[A man with brown discolorations]. / Een man met bruine vlekjes.

A 58-year-old man presents with spontaneous brown discolorations of his mouth and hands. Our differential diagnosis included Peutz-Jeghers syndrome, Laugier-Hunziker syndrome or Addison's disease. There were no polyps in a previously performed colonoscopy and no other systemic symptoms. We made the diagnosis Laugier-Hunziker syndrome, a benign skin disorder that doesn't require treatment, confirmed by skin biopsy.

Efficacy, cost-minimization, and budget impact of a personalized discharge letter for basal cell carcinoma patients to reduce low-value follow-up care.

BACKGROUND: The incidence of keratinocyte carcinomas is high and rapidly growing. Approximately 80% of keratinocyte carcinomas consist of basal cell carcinomas (BCC) with 50% of these being considered as low-risk tumors. Nevertheless, 83% of the low-risk BCC patients were found to receive more follow-up care than recommended according to the Dutch BCC guideline, which is one visit post-treatment for this group. More efficient management could reduce unnecessary follow-up care and related costs. OBJECTIVES: To study the efficacy, cost-utility, and budget impact of a personalized discharge letter for low-risk BCC patients compared with usual care (no personalized letter). METHODS: In a multi-center intervention study, a personalized discharge letter in addition to usual care was compared to usual care in first-time BCC patients. Model-based cost-utility and budget impact analyses were conducted, using individual patient data gathered via surveys. The outcome measures were number of follow-up visits, costs and quality adjusted life years (QALY) per patient. RESULTS: A total of 473 first-time BCC patients were recruited. The personalized discharge letter decreased the number of follow-up visits by 14.8% in the first year. The incremental costs after five years were -€24.45 per patient. The QALYs were 4.12 after five years and very similar in both groups. The national budget impact was -€2,7 million after five years. CONCLUSIONS: The distribution of a personalized discharge letter decreases the number of unnecessary follow-up visits and implementing the intervention in a large eligible population would results in substantial cost savings, contributing to restraining the growing BCC costs.

What do patients and dermatologists prefer regarding low-risk basal cell carcinoma follow-up care? A discrete choice experiment.

BACKGROUND: Follow-up after low-risk basal cell carcinoma (BCC) is being provided more frequently than recommended by guidelines. To design an acceptable strategy to successfully reduce this 'low-value' care, it is important to obtain insights into the preferences of patients and dermatologists. OBJECTIVE: To determine the preferences and needs of patients and dermatologists to reduce low-risk BCC follow-up care, and the trade-offs they are willing to make. METHODS: A questionnaire including a discrete choice experiment was created, containing attributes regarding amount of follow-up, continuity of care, method of providing addition information, type of healthcare provider, duration of follow-up visits and skin examination. In total, 371 BCC patients and all Dutch dermatologists and dermatology residents (n = 620) were invited to complete the questionnaire. A panel latent class model was used for analysis. RESULTS: Eighty-four dermatologists and 266 BCC patients (21% and 72% response rates respectively) completed the discrete choice experiment. If the post-treatment visit was performed by the same person as treatment provider and a hand-out was provided to patients containing personalised information, the acceptance of having no additional follow-up visits (i.e. following the guidelines) would increase from 55% to 77% by patients. Female patients and older dermatologists, however, are less willing to accept the guidelines and prefer additional follow-up visits. LIMITATIONS: The low response rate of dermatologists. CONCLUSION: This discrete choice experiment revealed a feasible strategy to substantially reduce costs, while maintaining quality of care, based on the preferences and needs of BCC patients, which is supported by dermatologists.

Health-Related Quality of Life, Satisfaction with Care, and Cosmetic Results in Relation to Treatment among Patients with Keratinocyte Cancer in the Head and Neck Area: Results from the PROFILES Registry.

BACKGROUND: Little is known about the impact of keratinocyte cancer (KC) and its treatment on health-related quality of life (HRQoL). OBJECTIVES: The objectives of the present study were (1) to evaluate HRQoL among patients with KC in a population-based setting and compare this with an age- end sex-matched normative population and (2) to compare HRQoL, satisfaction with care, and cosmetic results among patients who underwent conventional excision, Mohs' micrographic surgery, or radiotherapy. METHOD: A random sample of 347 patients diagnosed with cutaneous basal cell or squamous cell carcinoma in the head and neck area between January 1, 2010, and December 31, 2014, were selected from the Netherlands Cancer Registry (NCR) and were invited to complete a questionnaire on HRQoL, satisfaction with care, and cosmetic results. Data were collected within Patient-Reported Outcomes Following Initial Treatment and Long-term Evaluation of Survivorship (PROFILES). Outcomes were compared to an age- and sex-matched normative population. RESULTS: Two hundred fifteen patients with KC returned a completed questionnaire (62% response). Patients with KC reported better global quality of life (79.6 vs. 73.3, p < 0.01) and less pain (p < 0.01) compared to the normative population. No statistically significant differences in HRQoL, satisfaction with care, and cosmetic results were found between patients with KC who underwent conventional excision, Mohs' micrographic surgery, or radiotherapy. CONCLUSIONS: The impact of KC and its treatment seems relatively low and more positive than negative as patients reported better HRQoL compared to an age- and sex-matched normative population, probably due to adaptation. No statistically significant differences between treatment types were found concerning HRQoL, patient satisfaction, and cosmetic results. This information could be used by healthcare professionals involved in KC care to improve patients' knowledge about different aspects of the disease as patient's preference is an important factor for treatment choice.

[Melanocytic tumour of uncertain malignant potential; practical dilemmas]. / Melanocytaire tumor met een onzekere maligne potentie.

BACKGROUND: 'MELTUMP' (melanocytic tumour of uncertain malignant potential) is a collective category for different melanocytic tumours in which the diagnosis 'melanoma' cannot be demonstrated, but equally cannot be excluded. Since the malignant potential of these disorders is unpredictable, there is no singular approach. CASE DESCRIPTION: A 48-year-old woman attended a dermatology clinic for an atypical mole on the left lower leg. Her medical history included two previous melanomas. The mole was photographed and excised. Histopathological diagnostics showed atypical melanocytic proliferation; the abnormality was classified as a MELTUMP. Based on the photo of the mole, it was decided to perform a re-excision with a margin of 5 mm. CONCLUSION: It is recommended to obtain photographic evidence for each pigmented abnormality that is suspected of being malignant. Based on this photo, a clinical suspicion of melanoma can be assessed later. Particularly for MELTUMP patients this can be useful when determining the clinical management.

Varicose veins due to reflux in a tortuous sartorius muscle vein.

In daily phlebology practice, duplex ultrasound may sometimes reveal unusual pathways of reflux. A 46-year-old woman presented with heaviness and pain at the medial side of the left thigh after exercise. A tortuous intramuscular course of a large refluxing vein was seen in the sartorius muscle in connection with a femoral vein perforator cranially and the below-knee great saphenous vein distally. Magnetic resonance imaging confirmed these findings. Treatment consisted of a combination of foam sclerotherapy, radiofrequency ablation, and phlebectomies.

Cancer survivors' preference for follow-up care providers: a cross-sectional study from the population-based PROFILES-registry.

BACKGROUND: The best practice for the organization of follow-up care in oncology is under debate, due to growing numbers of cancer survivors. Understanding survivors' preferences for follow-up care is elementary for designing patient-centred care. Based on data from prostate cancer and melanoma survivors, this study aims to identify: 1) preferences for follow-up care providers, for instance the medical specialist, the oncology nurse or the general practitioner; 2) characteristics associated with these preferences and 3) the preferred care provider to discuss cancer-related problems. MATERIAL AND METHODS: Survivors diagnosed with prostate cancer (N = 535) and melanoma (N = 232) between 2007 and 2013 as registered in The Netherlands Cancer Registry returned a questionnaire (response rate was 71% and 69%, respectively). A latent class cluster model analysis was used to define preferences and a multinomial logistic regression analysis was used to identify survivor-related characteristics associated with these preferences. RESULTS: Of all survivors, 29% reported no preference, 40% reported a preference for the medical specialist, 20% reported a preference for both the medical specialist and the general practitioner and 11% reported a preference for both the medical specialist and the oncology nurse. Survivors who were older, lower/intermediate educated and women were more likely to have a preference for the medical specialist. Lower educated survivors were less likely to have a preference for both the medical specialist and the general practitioner. Overall, survivors prefer to discuss diet, physical fitness and fatigue with the general practitioner, and hereditary and recurrence with the medical specialist. Only a small minority favored to discuss cancer-related problems with the oncology nurse. CONCLUSION: Survivors reported different preferences for follow-up care providers based on age, education level, gender and satisfaction with the general practitioner, showing a need for tailored follow-up care in oncology. The results indicate an urgency to educate patients about transitions in follow-up care.

[A man with thumb nail abnormalities]. / Een man met nagelafwijkingen aan zijn duimen.

UNLABELLED: A 56-year-old, otherwise healthy patient was seen in the Dermatology department with longstanding central splitting of the nail plate of his right thumb. Because his left thumb nail also started to become affected he sought help. DIAGNOSIS: median canaliform nail dystrophy.

Dutch Venous Ulcer guideline update.

The revised guideline of 2013 is an update of the 2005 guideline "venous leg ulcer". In this special project four separate guidelines (venous leg ulcer, varicose veins, compression therapy and deep venous disorders) were revised and developed simultaneously. A meeting was held including representatives of any organisation involved in venous disease management including patient organizations and health insurance companies. Eighteen clinical questions where defined, and a new strategy was used to accelerate the process. This resulted in two new and two revised guidelines within one year. The guideline committee advises use of the C of the CEAP classification as well as the Venous Clinical Severity Score (VCSS) and a Quality of life (QoL) score in the assessment of clinical signs. These can provide insight into the burden of disease and the effects of treatment as experienced by the patient. A duplex ultrasound should be performed in every patient to establish the underlying aetiology and to evaluate the need for treatment (which is discussed in a separate guideline). The use of the TIME model for describing venous ulcers is recommended. There is no evidence for antiseptic or antibiotic wound care products except for a Cochrane review in which some evidence is presented for cadexomer iodine. Signs of infection are the main reason for the use of oral antibiotics. When the ulcer fails to heal the use of oral aspirin and pentoxifylline can be considered as an adjunct. For the individual patient, the following aspects should be considered: the appearance of the ulcer (amount of exudate) according to the TIME model, the influence of wound care products on moisturising the wound, frequency of changing compression bandages, pain and allergies. The cost of the dressings should also be considered. Education and training of patients t improves compliance with compression therapy but does not influence wound healing rates.

Clinical aspects and indications for endovenous treatments for varicose veins.

Endovenous laser treatment has been around for more than a decade. A brief history of circumstances that have made this treatment modality possible is provided.

Duplication of the great saphenous vein: a definition problem and implications for therapy.

BACKGROUND: In the literature there is a range from 1% to 20 % of duplication (up to 20%) of the great saphenous vein (GSV) reported, because there is a lack of an accurate definition of the GSV and objective parameters for an anatomical identification. OBJECTIVE: To investigate the frequency of true duplications of the GSV. MATERIALS AND METHODS: A systematic review of the literature, a retrospective analysis of duplex examinations, and a prospective study of duplex examinations to investigate the frequency of true duplications of the GSV. RESULTS: In the literature review, a great variety of definitions is used for duplication of the GSV. Before the consensus of the Union International de Phlébologie (UIP) in 2006, Only in a small number of studies, the definition of the GSV in the saphenous compartment between the fascial blades is mentioned. CONCLUSION: Phlebographic studies have been the criterion standard for the identification of venous anatomy. Now, duplex is regarded as the criterion standard for accurate detection of the veins. True duplication of the GSV is less common than the previous literature has suggested, namely 1.6% to 2%. It is recommended that the duplicated GSV should be treated to avoid an important risk of recurrence of venous insufficiency.

Foam sclerotherapy: investigating the need for sterile air.

BACKGROUND: Sclerotherapy with foam is becoming increasingly popular for the treatment of varicose veins. There is no consensus on the necessity of sterile air or other gases to produce foam. OBJECTIVES: To evaluate the potential risk of bacterial inoculation of polidocanol (POL) foam using room air and the antimicrobial properties of polidocanol. MATERIALS AND METHODS: The amount of airborne microorganisms was quantitatively measured. Four bacterial strains were tested for susceptibility to polidocanol: Staphylococcus aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa, and Streptococcus pyogenes. RESULTS: Air measurements varied as a result of air movement and the number of people in the room. Although the risk of introducing one colony-formin unit can be calculated as less than 1 in 330, the clinical relevance is still to be determined. No inhibition of bacterial growth was achieved with POL in of any of the tested strains. CONCLUSIONS: Foam sclerotherapy with POL prepared in a standard treatment room is a safe procedure without the risk of introducing a severe bacterial complication. The use of sterile air, nitrogen, or carbon dioxide is unnecessary and will make foam sclerotherapy with POL more elaborate and more expensive to use.

Wound stimulation by growth-arrested human keratinocytes and fibroblasts: HP802-247, a new-generation allogeneic tissue engineering product.

BACKGROUND: HP802-247 is a new-generation, allogeneic tissue engineering product consisting of growth-arrested, human keratinocytes (K) and fibroblasts (F) delivered in a fibrin matrix by a spray device. OBJECTIVE: To identify the preferred dose of HP802-247 based on cell concentration and K/F ratio. METHODS: A multicenter, randomized, double-blind, placebo-controlled, explorative phase II study of 6 different doses of HP802-247 administered once per week for 12 consecutive weeks in chronic venous leg ulcers. RESULTS: HP802-247 was safe and well tolerated and showed increasing efficacy dependent on cell concentration and K/F ratio, in line with in vitro growth factor release data. The mean complete closure rate at week 12 for all patients treated with HP802-247 was 40%, and for placebo it was 33%. In contrast to placebo, all HP802-247 dose groups improved from week 12 to 24. CONCLUSION: As an integral part of a rational tissue engineering product development, this explorative trial identified the preferred dose of HP802-247 for further clinical studies.

[Guideline 'Diagnosis and treatment of varicose veins']. / Richtlijn 'Diagnostiek en behandeling van varices'.

The Dutch guideline on the diagnosis and treatment of varicose veins recommends that the 'C' from the North American Venous Forum classification CEAP ('C' = clinical, 'E' = aetiological, 'A' = anatomical, and 'P' = pathophysiological classification ) be recorded in the clinical case notes and that traditional tests as described by Trendelenburg and Perthes be omitted as they are of no use in patients with C2 and C3 varicose veins. In primary C1, C2 and C3 varicose veins that have not previously been treated, a handheld Doppler may be used to exclude reflux. If reflux is found or if in doubt, duplex investigation is necessary. Before any invasive treatment of C2 or C3 varicose veins is scheduled, duplex investigation of the superficial and deep systems is mandatory. In C2 and C3 varicose veins functional investigations such as plethysmography and intravenous pressure measurement are superfluous. With respect to treatment of an insufficient greater saphenous vein, stripping from knee to groin with side branch interruption in the groin is the gold standard in the treatment of C2 and C3 varicose veins. Endovenous techniques such as radio frequency ablation or laser are comparable with the classical stripping method in the treatment of C2 and C3 varicose veins. Insufficient perforating C2 or C3 veins in these patients need no specific treatment. Prior to surgery the entrance level of the lesser saphenous vein into the popliteal vein should be marked with the patient lying in supine position and with the aid of duplex. For patients with side-branches hook needle extraction through mini- incisions is the treatment of choice.

Endovenous laser ablation-induced complications: review of the literature and new cases.

BACKGROUND: In the last decade, minimally invasive techniques have been introduced in the treatment of lower extremity varicosities. Of these therapies, endovenous laser ablation is the most widely accepted and used treatment option for insufficient great and short saphenous veins. OBJECTIVE: To present a review of reported common and rare and minor and major complications associated with endovenous laser ablation. METHODS: A systematic review of studies and case reports on endovenous laser ablation-induced complications. The complications were classified as minor or major according to the Society of Interventional Radiology Standards of Practice Committee guidelines on reporting complications. A case-series of complications after endovenous laser ablation is presented. RESULTS: Ecchymoses and pain are frequently reported side effects of endovenous laser ablation. Nerve injury, skin burns, deep vein thrombosis and pulmonary embolism seldom occur. An exceptional complication is a material or device that by accident remains inside the body after the procedure. Ecchymosis, pain, induration, skin burns, dysesthesia, superficial thrombophlebitis, and hematoma were classified as minor complications. Deep vein thrombosis and nerve injury were classified as major complications. CONCLUSION: Endovenous laser ablation may be considered a safe treatment of lower extremity varicosities. The incidence of common side effects may decrease with better laser parameters.

NewFill for skin augmentation: a new filler or failure?

BACKGROUND: New injectable materials for skin augmentation that promise to be the ideal filling material are introduced every year. Recently, we treated three patients with adverse reactions to a new substance for skin augmentation: polylactic acid (NewFill, Ashford Aesthetics Inc, Belgium). OBJECTIVE: To present three cases in which serious adverse reactions had occurred after skin augmentation with a new filling substance, polylactic acid (NewFill). Because an identical substance (Sculptra, Aventis Pharmaceuticals, Bridgewater, NJ, USA) was recently introduced in the United States, we want to alert future users of these substances to possible adverse events. MATERIALS AND METHODS: We report three cases with serious adverse events more than 12 months after skin augmentation with polylactic acid (NewFill). They were treated with intralesional steroid therapy and topical imiquimod application. RESULTS: Both intralesional steroid therapy and topical imiquimod application lead to moderate results. If feasible, surgical excision is the best available option. CONCLUSIONS: Great care should be taken when polylactic acid is used for intradermal injection because giant cell granulomatous reactions may be the result. Other than surgical excision, effective treatment options are lacking.

Ambulatory phlebectomy versus compression sclerotherapy: results of a randomized controlled trial.

BACKGROUND: Although no randomized controlled trial has assessed the effects of either compression sclerotherapy or ambulatory phlebectomy, both techniques are used to treat varicose veins worldwide. We performed a randomized controlled trial to compare recurrence rates of varicose veins and complications after compression sclerotherapy and ambulatory phlebectomy. METHODS: From September 1996 to October 1998, we randomly allocated 49 legs to compression sclerotherapy and 49 legs to ambulatory phlebectomy. Our primary outcome parameters were as follows: recurrence rates at 1 and 2 years and complications related to therapy. Eighty-two patients were included, of whom 16 were included with both of their legs. The number of treated legs was therefore 98, but two patients were lost to follow-up. RESULTS: One year recurrence amounted to 1 out of 48 for phlebectomy and 12 out of 48 for compression sclerotherapy (P<0.001); at 2 years, six additional recurrences were found, but then solely for compression sclerotherapy (P<0.001). Significant differences in complications occurring more in phlebectomy than in compression sclerotherapy therapy were blisters, teleangiectatic matting, scar formation, and bruising from bandaging. CONCLUSION: Our results show that ambulatory phlebectomy is an effective therapy for varicose veins of the leg. Recurrence rates are significantly lower than for compression sclerotherapy therapy. If varicose veins persist 4 weeks after compression sclerotherapy, it can be argued that to reduce the risk of future recurrence ambulatory phlebectomy should be considered as the better treatment option.

Patient satisfaction after ambulatory phlebectomy of varicose veins in the foot.

BACKGROUND: Ambulatory phlebectomy is an accepted therapy for varicose veins of the ankle and foot region. Although most phlebologists regard this therapy highly, little is known about patient satisfaction. OBJECTIVE: To investigate patient satisfaction and complaints as reported by the patient after ambulatory phlebectomy for varicose veins in the ankle and foot region. METHODS: A questionnaire was taken from patients who received ambulatory phlebectomy for varicose veins of the ankle and foot region between 1996 and 2000. RESULTS: According to the results of the questionnaire, 50% of the patient population was not completely satisfied, mostly because of persisting pain, reported discoloration, and perceived recurrence. CONCLUSION: The most important factors that influence patient satisfaction are discoloration, persistent pain, and the perception of varices after surgery. To avoid misunderstandings and/or disappointments, attention should be given to patient information before and after surgery.