Patients' acceptance of medical photography in a French adult and paediatric dermatology department: a questionnaire survey.

BACKGROUND: Despite the increasing use of medical photography by dermatologists, no study on patients' perceptions of photography in dermatology has been performed to date. OBJECTIVES: Firstly, to evaluate patients' perceptions of medical photography. Secondly, to assess whether perceptions differed between patients in our adult department and parents accompanying a child in our paediatric department. METHODS: An opinion survey was conducted at the Hospital of Tours (France) among adult patients (adult department) and accompanying parents (paediatric department) by completion of a questionnaire after any medical photography had been performed. RESULTS: We collected 272 questionnaires regarding 158 adults and 114 children. A camera used only in the department, and storage of the images in the department's records were the most accepted modalities (> 90%), especially in the paediatric survey. Respondents agreed with the sharing of the images with other practitioners and in medical meetings (> 85%) rather than distribution via publications (58·3%), e-mails (45·5%), health magazines (44·3%) and websites (32·0%). Most (78·8%) considered that the consent form should list all the possible uses of the images. Need for renewed consent for each use of the images was significantly more often expressed in the paediatric than the adult survey (44·5% vs. 24·5%, P = 0·001). More than 95% of respondents considered medical photography to be useful for improving diagnosis, monitoring of skin disease and aiding teaching. CONCLUSIONS: These findings could be used to improve practice, to increase the acceptability of medical photography and for devising a standardized consent form for medical practitioners performing medical photography.

[A rare side effect of mesotherapy: Nicolau syndrome]. / Un effet indésirable rare de la mésothérapie : la dermite de Nicolau.

BACKGROUND: Nicolau's livedoid dermatitis is associated with drug-induced embolism in the cutaneous arterial bed, generally as a result of accidental intra-arterial injection. Herein, we report a case that is somewhat surprising because of its late onset following mesotherapy injections. CASE REPORT: A 53-year-old man, with a history solely of tendinopathy for which he underwent mesotherapy sessions, consulted for livedoid lesions of the front of the knee with central necrosis. History-taking revealed a final course of mesotherapy three weeks earlier for patellar tendinitis below the left kneecap; intradermal injection of procaine and piroxicam had been unusually and intensely painful. The remainder of the clinical examination revealed additional livedoid lesions on the outside of the left ankle as well as purpuric lesions on the pads of the toes on the left foot. Laboratory tests revealed nothing of note. Skin biopsies of the livedoid circumference of the lesion showed arteriolar emboli of an amorphous material within the dermis obliterating the arteriolar lumen. The clinical appearance of skin lesions after mesotherapy led us to a diagnosis of Nicolau livedoid dermatitis. DISCUSSION: Nicolau dermatitis is a rare skin complication described as occurring mainly as a result of intramuscular injections. The reported case is special because it comprises Nicolau dermatitis arising out of a session of mesotherapy employing an intradermal injection. However, there are only very few cases in which subcutaneous injections have induced Nicolau dermatitis. The pathophysiology is not well known, but several mechanisms are involved: arterial ischaemia by vasospasm or thrombosis. In this case, the semiotic appearance of the lesions and histological analysis militate in favour of accidental injection of a skin product into an arteriole, resulting in obliteration of the latter. Mesotherapy can induce Nicolau dermatitis.

[Anti-p200 pemphigoid: Remission under mycophenolate mofetil (Cellcept®)]. / Pemphigoïde anti-p200: rémission sous mycophénolate mofétil (Cellcept®).

BACKGROUND: Anti-p200 pemphigoid is a recently described autoimmune subepidermal bullous dermatosis characterized by its target antigen and the associated anatomoclinical picture. The treatment is not as yet well defined. PATIENT AND METHODS: A 73-year-old man consulted for a pruritic bullous eruption with buccal involvement. Direct immunofluorescence revealed linear deposits of IgG and C3 at the dermal-epidermal junction. Elisa screening for circulating anti-BP180 and anti-BP230 antibodies was negative. A diagnosis of bullous pemphigoid was suspected. After an unfavourable clinical outcome under clobetasol and then prednisolone and methotrexate, other immunological tests were performed. Indirect immunofluorescence on NaCl-cleaved skin revealed a deposit of IgG4 antibodies on the dermal side. Immunoblotting showed antibodies directed against a 200-kDa antigen on a dermal extract. A diagnosis of anti-p200 pemphigoid was made. The patient was treated with dapsone combined with prednisolone. Seventy-two hours later, treatment was stopped due to hepatic cytolysis related to immunoallergic hepatitis. Treatment with mycophenolate mofetil was then initiated and resulted in complete remission, which persisted at seven months. DISCUSSION: The diagnosis of anti-p200 pemphigoid was made on the basis of a set of clinical and immunological factors. Anti-p200 pemphigoid differs from standard bullous pemphigoid in terms of more frequent cephalic, acral and mucous membrane involvement, as well as a greater degree of miliary scarring. There was no eosinophilia. Elisa screening for anti-BP180 and anti-BP230 antibodies was negative. Immunoblotting showed antibodies directed against a 200kDa protein on dermal extract. The treatment is not well defined, even if dapsone appears to be the most effective therapy. To our knowledge, our patient is the first to be successfully treated with mycophenolate mofetil. CONCLUSION: Treatment of anti-p200 pemphigoid is difficult. In our case, treatment by mycophenolate mofetil was effective and could offer an alternative to dapsone.

Primary cutaneous Ewing sarcoma: a systematic review focused on treatment and outcome.

BACKGROUND: Despite intensive treatment, the overall prognosis of Ewing sarcoma of the bone remains poor. Primary cutaneous Ewing sarcoma very rarely occurs and the prognosis has been reported to be better in some small series. All cases of Ewing sarcoma are currently treated in the same way, regardless of their location. OBJECTIVES: To determine whether Ewing sarcoma of the bone and primary cutaneous Ewing sarcoma are different in terms of epidemiology and prognosis. METHODS: A systematic review of the literature was carried out using the keywords 'cutaneous Ewing's sarcoma', 'primary Ewing's sarcoma of skin' and 'primary neuroectodermal tumour and skin' in the Medline database. Series of five or more cases were included. RESULTS: Six series met the inclusion criteria, making a total of 61 patients. Median age at diagnosis was 17 years and 33% were male. The median size of the tumour was 2·3 cm. The treatment consisted of surgery in all cases, adjuvant multiagent chemotherapy in 69% of cases, adjuvant chemoradiotherapy in 38% of cases and adjuvant radiotherapy without adjuvant chemotherapy in 3% of cases. Six patients developed metastases, four of whom died. The overall survival was 93% and the 10-year probability of survival was estimated at 91% (95% confidence interval 83-100). CONCLUSION: This systematic review demonstrated epidemiological and prognostic differences between Ewing sarcoma of the bone and primary cutaneous Ewing sarcoma. Primary cutaneous Ewing sarcoma has a female predominance, occurs at a later age, but, more importantly, has a better outcome. Multimodal therapy for Ewing sarcoma is associated with immediate and long-term morbidity and mortality. Although the size of our study does not allow a definitive conclusion about treatment modalities, we suggest that a less toxic approach compared with conventional treatment should be investigated in primary cutaneous Ewing sarcoma.

[Primitive cutaneous Ewing's sarcoma: a diagnostic and therapeutic dilemma]. / Sarcome d'Ewing cutané primitif : difficultés diagnostiques et thérapeutiques.

BACKGROUND: Ewing's sarcoma (or peripheral neuroectodermal tumour) is generally found in bone tissue, and a primary dermal site is extremely rare. We report a case of primary cutaneous Ewing's sarcoma in a 21-year-old woman. PATIENTS AND METHODS: A 21-year-old woman presented with a scapular lesion that had been slowly developing for one year. The 1-cm lesion was removed and histological examination showed proliferation of small round cells in the dermis. Immunostaining revealed cytoplasmic membrane expression of CD99 and a negative immunoprofile for other small round-cell tumors. Ewing's sarcoma fusion gene transcripts were detected using fluorescence in situ hybridization (FISH). A staging examination revealed no other abnormalities. It was decided to treat the lesion as for osseous Ewing's sarcoma with wide resection followed by systemic adjuvant chemotherapy. DISCUSSION: Cutaneous Ewing's sarcoma raises concerns about diagnosis and treatment. Owing to the non-specificity of its clinical presentation, histology and immunoprofile, diagnosis of superficial Ewing's sarcoma is difficult and numerous differential diagnoses must be considered. When dealing with a surface tumour, the diagnosis of cutaneous Ewing's sarcoma must be considered. CD99 immunostaining and molecular testing for evidence of EWSR1 rearrangement are useful investigations to confirm the diagnosis. Furthermore, modalities of treatment must be carefully discussed. Cutaneous Ewing's sarcoma is currently treated in the same way as osseous Ewing's sarcoma (wide surgical excision, adjuvant radiotherapy when surgical margins are unsatisfactory, systemic adjuvant chemotherapy, and, in some cases, bone marrow transplant). However, some studies show a more favourable prognosis for cutaneous Ewing's sarcoma than for osseous Ewing's sarcoma. We may thus ask whether such aggressive multimodal treatment is needed.

[Two cases of cutaneous erythema following spinal cord stimulation]. / Erythème cutané provoqué par une neurostimulation cordonale postérieure: deux observations.

INTRODUCTION: Cutaneous complications following implantation of an electric system have been reported mainly after the implantation of pacemakers, cardiac defibrillators and morphine pumps. However, cutaneous complications following implantation of spinal cord stimulators are rarely described in the literature. Here we report two cases of cutaneous eruption at the spinal cord stimulation site, one involving foreign-body reaction to silicone in the neurostimulator electrodes or connector block and the other comprising contact dermatitis to silicone. CASE REPORTS: Case 1: A 43-year-old woman had been implanted with a spinal cord stimulator. Four months after implantation, burning sensation and cutaneous inflammatory erythema were observed in the dorsolumbar region, with reduced efficiency of stimulation. Removal of the neurostimulator led to resolution of the cutaneous symptoms. Histopathological examination of the biopsy sample showed foreign-body granuloma formation. The same symptoms subsequently recurred on the surgical scar and histopathology showed granuloma formation in response to particles of silicone present in the connector. The cutaneous eruption subsided rapidly after excision. Case 2: In a 60-year-old man implanted with a spinal cord stimulator, pruriginous reticular erythema was rapidly observed on the skin just above the neurostimulator, with papules around the erythema. Histopathology of two cutaneous biopsies showed evidence of contact dermatitis. Skin-patch tests performed with components of the neurostimulator leads proved positive to two types of silicone after 72 hours. The eruption was successfully controlled using topical corticosteroid therapy. DISCUSSION: Reports of cutaneous eruptions after spinal cord stimulation are extremely rare. Here we report two different cutaneous reactions with two different pathophysiological mechanisms, both involving silicone. The first case is original because it is the first documented case of a foreign-body reaction involving granuloma formation in response to particles of silicone present in the components of a neurostimulator. The second case concerns contact dermatitis to silicone (present in the connector block and electrode sheaths).