lentigo maligna melanoma (LMM) can be difficult. Dermoscopy improves the diagnoses in pigmented skin lesions (PSLs), but it is not helpful for the sun-exposed face because of the flat rete ridges without network-derived features. Therefore, development of new diagnostic criteria for this particular localization is a current issue of dermatology. In this retrospective study, dermoscopic slides of facial pigmented skin lesions of 66 patients referred to two clinics in Turkey were evaluated. Our aim was to determine the reliability of dermoscopy in the differentiation of these entities. The facial PSLs of 66 patients (34 males and 32 females) (median age: 58.2) were photographed with a Dermaphot (Heine, Hersching, Germany) over a five year period from November of 1995 to May of 2000. All of the dermoscopic slides were analysed according to 27 dermoscopic criteria developed by Schiffner et al. This data set contained 22 histologically proven malignant (14 LM, 8 early LMM) and 44 benign (18 SK, 26 LS/ISK) PSLs. In general, asymmetric pigmented follicular openings, dark streaks, slate-gray streaks, dark globules, slate-gray globules, dark dots, dark rhomboidal structures, light brown rhomboidal structures, dark homogeneous areas and dark pseudonetworks were statistically significant for malignant growth. On the other hand, milia-like cysts, pseudofollicular openings, cerebriform structures, light brown globules, light brown dots, light brown homogeneous areas, yellow opaque homogeneous areas, and light brown pseudonetworks were statistically significant for benign growth. This research emphasizes that dermoscopic features on the face differ from criteria used in other locations of the body. Analysis of the data suggests that dermoscopy can be used in the differentiation of LS/ISK, SK, LM and LMM from each other.

Inguinal keratotic Basal cell carcinoma mimicking giant solitary trichoepithelioma.

Keratotic basal cell carcinoma may not only clinically but also histologically share more or less the same features with giant solitary trichoepithelioma. It can be difficult to distinguish these two entities from each other, even for an experienced dermatopathologist. We present an unusual case of inguinal keratotic basal cell carcinoma mimicking giant solitary trichoepithelioma in a 56-year-old woman with a finger-like tumor of 20 years duration. The patient presented with an asymptomatic, skin colored, firm, nonulcerative, nodular lesion. Scanty mitotic activity and apoptotic cells were the histopathologic findings against basal cell carcinoma, whereas absence of papillary mesenchymal bodies, presence of peritumoral lacunae detected only around the solid areas, and accumulation of amyloid-like hyalinized material were the findings in favor of basal cell carcinoma. This case illustrates that keratotic basal cell carcinoma must be taken into account in the differential diagnosis of inguinally located solitary, polypoid masses, especially giant solitary trichoepithelioma.