The Quadrivalent Human Papillomavirus Vaccine in Recalcitrant Non-genital Warts: A Retrospective Study.

INTRODUCTION: The human papillomavirus (HPV) vaccine has been reported to lead to clinical clearance of lesions when used as an off-label treatment for recalcitrant extragenital warts. The aim of the study is to evaluate the therapeutic and adverse effects of HPV vaccine as an adjunctive therapy for treatment-resistant acral warts. METHODS: Patients with persistent warts despite first and second line therapies, and subsequently receiving the quadrivalent HPV vaccine between July 2013 and June 2016 as an adjunctive treatment for recalcitrant warts at the National Skin Centre, were included. RESULTS: Twenty-six patients with a median age of 34 years (range 8 to 77 years) were treated with the HPV vaccine. Nineteen (73.1%) patients completed 3 doses of the vaccine, of whom 5 (26%) achieved complete clearance, 8 (42%) had partial clearance and 6 (32%) did not respond to the vaccine. Among the 4 patients who received 2 doses of the vaccine, 3 (75%) had complete clearance whereas 1 (25%) had partial improvement of their warts. None of the patients reported adverse reactions. CONCLUSION: Our study suggests a potential adjunctive role of the HPV vaccine in the treatment of acral warts recalcitrant to conventional therapy.

Efficacy and Safety of a New Cosmeceutical Regimen Based on the Combination of Snail Secretion Filtrate and Snail Egg Extract to Improve Signs of Skin Aging.

BACKGROUND: Two extracts derived from the gastropod Cryptomphalus aspersa have been shown to have dermal regeneration properties: SCA® (secretion filtrate) with fibroblast growth factor-like activity and IFC®-CAF (cellular activating factor), a snail egg extract with skin stem cell activation activity. OBJECTIVE: The objectives of this study were to evaluate the synergic antiaging activity and tolerability of SCA and IFC-CAF in a combined regimen compared to vehicle as a placebo control. METHODS: A three-month, single-center, double-blinded, randomized, vehicle-controlled trial assessed the effects of a daily skincare routine divided into two treatment phases, as follows: intensive (1 month) and maintenance (2 months). Fifty women, aged 45-65 years, with signs of photoaging were randomized to receive either the active ingredients (n=30) or vehicle (n=20). Clinical evaluations included objective measurements of barrier function and skin hydration, elasticity, and color/brightness. Subjective assessments were conducted according to the Rao-Goldman and Glogau scales for wrinkles, the Patient Global Assessment (PGA) scale and Investigator Global Assessment (IGA) scale. RESULTS: Subjects in the active treatment group experienced reductions in transepidermal water loss and significant improvements in skin roughness, firmness, and elasticity. Both groups showed significant improvements in fine lines and wrinkles. PGA and IGA assessments indicated greater improvement in the active treatment group. CONCLUSION: The active snail extract treatment appears to be effective in improving signs of skin aging in women 45 to 65 years old. Larger randomized, controlled studies are needed to confirm our results.

Mapping of γ/δ T cells reveals Vδ2+ T cells resistance to senescence.

BACKGROUND: Immune adaptation with aging is a major of health outcomes. Studies in humans have mainly focus on αß T cells while γδ T cells have been neglected despite their role in immunosurveillance. We investigated the impact of aging on γδ T cell subsets phenotypes, functions, senescence and their molecular response to stress. METHODS: Peripheral blood of young and old donors in Singapore have been used to assess the phenotype, functional capacity, proliferation capacity and gene expression of the various γδ T cell subsets. Peripheral blood mononuclear cells from apheresis cones and young donors have been used to characterize the telomere length, epigenetics profile and DNA damage response of the various γδ T cell subsets phenotype. FINDINGS: Our data shows that peripheral Vδ2+ phenotype, functional capacity (cytokines, cytotoxicity, proliferation) and gene expression profile are specific when compared against all other αß and γδ T cells in aging. Hallmarks of senescence including telomere length, epigenetic profile and DNA damage response of Vδ2+ also differs against all other αß and γδ T cells. INTERPRETATION: Our results highlight the differential impact of lifelong stress on γδ T cells subsets, and highlight possible mechanisms that enable Vδ2+ to be resistant to cellular aging. The new findings reinforce the concept that Vδ2+ have an "innate-like" behavior and are more resilient to the environment as compared to "adaptive-like" Vδ1+ T cells.

Treatment of xanthelasma palpebrarum with a 1064-nm, Q-switched Nd:YAG laser.

BACKGROUND: Xanthelasma palpebrarum is the most common cutaneous xanthoma characterized by soft, yellow papules or plaques that arise on the periorbital skin. As these lesions can be cosmetically disfiguring, many patients seek medical help to remove these lesions. OBJECTIVE: To determine the effectiveness and minimum number of treatment sessions with a 1064-nm, Q-switched neodymium-doped yttrium aluminum garnet (Nd:YAG) laser for the treatment of xanthelasma. METHODS: A retrospective review of patients with xanthelasma consecutively treated with Q-switched Nd:YAG laser was conducted. Forty-six patients with 103 lesions were identified from January 2012 through August 2015. Photographs taken of patients immediately before treatment and 4-8 weeks after treatment were independently evaluated by 2 dermatologists. RESULTS: After a single treatment session, 93.2% of lesions had some degree of clearance. All lesions had excellent-to-complete clearance after at least 4 treatment sessions. Patients usually required 4 treatment sessions for optimal results. LIMITATIONS: This was a retrospective study. Treatment parameters varied, follow-up periods were not uniform, and response was not assessed with a validated scale. CONCLUSION: The Q-switched Nd:YAG laser is effective and well tolerated in the treatment of xanthelasma in our study population.

Treatment of Facial Acne Scarring With Fractional Carbon Dioxide Laser in Asians, a Retrospective Analysis of Efficacy and Complications.

BACKGROUND: Fractional carbon dioxide (CO2) laser resurfacing unites the idea of fractional photothermolysis with an ablative 10,600-nm wavelength. This technology permits effective treatment of acne scarring, with shorter recovery and a decreased side effect profile as compared to traditional CO2 laser resurfacing. OBJECTIVE: The aims of this study were to study the efficacy and safety of fractional CO2 laser for acne scars in Asian patients. METHODS: This was a retrospective study of all patients treated with the fractional CO2 laser for facial acne scarring between January 2, 2008, and December 31, 2010, at the National Skin Centre, Singapore. Data reviewed included sex, age, and severity of acne, type of scarring, previous treatment history, frequency of treatments, adverse events, and efficacy. RESULTS: Two hundred and ten fractional CO2 laser treatments for facial acne scars were performed on 107 patients (65 men and 42 women, Fitzpatrick skin Types II to V) during the study period. Sixteen of 107 patients experienced (15.0%) adverse events. The adverse events include hyperpigmentation (6.4%), blistering (4.0%), crusting (2.9%), aggravation of inflammatory acne lesions (1.7%), and scarring (0.6%). There were no reported side effects of hypopigmentation, bacterial or viral infection. Follow-up results after final laser treatment showed that 66.4% of patients reported Grade 1 skin texture improvement, that is, <25% (n = 71); 30.0% had Grade 2 improvement, that is, 25% to 50% improvement (n = 31); 3.7% had Grade 3 improvement, that is, 51% to 75% improvement (n = 4); and 0.9% had Grade 4 improvement, that is, >75% improvement (n = 1). CONCLUSION: The study demonstrated the efficacy and safety of a fractional CO2 laser in the treatment of acne scars in Asian. Future studies are required to establish optimum treatment parameters and achieve better clinical results.

Reflectance confocal microscopy is a useful non-invasive tool in the in vivo diagnosis of pigmented basal cell carcinoma in Asians.

BACKGROUND: The clinical differentiation between pigmented basal cell carcinoma (BCC) and other benign pigmented skin lesions can be challenging even with an additional dermoscopic evaluation, especially if the lesion is small. In vivo reflectance confocal microscopy (RCM) is an emerging, non-invasive imaging tool that allows near-microscopic evaluation of skin lesions. The features of RCM for pigmented BCC and seborrhoeic keratosis have previously been described. However, the use of RCM to differentiate between these clinically and dermoscopically challenging pigmented skin lesions among Asians has not yet been demonstrated. OBJECTIVES: We aimed to evaluate the usefulness of non-invasive RCM to differentiate between clinically and dermoscopically challenging pigmented skin lesions among Asians in a series of 11 lesions. METHODS: Nine patients with 11 clinically and dermoscopically difficult to distinguish pigmented skin lesions were evaluated by RCM to differentiate between pigmented BCC and benign lesions. In all cases, a histological confirmation of the RCM diagnosis was obtained. RESULTS: The clinical or dermoscopical characteristics were non-specific in all 10 cases. RCM detected features of pigmented BCC in nine patients and seborrhoeic keratosis in one patient. These were all confirmed by histological examination. CONCLUSIONS: This case series shows the value of non-invasive in vivo RCM imaging in the differentiation of malignant and benign pigmented lesions. Early diagnosis of small, pigmented BCC allows earlier excision with better prognosis. Future biopsies of benign lesions in cosmetic areas could also be avoided.

A retrospective review of cutaneous metastases at the National Skin Centre Singapore.

BACKGROUND/OBJECTIVES: Cutaneous metastases occur in up to 10% of all visceral malignancies. This study aims to determine the clinico-epidemiological characteristics of patients diagnosed with cutaneous metastases at a leading Asian tertiary dermatological centre. METHODS: A retrospective chart review was carried out on all patients diagnosed with cutaneous metastases from 2001 to 2010, identified through the National Skin Centre's clinical and histological databases. RESULTS: In all, 35 patients were diagnosed with cutaneous metastases at a mean age of 65 years, with a female: male ratio of 3:2 and with most (97%) being Chinese. Cutaneous metastases were the first presentation of cancer in 34% of patients (n = 12). The two commonest primaries were breast (49%, n = 17) and lung (9%, n = 3). Most had cutaneous metastases on the chest (37%, n = 13) followed by the pelvis (17%, n = 6) and 20% (n = 7) had skin lesions on multiple sites. Clinically, 46% of patients (n = 16) presented with nodule(s), 26% (n = 9) with plaque(s) and 20% (n = 7) with heterogeneous morphologies. Cutaneous metastases were suspected in 72% of patients (n = 25), attributed to clinical features (46%, n = 16) or the presence of active metastatic disease elsewhere (26%, n = 9). All lesions appeared dermal in origin. CONCLUSIONS: Cutaneous metastases are highly variable in presentation and a high index of suspicion is required for prompt diagnosis, especially in patients with a history of cancer, regardless of stage of treatment of the primary tumour.

Extramammary Paget disease: Immunohistochemistry is critical to distinguish potential mimickers.

Extra-mammary Paget disease (EMPD) is a rare intra-epithelial carcinoma that is usually found on the apocrine-rich skin of the perineum. We report 2 cases in which EMPD was initially misdiagnosed on the initial punch biopsy as melanoma-in-situ and Bowen disease respectively. Reasons for the misdiagnoses included a rare pigmented axillary variant of EMPD in the first case and atypical bowenoid features on H&E in the second. The cases are described with a critical review of the histopathological findings, along with a review of the current literature. This highlights the necessity of a comprehensive immunohistochemical panel for the assessment of intra-epithelial pagetoid atypical cells.

Melanization in basal cell carcinomas: microscopic characterization of clinically pigmented and non-pigmented tumours.

Clinical and microscopic pigmentation may affect the treatment outcomes in basal cell carcinoma. However, there have not been any in-depth histopathological comparisons between clinically pigmented and non-pigmented basal cell carcinomas with regards to microscopic melanization. The aims of our study were to determine the proportion of pigmented basal cell carcinomas presenting to the National Skin Centre in Singapore, to characterize the histological pattern of melanization and to perform a semi-quantitative analysis of the degree of microscopic melanization of the tumours. Patients with clinical features and histologically confirmed basal cell carcinomas were recruited. Demographic data and clinical characteristics were recorded and basal cell carcinoma sections were examined for histological subtype and pattern of melanization. Twenty-five Chinese patients with 30 basal cell carcinomas were recruited. Three of the five clinically non-pigmented and all of the clinically pigmented basal cell carcinomas had microscopic evidence of melanization. Microscopic melanization in clinically non-pigmented basal cell carcinomas was present only focally or in the centre of the tumour mass. Both groups of basal cell carcinomas may be colonized by melanocytes. Two morphological types of melanocytes, a dendritic and round cell type, were identified. Future research is required to evaluate if the degree of microscopic melanization influences the treatment outcome of basal cell carcinomas.

Clinical predictors of bleeding esophageal varices in the ED.

OBJECTIVES: Some authors have found that thrombocytopenia (<118,000/mm3), splenomegaly, and ascites are useful predictors of large esophageal varices in cirrhotic patients. We decide to see whether these factors could also be used to predict bleeding esophageal varices in patients known to have chronic liver disease in the ED. METHODS: A case record review was done of all patients admitted to the ED of Changi General Hospital with upper gastrointestinal bleeding from esophageal varices from October 1999 to April 2004. The criteria of thrombocytopenia, splenomegaly, and ascites were applied retrospectively to these patients to see how accurately they performed in predicting bleeding esophageal varices. RESULTS: Only 55% of patients had thrombocytopenia, whereas 45% had splenomegaly, and 27.5% had ascites. Combining thrombocytopenia with the presence of either ascites or splenomegaly did not improve the yield (only 40%), and only 6 patients had all 3 criteria. Twelve patients with bleeding varices did not have any of the criteria. CONCLUSIONS: Thrombocytopenia, splenomegaly, or ascites is an unreliable predictor of bleeding esophageal varices. Urgent or emergent endoscopy is still advocated to accurately diagnose bleeding esophageal varices.