Cumulative incidence and risk factors for cutaneous squamous cell carcinoma metastases in organ transplant recipients: The Skin Care in Organ Transplant Patients in Europe-International Transplant Skin Cancer Collaborative metastases study, a prospective multicenter study.

INTRODUCTION: Solid organ transplant recipients (SOTRs) are believed to have an increased risk of metastatic cutaneous squamous cell carcinoma (cSCC), but reliable data are lacking regarding the precise incidence and associated risk factors. METHODS: In a prospective cohort study, including 19 specialist dermatology outpatient clinics in 15 countries, patient and tumor characteristics were collected using standardized questionnaires when SOTRs presented with a new cSCC. After a minimum of 2 years of follow-up, relevant data for all SOTRs were collected. Cumulative incidence of metastases was calculated by the Aalen-Johansen estimator. Fine and Gray models were used to assess multiple risk factors for metastases. RESULTS: Of 514 SOTRs who presented with 623 primary cSCCs, metastases developed in 37 with a 2-year patient-based cumulative incidence of 6.2%. Risk factors for metastases included location in the head and neck area, local recurrence, size > 2 cm, clinical ulceration, poor differentiation grade, perineural invasion, and deep invasion. A high-stage tumor that is also ulcerated showed the highest risk of metastasis, with a 2-year cumulative incidence of 46.2% (31.9%-68.4%). CONCLUSIONS: SOTRs have a high risk of cSCC metastases and well-established clinical and histologic risk factors have been confirmed. High-stage, ulcerated cSCCs have the highest risk of metastasis.

Consensus-Based Recommendations on the Prevention of Squamous Cell Carcinoma in Solid Organ Transplant Recipients: A Delphi Consensus Statement.

IMPORTANCE: There is a paucity of evidence to guide physicians regarding prevention strategies for cutaneous squamous cell carcinoma (CSCC) in solid organ transplant recipients (SOTRs). OBJECTIVE: To examine the development and results of a Delphi process initiated to identify consensus-based medical management recommendations for prevention of CSCC in SOTRs. EVIDENCE REVIEW: Dermatologists with more than 5 years' experience treating SOTRs were invited to participate. A novel actinic damage and skin cancer index (AD-SCI), consisting of 6 ordinal stages corresponding to an increasing burden of actinic damage and CSCC, was used to guide survey design. Three sequential web-based surveys were administered from January 1, 2019, to December 31, 2020. Pursuant to Delphi principles, respondents thoroughly reviewed all peer responses between rounds. Supplemental questions were also asked to better understand panelists' rationale for their responses. FINDINGS: The Delphi panel comprised 48 dermatologists. Respondents represented 13 countries, with 27 (56%) from the US. Twenty-nine respondents (60%) were Mohs surgeons. Consensus was reached with 80% or higher concordance among respondents when presented with a statement, question, or management strategy pertaining to prevention of CSCC in SOTRs. A near-consensus category of 70% to less than 80% concordance was also defined. The AD-SCI stage-based recommendations were established if consensus or near-consensus was achieved. The panel was able to make recommendations for 5 of 6 AD-SCI stages. Key recommendations include the following: cryotherapy for scattered actinic keratosis (AK); field therapy for AK when grouped in 1 anatomical area, unless AKs are thick in which case field therapy and cryotherapy were recommended; combination lesion directed and field therapy with fluorouracil for field cancerized skin; and initiation of acitretin therapy and discussion of immunosuppression reduction or modification for patients who develop multiple skin cancers at a high rate (10 CSCCs per year) or develop high-risk CSCC (defined by a tumor with approximately ≥20% risk of nodal metastasis). No consensus recommendation was achieved for SOTRs with a first low risk CSCC. CONCLUSIONS AND RELEVANCE: Physicians may consider implementation of panel recommendations for prevention of CSCC in SOTRs while awaiting high-level-of-evidence data. Additional clinical trials are needed in areas where consensus was not reached.

Evaluation of the Design and Methodology of Applications to the Local Ethics Committee.

Objectives: Proposals for scientific studies must have an original hypothesis and the appropriate design and methodology to test the premise. Methods: This study is an evaluation of the suitability of applications submitted to a local ethics committee (EC) and the rate of publication of that research. Results: A total of 899 files submitted for EC approval were retrospectively assessed. The EC found that the description of the methods in 44% of the applications was inaccurate, and that this type of error was most often seen in submissions from the surgical branch. In all, 52% of the applications for which we were informed about their final status were not published. Conclusion: The results suggest that improved training in epidemiology is required to reduce the number of application errors and that new regulations could help to motivate healthcare personnel to conduct scientific research and publish their findings.

Intralesional triamcinolone acetonide in notalgia paresthetica: Treatment outcomes in five patients.

Numerous treatment modalities have been tried with diverse results for pruritus due to notalgia paresthetica (NP). Corticosteroids suppress ectopic neural discharges from injured nerve fibers and also have short-lived suppressive effect on transmission in normal C-fibers. Herein, we evaluated the efficacy of intralesional triamcinolone acetonide in the treatment of NP. The medical reports of five patients who had been diagnosed with NP and treated with intralesional triamcinolone acetonide injections were retrospectively evaluated. Triamcinolone acetonide solution was injected intradermally (10 mg/mL; 0.1 mL/cm2 ) every 3 weeks for a maximum of four treatments. The severity of itch was scored by the patients on a combined numerical and visual analogue scale. After treatment, reduction in itch severity scores varied between 33% and 100%.

Management of Kaposi sarcoma after solid organ transplantation: A European retrospective study.

BACKGROUND: Systemic therapeutic management of post-transplant Kaposi sarcoma (KS) is mainly based on 3 axes: reduction of immunosuppression, conversion to mammalian target of rapamycin (mTOR) inhibitors, chemotherapy, or a combination of these. OBJECTIVE: To obtain an overview of clinical strategies about the current treatment of KS. METHODS: We conducted a multicenter retrospective cohort study including 145 solid organ transplant recipients diagnosed with KS between 1985 and 2011 to collect data regarding first-line treatment and response at 6 months. RESULTS: Overall, 95%, 28%, and 16% of patients had reduction of immunosuppression, conversion to mTOR inhibitor, and chemotherapy, respectively. Patients treated with chemotherapy or mTOR inhibitor conversion were more likely to have visceral KS. At 6 months, 83% of patients had response, including 40% complete responses. LIMITATIONS: The retrospective design of the study. CONCLUSION: Currently available therapeutic options seem to be effective to control KS in most patients. Tapering down the immunosuppressive regimen remains the cornerstone of KS management.

The Prevalence of Malassezia Folliculitis in Patients with Papulopustular/Comedonal Acne, and Their Response to Antifungal Treatment.

Because Malassezia folliculitis (MF) may clinically mimic acne vulgaris (AV), patients usually receive unnecessary and prolonged antibiotic treatment. We aimed to determine the prevalence of MF among patients with AV, and to evaluate its response to antifungal treatment. A total of 217 patients with AV underwent cytologic examination for the presence of Malassezia yeasts. Samples were obtained from lesional and nonlesional skin and stained with May-Grünwald-Giemsa. MF was diagnosed if there were more than six spores in one microscopic field (at ×400 magnification). A modified "lesion-counting" method was used to assess the clinical severity of acne. Treatment included oral itraconazole (2×100 mg daily) and topical ketaconazole for 4 weeks. Fifty-five (25.3%) patients were diagnosed with MF; of these, 38 (69.1%) completed the antifungal treatment. The lesions decreased by 50% or more in 26 (68.4%) of the patients who completed the antifungal treatment, which reduced the number of closed comedones/comedolike or molluscoid papules and inflammatory papules. The average number of spores in lesional samples was significantly decreased after treatment (P=<.0005). We observed that MF can present with AV-like lesions, or the two diseases may coexist. Cytology is helpful for making the correct diagnosis and providing proper management of MF.

A Multicenter Survey: How Do Transplant Dermatologists Monitor Organ Transplant Recipients With Nevi?

OBJECTIVES: The incidence and mortality of melanoma are increased in organ transplant recipients. Multiple acquired common and dysplastic nevi are risk factors for melanoma. A new or changing nevus may suggest melanoma. Strategies used by transplant dermatologists to monitor nevi are unknown. Herein, we aimed to assess the methods used by transplant dermatologists for monitoring multiple acquired common nevi, dysplastic nevi, and new or changing nevi. MATERIALS AND METHODS: A questionnaire was e-mailed to 63 members of the Skin Care in Organ Transplant Patients, Europe. RESULTS: Thirty-eight (92.7%) of 41 responders reported that they instruct their patients to perform regular self-skin examinations. Of 41 responders, 41.5% prescribed screening every 6 months, 36.6% prescribed it every 12 months, 12.2% prescribed it every 3 months, and 9.7% performed screening without regular intervals. Regarding type of examination, 80.5% performed full-body skin examinations with the naked eye, 70.7% performed dermoscopy of clinically suspicious nevi, 53.6% offered dermoscopic photography of dermoscopically suspicious nevi, 36.6% provided close-up photography of clinically suspicious nevi, 34.1% performed baseline total body photography, and 24.4% conducted dermoscopy of all nevi. We also found that 7.3%, 4.9%, and 4.9% performed only full-body skin examination with the naked eye, only dermoscopy of clinically suspicious nevi, and only dermoscopy of all nevi, respectively. CONCLUSIONS: Dedicated transplant dermatologists perform a wide variety of nevi screening procedures in organ transplant recipients. Transplant dermatologists should include sequential digital dermoscopic imaging in their armamentarium to follow organ transplant recipients with melanocytic lesions. A combination of techniques is advisable for detecting early posttransplant melanomas.

Epidemiology of Pemphigus in Turkey: One-year Prospective Study of 220 Cases.

Pemphigus is a group of rare and life-threatening autoimmune blistering diseases of the skin and mucous membranes. Although they occur worldwide, their incidence shows wide geographical variation, and prospective data on the epidemiology of pemphigus are very limited. Objective of this work is to evaluate the incidence and epidemiological and clinical features of patients with pemphigus in Turkey. All patients newly diagnosed with pemphigus between June 2013 and June 2014 were prospectively enrolled in 33 dermatology departments in 20 different provinces from all seven regions of Turkey. Disease parameters including demography and clinical findings were recorded. A total of 220 patients were diagnosed with pemphigus during the 1-year period, with an annual incidence of 4.7 per million people in Turkey. Patients were predominantly women, with a male to female ratio of 1:1.41. The mean age at onset was 48.9 years. Pemphigus vulgaris (PV) was the commonest clinical subtype (n=192; 87.3%), followed by pemphigus foliaceus (n=21; 9.6%). The most common clinical subtype of PV was the mucocutaneous type (n=83; 43.2%). The mean Pemphigus Disease Area Index was 28.14±22.21 (mean ± Standard Deviation). The incidence rate of pemphigus in Turkey is similar to the countries of South-East Europe, higher than those reported for the Central and Northern European countries and lower than the countries around the Mediterranean Sea and Iran. Pemphigus is more frequent in middle-aged people and is more common in women. The most frequent subtype was PV, with a 9-fold higher incidence than pemphigus foliaceus.

Eosinophilic annular erythema: A late but complete response to hydroxychloroquine.

A 69-year-old woman with a 12-month history of asymptomatic erythematous, non-scaly, annular and arciform plaques on her face, trunk and extremities is presented. The skin lesions had been unresponsive to treatment with systemic corticosteroids and antihistamines. Skin biopsy demonstrated superficial and deep dermal inflammatory infiltration consisting mainly of eosinophils and a few neutrophils. Dermal interstitial mucin deposition was also detected in the absence of vasculitis, flame figures or granulomatous reaction. The patient was diagnosed as having eosinophilic annular erythema and treated with hydroxychloroquine (2 × 200 mg/day, p.o.). Response to treatment was observed after 7 weeks and full recovery was achieved after 10 weeks. Eosinophilic annular erythema is rarely reported in the literature. Although hydroxychloroquine is a good choice for treatment, response time can vary between patients.

Efficacy and safety of diphenylcyclopropenone alone or in combination with anthralin in the treatment of chronic extensive alopecia areata: a retrospective case series.

BACKGROUND: Some patients with chronic extensive alopecia areata (AA) may be refractory to topical immunotherapy. Combination therapy is recommended for such patients. Efficacy and safety of a combination therapy with diphenylcyclopropenone (DPCP) and anthralin in chronic extensive AA is unknown. OBJECTIVE: We sought to determine whether the combination therapy of DPCP and anthralin is superior to DPCP alone in chronic extensive AA. METHODS: We retrospectively analyzed the efficacy, side effects, and relapse rates of DPCP (alone or with anthralin) in chronic extensive AA. RESULTS: A total of 47 patients (22 were treated only with DPCP, and 25 with DPCP and anthralin for at least 30 weeks) were evaluated. Complete hair regrowth was observed in 36.4% and 72% of the patients who received DPCP and combination therapy, respectively (P = .01). Hair regrowth duration was shorter with combination therapy (P = .01). Regrowth rates of the eyebrows, eyelashes, and beard in patients on combination therapy were higher than those in patients on DPCP (P = .01). Side effects such as folliculitis, hyperpigmentation, and staining of skin, hair, and clothes were more common in combination therapy group. LIMITATIONS: The retrospective design and small number of patients are limitations. CONCLUSION: Combination therapy with DPCP and anthralin is superior to DPCP alone in chronic extensive AA.

Acquired aquagenic syringeal acrokeratoderma: A case series of 10 patients.

Aquagenic syringeal acrokeratoderma is a rare acquired disorder that predominantly affects young women. It is most commonly localised on the palms. It is characterised by translucent papules, oedematous plaques and keratoderma developing after brief exposure to water and resolving shortly after drying. We have observed 10 patients with this disorder within 13 months. We think that aquagenic syringeal acrokeratoderma is a more common condition than was originally anticipated as one can easily underdiagnose this entity due to the transient nature of its clinical findings.

A collodion baby with facial dysmorphism, limb anomalies, pachygyria and genital hypoplasia: a mild form of Neu-laxova syndrome or a new entity?

Neu-Laxova syndrome is a rare, lethal, autosomal recessive disorder characterized by intrauterine growth retardation, central nervous system anomalies, skin findings, such as ichthyosis, edema, collodion baby and harlequin fetus, facial dysmorphic features, limb anomalies and genital hypoplasia. Although it is generally a lethal condition, cases of such patients who lived beyond 6 months and 10 months of age have been reported. Here, we describe an 8-year-old boy who was born with collodion membrane, facial dysmorphic features, limb anomalies, genital hypoplasia and pachygyria. He had no major health problems over the course of 8 years of follow-up, except for mild mental/motor retardation, ichthyosis, facial dysmorphic features and limb anomalies. Based on these features, we suggest that because Neu-Laxova syndrome represents a heterogeneous phenotype, our case may be a milder variant of this syndrome or a new genetic entity.

Mucocutaneous disorders in renal transplant recipients receiving sirolimus-based immunosuppressive therapy: a prospective, case-control study.

BACKGROUND: Sirolimus (SRL) has some dermatologic complications including acneiform eruptions, edema, aphthous ulceration, and onychopathy. However, controlled studies reporting the prevalence and clinical characteristics of mucocutaneous disorders are scarce. OBJECTIVE: To investigate the prevalence and clinical spectrum of mucocutaneous disorders in renal transplant recipients (RTRs) receiving SRL and to compare the findings with those in RTRs not receiving SRL. METHODS: Fifty RTRs (35 men, 15 women; mean age, 34.6 ± 11.6 yr) receiving SRL, 50 RTRs (36 men, 14 women; mean age, 34.4 ± 11.3 yr) not on SRL were screened for mucocutaneous disorders. RESULTS: In RTRs receiving SRL, skin infection (78%) was the most common dermatologic disorder followed by facial hyperpigmentation (50%) and acneiform eruption (46%). Herpes simplex virus infections (14%) and seborrheic dermatitis (38%) were significantly more common in RTRs on SRL (p < 0.05); the frequencies of edema, aphthous ulceration, acne, and longitudinal nail ridging were similar in both groups (p > 0.05). LIMITATIONS: This study had a small sample size. The investigator was not blinded to immunosuppressive treatment protocols. CONCLUSION: Renal transplant recipients receiving SRL are more likely to develop seborrheic dermatitis and herpes simplex virus infections than those not taking SRL. Whereas, they are not more prone to edema, aphthous ulceration, acne, or longitudinal nail ridging.