Cutaneous metastasis of cervical adenocarcinoma to the vulva.

Cervical cancer is one of the most common cancers and cause of cancer-related deaths in women worldwide. Cutaneous metastasis of cervical cancer, however, is exceedingly rare. It is generally seen late in the disease course and portends a poor prognosis. Herein we report a woman with a history of recurrent cervical cancer complicated by an unusual occurrence of metastasis to the vulva.

Update on Keloid Management: Clinical and Basic Science Advances.

BACKGROUND: Keloids are benign, fibroproliferative lesions that represent abnormal healing resulting in excessive fibrosis. They are composed of mainly type III (early) or type I (late) collagen. Some of the symptoms include pruritus, tenderness, and pain. Often, they are very difficult to treat and prevent from recurrence. In contrast to hypertrophic scars, keloids extend beyond the margin of the wound. THE PROBLEM: There is very limited evidence on the best wound management for minimizing scarring. Multiple available therapeutic modalities have been used for the treatment of keloids; however, high-recurrence rates continue to be reported. Unsuccessful treatment of keloids leads to psychological impact on the patients and increased economic burden. BASIC/CLINICAL SCIENCE ADVANCES: Currently, there are biological and antineoplastic agents that can potentially treat and prevent excessive scar formation. Some of them have been used as "off label" therapies, and others are still in the experimental phase such as interferon alpha (IFN-α), imiquimod, and transforming growth factor beta1 (TGF-ß1). The use of IFN-α2b showed 18% recurrence rate when applied to postsurgical excised keloids. Imiquimod 5% can lower recurrence rate on postshaved keloids to 37.5% at 6-month and to 0% at a 12-month follow-up period. TGF-ß1 oligonucleotides have shown effective and long-lasting inhibition of TGF-ß-mediated scarring in vitro as well as in animal models. Daily injections of neutralizing antibodies against TGF-ß1 and -ß2 have shown successful reductions in scarring. CONCLUSION: Latest discoveries in the use of novel agents suggest therapeutic alternatives for the prevention of recurrences of hypertrophic scars and postexcision keloid lesions.

Laser therapy in black skin.

This article provides a systematic overview of laser, light, and other energy devices for patients of African descent. It also reviews complications in skin of color and some treatment options for these adverse events.

Advances in the treatment of keloids.

Occurring with higher proportions in skin of color, keloid formation is seen in individuals of all races, with the lowest incidence in albinos. Interestingly, prevalence of keloids is correlated to skin pigmentation, with dark-skinned individuals suffering disproportionately. Many factors are taken into consideration when deciding which modalities to use in the treatment of keloids, including size, anatomical site, cause, symptoms, duration of treatment and not least importantly, pigmentation of the patient. In patients with skin of darker color it is necessary to communicate the effects these treatments may have on epidermal pigmentation to the patient. Of course, the best treatment for keloids remains prevention. Physicians should be alert to delays in wound healing, persistent erythema, or pruritus as impending symptoms of possible keloid formation and make all reasonable attempts to reduce inflammation and tension on the skin with appropriate methods.

Nonsurgical innovations in the treatment of nonmelanoma skin cancer.

Basal cell carcinoma and squamous cell carcinoma are the most frequent types of cancer in the United States and represent 75 percent and 20 percent, respectively, of all nonmelanoma skin cancers. Since ultraviolet radiation is implicated in their development, photoprotection is fundamental in their prevention. Additional preventive measures include identifying high-risk individuals for early detection along with using agents, such as retinoids, that are effective in decreasing the risk of premalignant cells further developing into carcinomas. Newer agents achieving this goal include perillyl alcohol, T4 endonuclease 5, DL-alpha-tocopherol, and alpha-difluoromethylornithine. Procedural modalities are currently the standard of treatment, but recent evidence has consistently shown that newer (nonsurgical) therapies, such as interferon, imiquimod, retinoids, and 5-fluorouracil, can be used effectively either as monotherapies or as adjuvants to those surgical modalities for the treatment of superficial nonmelanoma skin cancers and premalignant lesions. These newer therapies have achieved significant reductions in morbidity and mortality. Procedural modalities that have been evolving into important tools for the treatment of actinic keratosis and nonmelanoma skin cancers include photodynamic therapy and lasers. Nonsurgical therapies currently proving to be effective in clinical trials include ingenol mebutate and cyclooxygenase-2 inhibitors. Agents that are showing promising results in early phases of clinical trials include betulinic acid; hedgehog signaling pathway inhibitors, such as cyclopamine and GDC-0449; alpha-melanocyte-stimulating hormone analogs, such as afamelanotide; epidermal growth factor receptor inhibitors, such as gefitinib and erlotinib; anti-epidermal growth factor receptor monoclonal antibodies, such as cetuximab and panitumumab; and the 5-fluorouracil prodrug capecitabine.

Innovative therapies in the treatment of keloids and hypertrophic scars.

Keloids and hypertrophic scars are benign fibrous overgrowths of scar tissue, which results from an abnormal response to trauma. Several therapeutic modalities have been described for the treatment and prevention of these conditions, but the optimal management approach has not yet been defined. This article reviews the most recent, innovative, therapeutic strategies for the management of hypertrophic scars and keloids, including mitomycin-C, tamoxifen citrate, methotrexate, imidazolaquinolines, retinoids, calcineurin inhibitors, phenylakylamine calcium channel blockers, botulinum toxin, vascular endothelial growth factor inhibitors, hepatocyte growth factor, basic fibroblast growth factor, interleukin-10, manosa-6-phosphate, transforming growth factor beta, antihistamines, and prostaglandin E2. No consensus in treatment regimens has been reached due to the limited evidence-based information found in the literature. Most therapeutic options have potential effectiveness as both monotherapy and as combination therapy. However, recent reports offer novel modalities that may approach scarring from different angles.

Herpes simplex virus and human papillomavirus genital infections: new and investigational therapeutic options.

Human papillomavirus and Herpes simplex virus are the most common genital viral infections encountered in clinical practice worldwide. We reviewed the literature focusing on new and experimental treatment modalities for both conditions, based on to the evidence-based data available. The modalities evaluated include topical agents such as immune response modifiers (imiquimod, resiquimod, and interferon), antivirals (penciclovir, cidofovir, and foscarnet), sinecatechins, microbiocidals (SPL7013 gel, and PRO 2000 gel), along with experimental (oligodeoxynucleotides), immunoprophylactic, and immunotherapeutic vaccines.

Phenytoin-associated hypersensitivity syndrome with features of DRESS and TEN/SJS.

Drug rash with eosinophilia and systemic symptoms (DRESS) syndrome, toxic epidermal necrolysis (TEN), and Stevens-Johnson syndrome (SJS) are rare and life-threatening conditions that may be precipitated by anticonvulsive agents. We describe a patient with overlapping features of these hypersensitivity syndromes.

A comparative study evaluating the tolerability and efficacy of two topical therapies for the treatment of keloids and hypertrophic scars.

BACKGROUND: Onion extract gel (OE) and 0.5% hydrocortisone, silicone and vitamin E lotion (HSE) are two over-the-counter preparations used to enhance the cosmesis of keloids and hypertrophic scars. OBJECTIVE: To determine the tolerability and efficacy of OE versus HSE versus placebo in subjects with keloids and hypertrophic scars. METHODS: Thirty subjects (> or =18 years) with keloids or hypertrophic scars were randomly assigned to one of three study preparations for 16 weeks. Scar volume was measured at baseline and weeks 4, 8, 12 and 16. Subjects and blinded investigators assessed scar parameters (induration, erythema, pigmentation alteration, pain, itching, tenderness and cosmetic appearance) and patient satisfaction at each visit using a visual analog scale (VAS). Data analysis included: mean percentage change (MPC) for subjects completing the study (n = 15); the mixed model test to determine differences between the groups over time; and the Kruskal-Wallis test for the analysis of differences in subjects' satisfaction within the three groups over 16 weeks for subjects who completed at least one follow-up visit (n = 21). RESULTS: All three preparations were well tolerated with the exception of a mild acneiform-like eruption in one OE patient. Significant improvements were obtained with OE in volume, length, width and induration and with HSE in volume, length, induration, erythema and pigmentation alteration. There was a trend showing that a higher percentage of subjects were satisfied with OE than with HSE or placebo. The Mix Model Analysis (MMA) showed significant improvements with OE over placebo in investigator cosmetic assessment, lesion induration, pigmentation and tenderness and with HSE over placebo in investigator cosmetic assessment, lesion induration, pigmentation and erythema. Improvements in erythema and pigmentation were significantly greater in HSE than in OE. CONCLUSION: Both OE and HSE were more effective than placebo in the management of hypertrophic scars and keloids.

Ecthyma gangrenosum caused by Escherichia coli bacteremia: a case report and review of the literature.

Ecthyma gangrenosum (EG) is a serious and well-recognized cutaneous condition. Development of EG is most commonly associated with Pseudomonas aeruginosa septicemia. Other organisms, such as Escherichia coli, have been identified less often as the cause of EG. We describe a 50-year-old man previously diagnosed with acute myelogenous leukemia (AML) who developed an E coli-colonized EG lesion secondary to E coli bacteremia. This case represents the seventh of its kind in the literature and the first case in a patient with AML. In addition, a brief review of the etiopathology and management of EG is presented.

Evaluating the tolerability and efficacy of etanercept compared to triamcinolone acetonide for the intralesional treatment of keloids.

BACKGROUND: Tumor necrosis factor-alpha (TNF-alpha) is a proinflammatory and profibrotic cytokine that inhibits degradation of collagen and glycosaminoglycans. Etanercept, a recombinant TNF-alpha receptor fusion protein, may decrease excessive fibrous tissue in keloids. OBJECTIVE: To evaluate the tolerability and efficacy of etanercept as compared to triamcinolone acetonide (TAC) for the treatment of keloids. METHODS: Twenty subjects were randomly assigned to receive monthly intralesional injections of either 25 mg of etanercept or 20 mg of TAC for 2 months. Keloids were evaluated at baseline, week 4, and week 8 by subjects and investigators in a blinded fashion using physical, clinical, and cosmetic parameters. Photographs were taken and adverse events were noted during each evaluation. RESULTS: Etanercept improved 5/12 parameters including significant pruritus reduction, while TAC improved 11/12 parameters at week 8, although no statistical difference was observed as compared to baseline. There was no significant difference between the 2 treatment groups. Both treatments were safe and well tolerated. CONCLUSION: Etanercept was safe, well tolerated, improved several keloid parameters, and reduced pruritus to a greater degree than TAC therapy. However, further studies are required before it can be recommended for the treatment of keloids.

Prevention and management of hypertrophic scars and keloids after burns in children.

Hypertrophic scars and keloids are challenging to manage, particularly as sequelae of burns in children in whom the psychologic burden and skin characteristics differ substantially from adults. Prevention of hypertrophic scars and keloids after burns is currently the best strategy in their management to avoid permanent functional and aesthetical alterations. Several actions can be taken to prevent their occurrence, including parental and children education regarding handling sources of fire and flammable materials, among others. Combination of therapies is the mainstay of current burn scar management, including surgical reconstruction, pressure therapy, silicon gels and sheets, and temporary garments. Other adjuvant therapies such as topical imiquimod, tacrolimus, and retinoids, as well as intralesional corticosteroids, 5-fluorouracil, interferons, and bleomycin, have been used with relative success. Cryosurgery and lasers have also been reported as alternatives. Newer treatments aimed at molecular targets such as cytokines, growth factors, and gene therapy, currently in developing stages, are considered the future of the treatment of postburn hypertrophic scars and keloids in children.

A review of the biologic effects, clinical efficacy, and safety of silicone elastomer sheeting for hypertrophic and keloid scar treatment and management.

Silicone elastomer sheeting is a medical device used to prevent the development of and improve the appearance and feel of hypertrophic and keloid scars. The precise mechanism of action of silicone elastomer sheeting has not been defined, but clinical trials report that this device is safe and effective for the treatment and prevention of hypertrophic and keloid scars if worn over the scar for 12 to 24 hours per day for at least 2 to 3 months. Some of the silicone elastomer sheeting products currently on the market are durable and adhere well to the skin. These products are an attractive treatment option because of their ease of use and low risk of adverse effects compared to other treatments, such as surgical excision, intralesional corticosteroid injections, pressure therapy, radiation, laser treatment, and cryotherapy. Additional controlled clinical trials with large patient populations may provide further evidence for the efficacy of silicone elastomer sheeting in the treatment and prevention of hypertrophic and keloid scars. The purpose of this article is to review the literature on silicone elastomer sheeting products and to discuss their clinical application in the treatment and prevention of hypertrophic and keloid scars.