Survival in 31 670 patients with thin melanomas: a Swedish population-based study.

BACKGROUND: The incidence of cutaneous malignant melanoma (CMM) continues to increase in most countries worldwide and the majority are diagnosed with thin tumours (≤ 1 mm). OBJECTIVES: The aim of the present study was to investigate the melanoma-specific survival (MSS) as well as conditional MSS (CMSS) in patients with thin CMM in Sweden. PATIENTS AND METHODS: Clinical and histological parameters were obtained from the Swedish Melanoma Registry for patients diagnosed with thin CMM between 1990 and 2017. Patients were followed until the end of 2017. MSS as well as CMSS for different thickness groups were calculated using the Kaplan-Meier method and Cox regression analyses were used to calculate for survival differences between thickness groups. RESULTS: There were 31 670 patients included for final analyses. The overall 10- and 20-year MSS for thin CMMs was 97% [95% confidence interval (CI) 97-97] and 95% (95% CI 95-96), respectively. From 0·7 mm and above, MSS decreased significantly with increasing thickness level. All thickness groups had an increased survival over time. The lowest CMSS was confirmed for men with 1·0 mm in thickness but their 10-year CMSS increased steadily over time. Women had overall better MSS as well as CMSS than men. However, the relation between MSS and CMSS was similar for both sexes. CONCLUSIONS: MSS was confirmed as excellent for patients with thin CMMs in Sweden. Although we could show a decreased MSS for patients with 0·7 mm thickness and above, the long-term survival and, in addition, a very favourable CMSS for those patients do not support more extended follow-up programmes than the current recommendations in Sweden.

Low and high body mass index in hidradenitis suppurativa patients-different subtypes?

INTRODUCTION: Overweight is a well-established risk factor for hidradenitis suppurativa (HS). In this cross-sectional study, we compare HS patients with a high body mass index (BMI) with HS patients with a low BMI to investigate differences in disease characteristics. MATERIALS AND METHOD: Patients were recruited from 17 dermatological centres from four continents. A total of 246 patients with a BMI below 25 were compared to 205 patients with a BMI of above 35. RESULTS: Patients with a high BMI suffered more severe disease (Hurley, physician global assessment, number of areas affected and patient-reported severity (PRS), P < 0.001 for all). There was no difference in smoking (P = 0.783) nor in family history (P = 0.088). In both low and high BMI patients, early onset of HS was a predictor of positive family history (P < 0.001, for each). For low BMI patients, an increase in BMI significantly increased PRS (P < 0.001). For patients with a high BMI, number of pack-years significantly increased PRS (P = 0.001). Cluster analysis of eruption patterns was location specific for low BMI patients but severity specific for high BMI patients. DISCUSSION: Patients with a low and high BMI could represent two clinically different subtypes. We suggest a non-linear relationship between BMI and impact of HS. As patients go from a low BMI patient to a high BMI patient (or from high to low), eruption patterns and risk factors may change.

Acute skin and hair symptoms followed by severe, delayed eye complications in subjects using the synthetic opioid MT-45.

BACKGROUND: The introduction of unclassified new psychoactive substances (NPS) on the recreational drugs market through open online sale ('legal highs' or 'Internet drugs') continues unabated and represents a growing health hazard. The use of NPS has resulted in numerous, severe, adverse events and fatalities, due to unintended overdose or unknown toxic side-effects. OBJECTIVES: To try to find a possible common underlying cause for the skin-hair-eye symptoms complex observed in three men. METHODS: From late 2013 to mid-2014, three Swedish men aged 23-34 years with a history of recreational drug use independently presented with similar and very remarkable clinical signs, requiring extensive examination and prolonged treatment. RESULTS: Common clinical signs included hair depigmentation, hair loss, widespread folliculitis and dermatitis, painful intertriginous dermatitis, dry eyes, and elevated liver enzymes. Two of them also showed transverse white Mees' lines (leukonychia striata) on the fingernails and toenails, suggesting a temporary, drug-induced, disorganized keratinization. The clinical signs gradually disappeared over time. However, later on, two developed severe bilateral secondary cataracts requiring surgery. Because drug tests within the Swedish STRIDA project had demonstrated intake of the NPS opioid MT-45 in all patients, this was suspected to be the common causative agent. CONCLUSIONS: These cases highlight the importance for physicians and health professionals to consider the increasing number of novel, untested recreational drugs, as a potential cause of unusual and otherwise unrecognized clinical signs and symptoms.

European S1 guideline for the treatment of hidradenitis suppurativa/acne inversa.

Hidradenitis suppurativa/acne inversa (HS) is a chronic, inflammatory, recurrent, debilitating skin disease of the hair follicle that usually presents after puberty with painful, deep-seated, inflamed lesions in the apocrine gland-bearing areas of the body, most commonly the axillae, inguinal and anogenital regions. A mean disease incidence of 6.0 per 100,000 person-years and an average prevalence of 1% has been reported in Europe. HS has the highest impact on patients' quality of life among all assessed dermatological diseases. HS is associated with a variety of concomitant and secondary diseases, such as obesity, metabolic syndrome, inflammatory bowel disease, e.g. Crohn's disease, spondyloarthropathy, follicular occlusion syndrome and other hyperergic diseases. The central pathogenic event in HS is believed to be the occlusion of the upper part of the hair follicle leading to a perifollicular lympho-histiocytic inflammation. A highly significant association between the prevalence of HS and current smoking (Odds ratio 12.55) and overweight (Odds ratio 1.1 for each body mass index unit) has been documented. The European S1 HS guideline suggests that the disease should be treated based on its individual subjective impact and objective severity. Locally recurring lesions can be treated by classical surgery or LASER techniques, whereas medical treatment either as monotherapy or in combination with radical surgery is more appropriate for widely spread lesions. Medical therapy may include antibiotics (clindamycin plus rifampicine, tetracyclines), acitretin and biologics (adalimumab, infliximab). A Hurley severity grade-relevant treatment of HS is recommended by the expert group following a treatment algorithm. Adjuvant measurements, such as pain management, treatment of superinfections, weight loss and tobacco abstinence have to be considered.

Trends in cutaneous malignant melanoma in Sweden 1997-2011: thinner tumours and improved survival among men.

BACKGROUND: Both patient survival and the proportion of patients diagnosed with thin cutaneous malignant melanoma (CMM) have been steadily rising in Sweden as in most Western countries, although the rate of improvement in survival appears to have declined in Sweden at the end of the last millennium. OBJECTIVES: To analyse the most recent trends in the distribution of tumour thickness (T category) as well as CMM-specific survival in Swedish patients diagnosed during 1997-2011. METHODS: This nationwide population-based study included 30,590 patients registered in the Swedish Melanoma Register (SMR) and diagnosed with a first primary invasive CMM during 1997-2011. The patients were followed through 2012 in the national Cause of Death Register. RESULTS: Logistic and Cox regression analyses adjusting for age at diagnosis, tumour site and healthcare region were carried out. The odds ratio for being diagnosed with thicker tumours was significantly reduced (P < 0·001) and the CMM-specific survival significantly improved in men diagnosed during 2007-2011 compared with men diagnosed during 1997-2001 (hazard ratio = 0·81; 95% confidence interval 0·72-0·91; P < 0·001), while the corresponding differences for women were not significant. Women were diagnosed with significantly thicker tumours during 2002-2006 and a tendency towards decreased survival was observed compared with those diagnosed earlier (during 1997-2001) and later (during 2007-2011). CONCLUSIONS: In Sweden, the CMMs of men are detected earlier over time and this seems to be followed by an improved CMM-specific survival for men. Women are still diagnosed with considerably thinner tumours and they experience a better survival than men.

Bacteriology of hidradenitis suppurativa exacerbations and deep tissue cultures obtained during carbon dioxide laser treatment.

BACKGROUND: Previous studies have shown different bacteria in hidradenitis suppurativa (HS) lesions, but the literature regarding bacteria in acute exacerbation of HS is sparse. OBJECTIVES: To determine the type of bacteria isolated from HS lesions during exacerbations of the disease. METHODS: Patients with HS with acute nodules or abscesses were examined and treated by carbon dioxide laser vaporization. Bacterial samples for aerobic and anaerobic cultures were taken from the skin surface (before surgery) and then from the deeper layers (during surgery) of the lesions. At each level two samples were taken, one with a punch biopsy and one by pressing a soft agar gel against the skin. The bacterial findings were typed and quantified. RESULTS: A total of 10 patients (eight women and two men), with a mean age of 37·2 years and a mean HS duration of 14·5 years, were included. All of them had an ongoing exacerbation (mean duration 5·6 days) of their HS, with one inflamed lesion that was treated by carbon dioxide laser vaporization. Coagulase-negative staphylococci (CNS) were found in the deep layers in all 10 patients. Nine of the patients carried Corynebacterium spp. and two alpha-haemolytic streptococci at various levels. Among the anaerobic microorganisms, Gram-positive cocci were the most common bacteria. CONCLUSIONS: As found in a previous study, CNS were the most common bacteria, but contrary to what we expected, Staphylococcus aureus was not found in any cultures from acute inflammatory nodules of HS exacerbations.

Interobserver variability of clinical scores in hidradenitis suppurativa is low.

BACKGROUND: Hidradenitis suppurativa (HS) is a chronic recurrent disease with scars and sinus tract formation that causes substantial impact on quality of life. For evaluation of HS and treatment results, a scoring system for disease severity (Hidradenitis Suppurativa Score, HSS) has been proposed. OBJECTIVES: To describe the interobserver reliability of the HSS and further to document its correlation with risk factors and other measures of disease severity. METHODS: Sixty-one consecutive patients with HS, referred to a clinical centre with special interest in the disease, were scored according to the HSS protocol: eight patients by four dermatologists together, 23 patients by all four observers independently and 30 patients by a single observer. Interobserver variability in HSS between the four observers was investigated in the group of 23 patients. Patients' reports of weight and height, smoking habits etc., were collected, as well as Dermatology Life Quality Index (DLQI) questionnaires. RESULTS: The interobserver concordance of HSS was 0·95. Median (interquartile range, IQR) HSS for all patients was 40 (18-73); women 39 (16-68); men 60·5 (30-95). Median (IQR) HSS for nonsmokers was 26 (12-65); former smokers 30 (10-56); smokers 44 (26-108). Median (IQR) HSS for normal weight patients was 12 (10-30); overweight 43 (25-58); obese 51 (24-95). Mean ± SD DLQI for all patients was 11·3 ± 8·6. CONCLUSIONS: HSS is simple to use and shows low interobserver variability. The score correlates with suggested risk factors, indicating that it reflects a valid estimation of disease severity.

Objective scoring of hidradenitis suppurativa reflecting the role of tobacco smoking and obesity.

BACKGROUND: Hidradenitis suppurativa (HS) is a long-standing disease with abscess and often fistula formation, predominantly in the axillae and groins. The disease is difficult to treat and has a severe impact on quality of life. A clinically relevant system for scoring disease severity is lacking in HS. OBJECTIVES: To evaluate the modified Hidradenitis Suppurativa Score (HSS) and to study the impact of body mass index (BMI) and smoking habits on disease severity. METHODS: Two hundred and fifty-one consecutive patients with HS referred to a clinic with special interest in the disease were included, of whom 115 were scored. Points were given for regions involved, types of lesion (nodules, fistulas), total area involved and whether lesions were separated by normal skin. Background characteristics included BMI and smoking habits. Two hundred and forty-six patients completed the Dermatology Life Quality Index (DLQI). RESULTS: The median (interquartile range, IQR) HSS for all patients was 38 (18-66): women 38 (18-71) and men 37 (19-51). Median (IQR) HSS for smokers was 41 (22-75.5), former smokers 27 (16-53) and nonsmokers 22 (10-57). Median (IQR) HSS for patients with BMI < 25 kg m(-2) was 32 (12-54), BMI 25-30 kg m(-2) 44 (22-56) and BMI > or = 30 kg m(-2) 50 (18-86). Mean +/- SD DLQI for the whole group of patients was 10.3 +/- 7.5, median 9, and showed no significant differences between the groups studied. There was a significant positive correlation of fair degree between HSS and DLQI. There were significant differences in HSS between nonsmokers and smokers as well as between women of normal weight compared with obese women. CONCLUSIONS: The modified HSS is simple and practical and it extracts important clinical information. A connection between disease severity and BMI as well as smoking habits in patients with HS is presented. The results suggest that the HSS may be a relevant outcome measure in future therapeutic trials in HS.

What causes hidradenitis suppurativa?

Hidradenitis suppurativa (HS)--a rather common, very chronic and debilitating inflammatory skin appendage disorder with a notoriously underestimated burden of disease--has long been a playground for the high priests of nomenclature: Ask a bunch of eminent dermatologists and skin pathologists to publicly share their thoughts on what causes HS, and they will soon get entrenched in a heated debate on whether this historical term is a despicable misnomer. Fortunately, the recently founded Hidradenitis Suppurativa Foundation (HSF; http://www.hs-foundation.org), to which EXP DERMATOL serves as home journal, has broken with this unproductive tradition and has encouraged publication of the current CONTROVERSIES feature. This is exclusively devoted to discussing the pathobiology of this chronic neutrophilic folliculitis of unknown origin. Although traces of terminological bickering remain visible, it does the HS experts in our virtual debate room credit that they engage in a constructive and comprehensive dissection of potential pathogenesis pathways that may culminate in the clinical picture we know under the competing terms HS or acne inversa. These experts sketch more often complementary than mutually exclusive pathogenesis scenarios, and the outlines of a conceivable consensus on the many open pathobiology questions begin to emerge in these CONTROVERSIES. Hopefully, this heralds a welcome new tradition: to get to the molecular heart of HS pathogenesis, which can only be achieved by a renaissance of solid basic HS research, as the key to developing more effective HS therapy.

Biophysical assessment of atopic dermatitis skin and effects of a moisturizer.

BACKGROUND: The mechanisms of the skin barrier impairment in patients with atopic dermatitis (AD) are still unknown and need further studying. OBJECTIVE: We evaluated the skin of healthy subjects and of patients having atopic dermatitis with an instrument measuring electrical impedance and other noninvasive methods (transepidermal water loss, capacitance) and studied the effects of a new emollient [Proderm (Pro-Q in the USA)]. METHODS: After a 2-week washout period, we treated clinically noneczematous skin on the forearm of 24 patients with AD and assessed the effects with the noninvasive methods. 22 healthy subjects were used as controls. RESULTS: The findings indicate that barrier function and hydration, and certain patterns of electrical impedance of AD skin are abnormal compared with normal skin. Moreover, there was an increase in hydration in patients' skin after treatment and a reversal of certain impedance indices towards normal. CONCLUSIONS: Our findings demonstrate that the moisturizer we used changes some biophysical parameters when applied to atopic skin. In addition, a technique based on electrical impedance seems to give valuable information in atopic skin studies, especially the effects of moisturizers.

Neutrophil-related host response in hidradenitis suppurativa: a pilot study in patients with inactive disease.

Host-defence defects in hidradenitis suppurativa patients have been suspected, but not proven. Activated neutrophils can destroy the surrounding tissues by a release of reactive oxygen species and active proteases. Peripheral neutrophils from 15 female patients (mean age 46, range 27-57 years) in an inactive state of their hidradenitis suppurativa, were studied and compared with 15 age-matched healthy female controls. There were no significant differences between patients and controls in the assessments of intracellular elastase activity, total content of antigenic elastase or release of elastase. Furthermore, no differences were found in total content and membrane expression of the receptors measured. The generation of free oxygen radicals, after stimulation with the protein kinase C activator phorbol myristate acetate, was significantly higher in the patients than in the controls, while there was no difference after Fc-receptor-mediated stimulation. Dysfunctional neutrophils might be involved in the pathogenesis of hidradenitis suppurativa, but the findings should be interpreted with caution because of the small number of observed cases.

Incidence of cancer among patients with hidradenitis suppurativa.

BACKGROUND: On the basis of some case reports, a relationship has been suggested between hidradenitis suppurativa (HS) and the development of nonmelanoma skin cancer. OBJECTIVES: To confirm this relationship and to explore the risk of other cancers among patients with HS. PATIENTS: Patients with a discharge diagnosis of HS were obtained from the computerized database of hospital discharge diagnoses from January 1, 1965, through December 31, 1997. A total of 2119 patients with HS were identified. SETTING: All hospitals in Sweden. DESIGN: With record linkage to the Swedish National Cancer Registry, standardized incidence ratios (SIR [the ratio of the observed to expected incidence]) were calculated to estimate relative risk. RESULTS: The risk of developing any cancer in the cohort with HS increased 50% (95% confidence interval of SIR, 1.1-1.8, based on 73 observed cases). Statistically significant risk elevations were observed for nonmelanoma skin cancer (5 cases; SIR, 4.6; 95% confidence interval, 1.5-10.7), buccal cancer (5 cases; SIR, 5.5; 95% confidence interval, 1.8-12.9), and primary liver cancer (3 cases; SIR, 10.0; 95% confidence interval, 2.1-29.2). CONCLUSIONS: This study confirms an increased risk of nonmelanoma skin cancer among patients with HS. The risk for buccal cancer and primary liver cancer was also elevated among this cohort, but these associations should be interpreted cautiously because the combination of multiple significance testing and the few observed cases may have generated chance findings.

No human leukocyte antigen-A, -B or -DR association in Swedish patients with hidradenitis suppurativa.

Hidradenitis suppurativa (HS) is a cicatrizing, inflammatory and recurrent disease restricted to inverse skin, such as that of the axilla and groin of younger adults. In a previous study, using serological tissue-typing techniques, no significant increases in the human leukocyte antigen (HLA)-A and -B specificities were found in patients with HS. The aim of this study was to determine the frequencies of HLA-A, -B and, for the first time, HLA-DR alleles, using genomic tissue-typing methods in patients with HS. Forty-two unrelated Swedish patients with HS were included and compared with 250 controls. According to clinical staging adopted from Hurley all of the patients had stage II HS, i.e. recurrent abscesses with tract formation and cicatrization and single or multiple widely separated lesions. No association with HLA-A, -B or -DRB1 alleles was found in patients with HS. Genetic factors associated with the HLA class I or II regions do not appear to contribute significantly to the possible genetic susceptibility of HS.

Coagulase-negative staphylococci are the most common bacteria found in cultures from the deep portions of hidradenitis suppurativa lesions, as obtained by carbon dioxide laser surgery.

The significance of bacterial findings in hidradenitis suppurativa (HS) is controversial. Interpretation of the results of bacteriological examinations from the surface of HS lesions is obscured by the possible contamination of resident skin bacteria. Bacteriological analysis of aspirates from deeper parts of HS is liable to show low sensitivity. We used a carbon dioxide (CO2) laser method to evaporate the diseased tissue level by level from the surface downwards, allowing concurrent sampling of bacteriological cultures from each level and thereby minimizing contamination with bacteria from the level above. In this study, 22 women and three men with a mean age of 35.3 years and a mean HS duration of 10.6 years were treated with this CO2 laser surgical method. Aerobic and anaerobic cultures from superficial and deep levels were taken during surgery. The regions treated were axillary in eight and perineal in 17 cases. Bacterial cultures were positive for one or more specimens from at least one level in all cases and from deep levels in all but three cases. Sixteen different species or sub-species were found. Staphylococcus aureus and coagulase-negative staphylococci (CNS) were the species most frequently found. Peptostreptococcus species and Propionibacterium acnes were not uncommon. S. aureus was detected in a total of 14 cases, six of which were from the deep levels. S. aureus was the sole bacterium isolated in two deep cultures. CNS were found in 21 patients and 16 of these isolates were from the deep levels. In nine of the 16 deep samples CNS were the only bacteria detected. These findings motivate a re-evaluation of the significance of bacteria in the progress of HS and in particular they suggest that CNS are true pathogens. It is known that foreign bodies aggravate the virulence of the CNS in surgical implants, and an environment which resembles that produced by a foreign body, as found in chronic HS tissue, serves to intensify the pathogenic properties of CNS in HS.