The causes of nail apparatus pigmentation presenting to a melanoma screening clinic a prospective study.

BACKGROUND: Advanced stage primary cutaneous malignant melanoma (PCMM) has a high mortality. PCMM may affect any area of the skin, including the nail apparatus (malignant melanoma or subungual melanoma). Although nail apparatus malignant melanoma (NAMM) is rare, delayed diagnosis carries a poor prognosis. AIM: The primary aim was to study the range of nail presentations and identify key patterns to aid in differential diagnosis. A secondary aim was to quantify the number of patients requiring surgery, indications for biopsy, and the incidence and characteristics of NAMM. METHODS: This was a prospective study of all referrals with nail apparatus pigmentation to a weekly dedicated melanoma screening clinic over a 6-month period. RESULTS: In total, 2246 patients were included. Of the 38 patients referred with nail pigmentation, 1 (2.6%) was diagnosed with NAMM and involved a fungating amelanotic lesion of the right hallux. The remaining patients were diagnosed with subungual haematoma (20/38; 52.6%), viral wart (2/38; 5.4%), acral fibrokeratoma (1/38; 2.6%), myxoid cyst (3/38; 7.9%), fungal nail infection (4/38; 10.5%), Pseudomonas nail infection (1/38; 2.6%), benign linear pigmentation (2/38, 5.3%), Bowen disease (1/38, 2.6%), psoriatic nail changes (2/38; 5.3%) and matrix malalignment (1/38; 2.6%). Of the eight patients (21.1%) who required surgery, five had a biopsy taken and three underwent surgery. Only 14 cases were followed up by Dermatology. NAMM accounted for 0.7% of all melanomas diagnosed. CONCLUSION: We illustrate the wide range of diagnoses for pigmented nail presentations and highlight the late presentation of advanced disease in a patient presenting with NAMM.

Cutaneous manifestations of phosphate solution extravasation.

Extravasation injuries are common in patients receiving multiple intravenous infusions. Although such injuries are closely associated with the infusion of cytotoxic chemotherapy, they have also been been associated with extravasation of noncytotoxic drugs. Extravasation injuries can lead to skin ulceration and nerve and tendon damage, and therefore to permanent disability. We report three cases of phosphate solution extravasation leading to unusual cutaneous manifestations.

Effect of tissue shrinkage on histological tumour-free margin after excision of basal cell carcinoma.

BACKGROUND: Histology reports of skin tumour excisions frequently describe a histological margin significantly less than the planned surgical excision margin. OBJECTIVES: A novel method of marking visible tumour margin was devised. This allowed us to evaluate the accuracy of tumour detection and to compare tissue contraction of the clinically normal perilesional skin with that of tumour tissue following excision and fixation. METHODS: Forty-four well-defined basal cell carcinomas were excised from 42 patients. The visible tumour edge was marked by scoring with a blade around its circumference prior to excision. This allowed comparison of visible and true histological tumour margin. The excision margin was carefully measured from the scored line and the tumour excised. After tissue fixation and processing the histological dimensions of tumour and perilesional margin skin were compared with the pre-excision measurements. RESULTS: The tumour edge was accurately identified to within 1 mm in 67% of margins and was underestimated in only 4%. The whole specimen contracted by a mean of 14%. Skin containing tumour contracted by a mean of 11% but adjacent tumour-free skin in the same plane contracted by a mean of 19%. There was no significant effect of age and site on difference in percentage shrinkage between tumour and margin. CONCLUSIONS: We underestimated tumour extent at only 4% of margins. Tissue shrinkage was the most important factor affecting eventual histological margin. Our novel technique allowed us to demonstrate that this shrinkage is not uniform across the specimen, but is disproportionately high in the tumour-free margin. This suggests that previous estimates of margin shrinkage, based on whole-specimen contraction measurements, may have been erroneously low.

Do antineutrophil cytoplasmic antibodies (ANCA) play a key role in neutrophilic dermatoses? A case of propylthiouracil-induced neutrophilic dermatosis with positive perinuclear ANCA.

We report a case of neutrophilic dermatosis caused by propylthiouracil (PTU), with positive perinuclear antineutrophil cytoplasmic antibodies (p-ANCA). PTU is well known to cause vasculitis associated with positive ANCA titres, and this typically occurs late in the treatment (after months to years). PTU rarely causes neutrophilic dermatoses (three case reports). In the three cases described, ANCA was positive at the outset. Our patient's initial ANCA testing was negative and her positive p-ANCA evolved. This may be because PTU binds to myeloperoxidase (MPO) inside neutrophils, altering its configuration and thus causing antibody formation to this abnormal MPO-PTU configuration, which would not be detected by standard laboratory techniques. ANCA has been implicated in spreading neutrophil activation and thus its pathogenic effect and clinical significance may extend beyond the realm of vasculitis alone.

Perioperative international normalized ratio level is a poor predictor of postoperative bleeding complications in dermatological surgery patients taking warfarin.

BACKGROUND: When planning dermatological surgery with patients on warfarin, clinicians must balance the risk of bleeding complications against that of a thrombotic event if anticoagulation is interrupted. OBJECTIVES: To evaluate the frequency of bleeding complications in warfarinized subjects undergoing cutaneous surgery, and to correlate the risk of bleeding with the international normalized ratio (INR) at the time of surgery. METHODS: In this prospective controlled observational study, 65 patients on warfarin underwent excision of 70 cutaneous tumours. Mean perioperative INR was 2.1 (range 1.0-4.2). A group of 92 nonwarfarinized controls underwent excision of 100 tumours by the same surgeons. The INR of those on warfarin was checked at the time of surgery. Intraoperative and postoperative bleeding was recorded by the operating surgeon. RESULTS: No increase in bleeding tendency during surgery was seen in those on warfarin when compared with controls. Five patients on warfarin (8%) reported moderate or severe postoperative bleeding. No significant postoperative bleeding was reported by controls (P=0.01). All patients on warfarin with bleeding complications had an INR of <2.6 at the time of surgery. CONCLUSIONS: Bleeding risk could not be correlated with INR and this study demonstrates that even when INR is in the therapeutic range the risk of postoperative bleeding is increased for warfarinized patients. The need for meticulous haemostasis in all patients on warfarin should not be forgotten and patients should be made aware preoperatively of the small but significant risk of postoperative bleeding complications.

Spontaneous clinical improvement in HIV-associated follicular syndrome.

Since 1991 infrequent reports have described a distinctive triad of nodulocystic acne, striking follicular spines and an eruption resembling pityriasis rubra pilaris (PRP) in HIV-positive patients. It has been suggested that this may represent a subtype of PRP, or alternatively that it should be viewed as a unique HIV-associated follicular occlusion triad. Clinical manifestations may be severe, and in several cases have been ultimately fatal, with death occurring due to complications of cutaneous sepsis. We describe a case demonstrating severe conglobate acne, follicular keratotic spines and histologically confirmed PRP in association with HIV infection. Clinical features and treatment modalities of previously reported cases are reviewed. Despite refusing all topical and systemic treatment our patient showed spontaneous remission of skin signs after 2 years.