A re-evaluation of teenage sunbed use following the introduction of banning legislation for under 18-year-olds.

BACKGROUND: There is little information on the effectiveness of introducing age restriction legislation alone to reduce the rate of sunbed usage by teenagers. Prior to the Public Health (Sunbed) Act of 2014 prohibiting the use of sunbeds in under 18-year-olds in Ireland we reported the rate of sunbed use at 7.5%. OBJECTIVES: The aim of the study was to compare the rate of sunbed usage among Irish teenagers before and after the introduction of banning legislation to determine if it had the desired effect of reducing its rate of use. METHODS: In a cross-sectional survey, students from the same schools as in our previous study completed an anonymous, written questionnaire pertaining to sunbed usage. RESULTS: In total, 783 questionnaires, from 13 schools across Ireland, were completed. The rate of sunbed use in the current study was 7.2%, compared to 7.5% in the pre-ban study, (P = 0.76). A higher rate of sunbed use was observed in Dublin schools and female public students. CONCLUSION: Our study suggests that legislation alone is ineffective at reducing sunbed usage in a teenage population. A multifaceted approach is required that includes enforcement of the legislation together with targeted public education and awareness campaigns using all aspects of the media.

Factitious panniculitis masquerading as pyoderma gangrenosum.

We report a case of factitious panniculitis masquerading as florid pyoderma gangrenosum in a 35-year-old woman. At presentation, she had tender, ecchymotic plaques over the lower trunk and limbs, and several biopsies showed active lobular panniculitis. However, the extensive ulceration that ensued was clinically persuasive for pyoderma gangrenosum. We elected to treat the inflammatory element symptomatically with a range of topical and systemic medications including clobetasol propionate, tacrolimus 0.1% ointment, prednisolone, dapsone, cyclosporin A and mycophenolate mofetil, none of which effected an improvement. The possibility of a factitious aetiology had been suspected from the outset, and when signs of clinical depression emerged, antidepressant therapy was initiated and the ulcers were encased in fibreglass casts. Within a short period, healing commenced and slowly progressed with scar formation. In retrospect, we consider the diagnosis to have been factitious panniculitis on the basis of strong circumstantial evidence and the disparity between the histological and clinical features.

A comparison of dermatologists', surgeons' and general practitioners' surgical management of cutaneous melanoma.

BACKGROUND: Current guidelines for the surgical management of melanoma aim to bring a combined consensus approach to the surgery of melanoma. Whether different outcomes for melanoma are related to the specialist who treats the patient is unknown. OBJECTIVES: To examine the clinicopathological features and surgical management of patients with primary cutaneous malignant melanoma treated by dermatologists, general surgeons, plastic surgeons and general practitioners (GPs). We also examined if the category of specialist had an effect on the survival outcome for the patient. METHODS: A retrospective, observational study of patients registered on a specialist database that records the clinicopathological features, surgical treatment and follow-up information of patients with malignant melanoma in Scotland. The patients had invasive primary cutaneous malignant melanoma without evidence of metastasis at the time of surgery, diagnosed between 1979 and 1997, with follow-up to the end of December 1999. Clinicopathological characteristics and surgical treatment of patients were compared for the four groups of specialist, as were overall survival (OS), disease-free survival (DFS) and recurrence-free interval (RF). RESULTS: Of 1536 patients, 663 (43%) were treated initially by a dermatologist, 486 (32%) by a general surgeon, 257 (17%) by a plastic surgeon and 130 (8%) by a GP. The proportion of patients managed by dermatologists rose over the lifetime of the study. Compared with the other specialists, the patients treated by general and plastic surgeons were older; a higher proportion of female patients was managed by dermatologists; median tumour thickness, lesion diameter and frequency of ulceration were all greater in the general surgeon-treated group; plastic surgeons treated a higher proportion of lentigo maligna melanomas; and general surgeons and GPs saw a higher proportion of nodular melanomas. Over 90% of patients managed by a dermatologist or GP underwent wider local excision following initial excision, compared with 43% and 25%, respectively, in the general and plastic surgery groups. General surgeons used wider excision margins than the other specialists. OS, DFS and RF were significantly better in the dermatology group compared with the general and plastic surgery groups. CONCLUSIONS: This study showed that dermatologists manage an increasing majority of melanoma patients and that there were significant differences in the surgical treatment of melanoma between dermatologists and surgeons. Survival was significantly better in the dermatology-treated group, suggesting that dermatologists should have a central role in melanoma management.

A retrospective observational study of primary cutaneous malignant melanoma patients treated with excision only compared with excision biopsy followed by wider local excision.

BACKGROUND: For primary cutaneous malignant melanoma the guidelines recommend an excision biopsy of the suspected lesion followed by wider local excision; the diagnosis can then be confirmed and excision margins planned. OBJECTIVES: To compare retrospectively the clinicopathological features, surgical margins and survival of patients from the Scottish Melanoma Group database whose tumour was removed by excision only (one-stage) or excision biopsy followed by wider local excision (two-stage) surgery. METHODS: The Scottish Melanoma Group database records the clinicopathological features, surgical treatment and follow-up information of all patients with malignant melanoma in Scotland. From this 1595 patients were identified over a 19-year interval from 1979 to 1997 with follow-up until the end of December 1999. Overall survival, disease-free survival and recurrence-free interval were examined with univariate and multivariate statistical methods. RESULTS: The patients in the one-stage excision group (n = 547) were statistically significantly older (P < 0.001), had thicker melanomas (P < 0.001), a higher proportion of lentigo maligna melanomas (P < 0.001), head and neck (P < 0.001), and ulcerated lesions (P < 0.003) compared with the two-stage group (n = 1048). The margins of excision were significantly narrower in the one-stage compared with the two-stage group (P < 1 x 10(-5)). Fifty-two percent of all one-stage excisions were performed with a margin < 1 cm compared with 20% of the two-stage group. The excision margin was more positively correlated with the Breslow thickness for the two-stage over the one-stage group (Spearman rho = 0.38, P < 0.001; and 0.27, P < 0.001, respectively). Overall survival (OS), disease-free survival (DFS), and recurrence-free survival (RF) were all statistically significantly better in the two-stage compared with the one-stage excision group, P < 1 x 10(-5), P < 1 x 10(-5) and P = 0.001, respectively (log rank test). After adjusting for the prognostic factors of age, sex, tumour thickness, site, histology and ulceration, OS, DFS and RF were still significantly better in the two-stage compared with the one-stage group [hazard ratio (HR) 0.75, 95% confidence interval (CI) 0.61-0.92, P = 0.006; HR 0.75, CI 0.62-0.90, P = 0.002; and HR 0.78, CI 0.62-0.99, P = 0.04, respectively]. CONCLUSIONS: This study showed that one-stage excisions were more common in patients with poorer prognostic features and that excision with margins narrower than those suggested by current guidelines was more likely. Patient survival was statistically significantly better with the two-stage procedure, although the reasons for this were unclear.

Evidence for an association between cutaneous malignant melanoma and lymphoid malignancy: a population-based retrospective cohort study in Scotland.

We analysed the risk of cutaneous malignant melanoma (CM) occurring in patients following a diagnosis of non-Hodgkin's lymphoma (NHL) or chronic lymphatic leukaemia (CLL), and of NHL or CLL subsequently developing in CM survivors. Cohorts of patients with CM, NHL or CLL (index cancer) diagnosed between 1975 and 1997 were identified from the Scottish national cancer registry and followed through the registry for subsequent CM, NHL or CLL. The standardised incidence ratio (SIR) for each cancer was calculated and overall risk, risk in relation to gender and age at diagnosis of the index cancers and time from diagnosis of the index cancer to the diagnosis of the second malignancy were measured. There were 9385 CM patients, 4016 CLL patients and 13 857 NHL patients identified with an index cancer with 56 195, 14 450 and 44 999 person-years of follow-up, respectively. There was an increased risk of both CLL and NHL following a diagnosis of CM (SIR 2.3 and 1.5, respectively) and of CM following a diagnosis of CLL and NHL (SIR 2.3 and 2.1, respectively). The risk was statistically significantly increased for CLL developing in CM patients and for CM occurring in NHL survivors (P<0.05). This study supports an association between CM, CLL and NHL developing in the same patient. Immunosuppression, exposure to ultraviolet radiation and genetic factors may lead to a host environment that is conducive to the development of these malignancies.

The time from diagnostic excision biopsy to wide local excision for primary cutaneous malignant melanoma may not affect patient survival.

BACKGROUND: The surgical management of primary cutaneous malignant melanoma usually involves an excision biopsy of the suspected lesion followed by wide local excision. No study has addressed whether a delay between these two surgical procedures influences patient outcome. OBJECTIVES: To determine if the surgical interval (SI) between the diagnostic excision biopsy and wide local excision for primary cutaneous malignant melanoma affects recurrence or survival outcome. METHODS: A cohort of 986 patients who had a diagnostic excision biopsy followed by wide local excision was identified from those registered on a specialist database that records the clinicopathological features, surgical treatment and follow-up information of all patients with malignant melanoma in Scotland. The cohort was divided into five arbitrary groups determined by the length of the SI as follows:< or =14 days, 15-28 days, 29-42 days, 43-91 days and > or = 92 days. Overall survival, disease-free survival and recurrence-free interval between the groups were compared univariately and multivariately. RESULTS: The mean age at excision biopsy was 47.4 years and the median period of follow-up was 5 years (range 27 days to 20.7 years). The median SI was 30 days (range 1-468 days). The SI was: (i)< or =14 days for 130 (13%); (ii) 15-28 days for 320 (33%); (iii) 29-42 days for 262 (27%); (iv) 43-91 days for 251 (25%); and (v) > or = 92 days for 23 (2%) patients. The latter group was older, had thinner melanomas, a higher percentage of lesions on the head and neck, fewer superficial spreading malignant melanomas and ulceration present less often compared with patients treated earlier. Univariately, there was no significant difference in overall survival (P = 0.60) or disease-free survival (P = 0.24) between the groups. Although there was a statistically significant difference in the percentage of recurrence-free patients between the groups (P = 0.011), the better recurrence-free rates occurred in the 29-42 and 43-91 day groups. After adjusting for age, sex, tumour thickness, site, histology, ulceration and mitotic activity using Cox's proportional hazards model, there was no statistically significant difference in overall survival, disease-free survival and recurrence-free percentages between the surgical groups (P = 0.88, P = 0.44 and P = 0.084, respectively). CONCLUSIONS: There was no evidence that survival outcome or recurrence was related to the time interval between the diagnostic excision biopsy and wide local excision of melanoma.

Herpes simplex virus-specific immune responses in subjects with frequent and infrequent orofacial recrudescences.

BACKGROUND: Following the primary infection of the orofacial region with herpes simplex virus (HSV) type 1, the virus remains latent in the ganglia for the lifetime of the host but can reactivate at intervals and cause recrudescent lesions. The frequency of these episodes varies considerably from one individual to another. OBJECTIVES: To compare immune responses in two groups of subjects: those with frequent orofacial lesions, defined as 10 or more per year (n = 12), and those with infrequent lesions, defined as three or fewer per year (n = 20). METHODS: Plasma and peripheral blood mononuclear cells were collected from each individual for the series of immunological tests listed in the following results section. RESULTS: Although IgG titres specific for HSV, measured by enzyme-linked immunosorbent assay (ELISA), were not different between the two groups, there was a significantly higher HSV-specific IgE titre in the frequent group. The percentages of CD3-, CD4- and CD8-positive cells in peripheral blood, assessed by flow cytometry, and the in vitro lymphoproliferative response to the non-specific mitogen concanavalin A, did not differ between the two groups. T-cell responses to HSV were assessed by in vitro lymphoproliferation with tritiated thymidine incorporation and subsequent calculation of the stimulation index; cytokine production [interferon (IFN)-gamma and interleukin (IL)-10] into the culture supernatant as a result of the stimulation was measured by ELISAs. The mean +/- SEM stimulation index was 4.1 +/- 0.2 in the subjects with frequent lesions and 11.8 +/- 3.1 in the subjects with infrequent lesions, a difference that was significant. The mean IL-10 concentrations found in the subjects with frequent and infrequent lesions were 154 and 110 pg mL-1, respectively, a difference that did not reach significance. However, the IFN-gamma production was significantly lower in the subjects with frequent lesions compared with those with infrequent lesions: mean 835 and 1679 pg mL-1, respectively. CONCLUSIONS: Thus, from the HSV-specific T-cell proliferation, IFN-gamma production and IgE results, patients who experience frequent recrudescences may tend towards the production of T-helper 2 cytokines in response to the virus, which may lead, in turn, to less effective control of viral replication in the periphery following reactivation from latency.

Leukaemia inhibitory factor and interleukin-8 expression in nonmelanoma skin cancers.

Leukaemia inhibitory factor (LIF) and interleukin (IL)-8 possess activities which may contribute to the development of carcinomas. LIF can stimulate proliferation of some tumour cell lines and IL-8 is angiogenic. Using semiquantitative reverse-transcription polymerase chain reaction (RT-PCR), we measured the expression of LIF and IL-8 mRNA in cultured normal keratinocytes (NKC) and the malignant carcinoma cells lines A431, SiHa, HeLa, and in biopsies of basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and normal skin. Protein expression for LIF was assessed by immunohistochemistry in the biopsies. LIF mRNA expression was increased significantly (P < 0.01) in all carcinoma lines, except SiHa, compared with NKC but the IL-8 mRNA expression in carcinoma cell lines was similar to that in NKC. Expression of LIF mRNA was elevated in BCC and SCC compared with normal skin, but a significant difference was observed only between SCC and normal skin (P < 0.01). Both BCC and SCC showed significantly greater expression of IL-8 compared with normal skin (P < 0.01). There was no correlation between LIF and IL-8 mRNA expression either in BCCs or in SCCs. Immunoreactivity for LIF was absent throughout BCC and SCC, however, normal epidermis surrounding the tumour stained positive, as in normal skin. These data may suggest a role for LIF and IL-8 in the development of skin carcinomas, but without co-ordinate regulation of these two cytokines in this process.

Malignant melanoma and lymphoproliferative malignancy: is there a shared aetiology?

We report seven patients who developed malignant melanoma either coincident with or before the diagnosis of non-Hodgkin's lymphoma or chronic lymphatic leukaemia. One patient died secondary to leukaemia, and chemotherapy-induced immunosuppression may have contributed to the development of metastatic melanoma in another patient. Immunosuppression, exposure to ultraviolet radiation and genetic factors may result in a host environment that is conducive to the development of both tumours in these patients.

Amelanotic malignant melanoma following cryosurgery for atypical lentigo maligna.

Cryosurgery is an alternative treatment option to surgical excision for lentigo maligna. Clinical evidence of recurrence is usually characterized by repigmentation at the treated site. We report two patients who developed amelanotic malignant melanoma following cryosurgery for a pigmented lentigo maligna. These cases illustrate the potential risk of treating lentigo maligna with cryosurgery.

A tri-linear pattern of scleroderma 'en coup de sabre' following Blaschko's lines.

Linear scleroderma 'en coup de sabre' is characterized by atrophy and furrowing of the skin of the frontoparietal region. In most cases it occurs as a single, paramedian line that may be associated with hypoplasia of underlying structures and hemiatrophy of the face. Rarely, lesions form two lines, either both on the same side or bilaterally. We describe an 18-year-old male with an unusual tri-linear pattern of scleroderma 'en coup de sabre' following Blaschko's lines.

Multiple perifollicular fibromas.

Perifollicular fibroma is a benign mesodermal tumour of the hair follicle. It can occur as a solitary papule or as multiple lesions that are clinically indistinguishable from other tumours of the pilar apparatus. Multiple perifollicular fibromas may be inherited although the pattern remains unclear. Adnexal tumours can be associated with internal malignancy and perifollicular fibromas have been linked with adenomatous colonic polyps. This report describes a patient with multiple perifollicular fibromas with no associated malignancy to date and a family pedigree suggestive of an autosomal dominant pattern of inheritance.

Aneurysmal fibrous histiocytoma: an unusual variant of cutaneous fibrous histiocytoma.

Aneurysmal fibrous histiocytoma (AFH) (Santa-Cruz DJ, Kyriakos M. Aneurysmal ('Angiomatoid') fibrous histiocytoma of the skin. Cancer 1981;47:2053-2061) is a distinct but poorly recognized clinicopathological variant of cutaneous fibrous histiocytoma (CFH) that may result from the slow extravasation of blood into the tumour. The resulting lesion can have a very different clinicopathological appearance resulting in diagnostic confusion. We describe a patient with an AFH that presented as a pigmented nodule on the foot and discuss clinical recognition and histological differentiation from other tumours.

Skin cancer chemoprophylaxis in renal transplant recipients: 5 years of experience using low-dose acitretin.

Renal transplant recipients have an increased risk of developing skin cancers, which are often multiple and aggressive. Frequently, these tumours develop on a background of widespread epidermal dysplasia. Systemic retinoids are known inhibitors of skin cancer but reports of their use in renal transplant patients are limited. We describe our experience using 0.3 mg/kg daily of acitretin in 16 patients over a 5-year period. Overall, there was a significant reduction in the number of new tumours excised in 12 of 16 patients during treatment compared with the same pretreatment interval. A significant chemoprophylactic effect was shown for up to 4 years of treatment. Patients with five or more tumours prior to acitretin benefited most. Two patients discontinued treatment because of side-effects and two patients developed hyperlipidaemia. Two patients with end-stage graft failure proceeded to haemodialysis. The introduction of low-dose acitretin proved to be a useful strategy in the long-term reduction of skin cancer in renal transplant recipients with multiple skin cancers and extensive epidermal dysplasia.

Altered expression of the p53-regulated proteins, p21Waf1/Cip1, MDM2, and Bax in ultraviolet-irradiated human skin.

The distribution of p21WAf1/CiP1, MDM2, and Bax/Bcl-2 proteins in ultraviolet (UV)-irradiated and nonirradiated human skin was examined immunohistochemically and compared with p53 protein levels. Sun-protected buttock skin from three volunteers was exposed to solar simulated irradiation, and biopsies were performed 0.5, 1, 2, 4, and 24 hours after irradiation as well as control unirradiated skin from the opposite buttock. A similar staining pattern was observed in each of the three volunteers. P53 protein was detectable in all skin samples examined. P21Waf1/CiP1 protein was visible in the nuclei of cells at 4 hours, and staining intensity increased at 24 hours. MDM2 protein expression was noted in isolated nuclei in the epidermis at 24 hours. Bax cytoplasmic staining was evident in the basal layer of the epidermis of all samples, and this staining appeared to increase in intensity in the 4- and 24-hour specimens. There was no Bcl-2 immunohistochemical staining in any sample. These results suggest that p53 and genes/proteins under the control of p53 are altered/ activated in normal human skin in response to UV exposure.