Suntanning: differences in perceptions throughout history.

In ancient times, the sun was venerated as a source of life in some cultures. Scientifically, the relationship between vitamin D and sunlight and the deficiency of vitamin D in patients with rickets were ultimately discovered. In 1903, Niels Finsen was awarded the Nobel Prize in medicine or physiology for his "Finsen light therapy" for infectious diseases, especially lupus vulgaris. In the 1930s and 1940s, the medical profession promoted sunbathing as beneficial for children. From these bases, the popularity of suntanning emerged, promoted by the availability of more leisure time and, eventually, the development of sunlamps and commercial tanning salons. Although the precise role of ultraviolet light in the pathogenesis of melanoma is uncertain, a melanoma epidemic began to be noticed in the 1970s. During the past 15 years, campaigns have attempted to educate the public about the potential dangers of suntanning and exposure to ultraviolet light. Whether the melanoma epidemic can be reversed remains to be seen.

Reversibility of blue-gray cutaneous discoloration from amiodarone.

A 45-year-old man had severe blue-gray cutaneous discoloration during amiodarone therapy for atrial fibrillation. Therefore, this drug regimen was discontinued, and long-term anticoagulation and digoxin therapy were used. The patient was advised to avoid exposure of his skin to sunlight, and a bleaching agent was prescribed. After 18 months of follow-up, the blue-gray hyperpigmentation had diminished. Although photosensitivity reactions from amiodarone occur in more than 50% of patients, blue-gray cutaneous discoloration occurs in less than 10% of patients on prolonged therapy with amiodarone. The presence of high concentrations of iodine, detected by electron probe analysis, suggests that the cutaneous deposits are amiodarone itself or a metabolite. The slow rate of elimination of amiodarone and a high uptake by fat-associated tissues may explain the delayed disappearance of cutaneous photosensitivity and late resolution of the blue-gray discoloration. Our current case supports the reversibility of these adverse effects on long-term follow-up.

Cutaneous micrographic surgery: Mohs procedure.

Skin cancer is an increasingly serious public health issue that affects a high percentage of the population. Surgical resection is still standard treatment for skin cancer, but for difficult cases, cutaneous micrographic surgery, originally described by Mohs, is our preferred technique because of the routine methodic accuracy for evaluation of the surgical margin, the high rate of oncologic cure, and the tissue-sparing quality of the procedure. We report the Mayo Clinic experience with cutaneous micrographic surgery from July 29, 1986, through June 30, 1991, which consisted of 3,355 cases (principally basal cell and squamous cell carcinoma). Herein we discuss practical concerns about this procedure: duration of the technique, reconstruction, cure rates, tumors best treated by cutaneous micrographic surgery, and cost. In addition, we review the Mayo Clinic multidisciplinary management of difficult skin cancers.

Steroid-induced acanthosis nigricans in dermatomyositis.

Acanthosis nigricans of the groin, axillae, and neck developed in a patient on long-term steroid therapy for dermatomyositis after eight years. The dermatosis resolved spontaneously ten years after the steroid use had been discontinued. Review of three personal cases and the literature suggests that acanthosis nigricans may have a hormonal basis.

Toxic doses of vitamin A for pityriasis rubra pilaris.

Seven patients who were disabled by pityriasis rubra pilaris were given toxic doses of oral vitamin A (1 million IU/day in six of the seven patients) for five to 14 days. Within 72 hours, the patients began to exfoliate the hyperkeratotic and keratodermatous lesions. The desquamative process was completed between ten and 14 days. The skin remained erythematous for several months before assuming a normal color. The skin of six of the seven patients was virtually cleared by the treatment, and none suffered a relapse of the pityriasis rubra pilaris. Serial skin biopsy specimens showed evidence suggestive of an accelerated turnover rate of epidermal cells during treatment. Transient abnormalities of liver function test results were noted in two patients.

Cutaneous granulomas in malignant lymphoma.

Two patients are described in whom the clinical manifestation of massive, localized dermal and subcutaneous epithelioid granulomatous masses occasioned an extensive year-long search for infectious organisms. In both instances, the true diagnosis of Hodgkin's disease or lymphoma was ultimately made by means of lymph node biopsy.

White lesions of the mouth.

All white, hyperkeratotic lesions of the mouth should be studied by biopsy, unless an infection (thrush) or other obvious cause is recognized. The lesions should be classified as benign, dysplastic, or malignant, and the patient should be treated and followed appropriately.

Treatment of oral ulcers.

Oral ulcers may be the result of allergic, infectious, metabolic, nutritional, or malignant systemic disorders or a variety of other inflammatory diseases. These range from minor irritations to signs of life-threatening illnesses. Patients with oral ulcers should adhere to a variety of general measures that are recommended plus specific treatments for specific diagnoses.

Reducing the pain of local anesthesia.

The administration of local anesthetic agents before cutaneous surgery usually results in discomfort. This paper reviews techniques and pharmaceutical agents that will minimize pain during this preoperative procedure.

Pityriasis rubra pilaris and celiac sprue with malabsorption.

A case is reported herein of a young man with pityriasis rubra pilaris, a disease of unknown cause, and malabsorption due to celiac bowel disease. The patient responded to high-dose vitamin A therapy (500,000 IU orally per day for fourteen days). There was complete exfoliation of the palmar-plantar keratoderma and a decrease in the peeling and follicular keratosis. He was then placed on a regimen of a gluten-free diet and 100,000 IU vitamin A per day. After seven months he had persistent erythema but minimal hyperkeratosis. The ways in which cutaneous lesions and malabsorption could be related are discussed.

Use of colchicine in Behçet's syndrome.

Colchicine is of benefit in the treatment of ocular, articular, oral, and genital lesions in BS. Polymorphonuclear neutrophil function, which is important in the pathogenesis of the disease, is modified by the drug. There is no evidence that colchicine alters the tendency for this disease to become chronic; however, the drug lessens the severity of certain manifestations and does not have the more deleterious side effects of prolonged steroid and immunosuppressive regimens.

Giant basal cell carcinoma and cigarette smoking.

Several recent studies have linked cigarette smoking to an increased risk of squamous cell skin cancer, but previous studies have found no correlation between smoking and basal cell carcinoma. This article is a retrospective chart review of 200 patients who had Mohs' surgery for basal cell carcinoma at the Mayo Clinic in Rochester, Minnesota, between 1986 and 1990. In patients with tumors less than or equal to 1.0 cm, 30% were smokers. In patients with tumors 1.1 to 2.0 cm, 42% were smokers. In patients with tumors 2.1 to 4.9 cm, 56% were smokers; and in patients with tumors greater than or equal to 5.0 cm, 50% were smokers. Cigarette smoking is associated with an increased prevalence of basal cell carcinomas larger than 1.0 cm in diameter.

Natural history of squamous cell carcinoma of the skin: case report.

Squamous cell carcinoma is a malignant proliferation of the epidermal keratinocyte. With early recognition and treatment, most of these tumors have a favorable prognosis. If the lesions are left untreated, however, the results may prove fatal. We describe a case of long-standing neglect of cutaneous squamous cell carcinoma leading to widely metastatic disease in a 69-year-old man.

Further experience with toxic vitamin A therapy in pityriasis rubra pilaris.

A patient with short-duration pityriasis rubra pilaris was successfully treated with high-dose, toxic vitamin A (retinol), but the disease subsequently recurred in new areas. Serum levels of vitamin A were highest four hours after treatment and returned to the base level within twelve hours. Fasting blood levels of vitamin A during treatment increased to five times the pretreatment level. Ultrastructural changes in the keratinocytes were notable vacuolation, granularity of the cytoplasm, and a decrease in tonofilament masses, all indications of the cellular effect of the vitamin A. We believe that patients with long-duration pityriasis rubra pilaris should be considered for this treatment.

Basal cell carcinoma. Identification and treatment of the high-risk patient.

BACKGROUND: Some cutaneous basal cell carcinomas have a significant potential to recur, disfigure, and metastasize. OBJECTIVES AND METHODS: The identification and selection of treatment of these high risk carcinomas is based on a review of studies of recurrence, giant size, metastasis, and mortality. RESULTS: Basal cell carcinomas with any of the following: long duration, location in the mid face or ear, larger than 2 cm, with aggressive histologic subtype, previous treatment, neglected, or a history of radiation exposure, should be considered "high risk." CONCLUSION: For basal cell carcinomas with this high risk profile, complete excision by margin control or total destruction should be considered.

Treatment of generalized lichen nitidus with PUVA.

Generalized lichen nitidus refractory to topical and systemic corticosteroids completely responded to PUVA. The similarity of lichen nitidus to lichen planus and the presumed lymphocytotoxic effect of PUVA were the bases for our use of oral photochemotherapy.

Serial excision of a large facial skin cancer.

BACKGROUND: In the management of large facial neoplasms, the dermatologic surgeon must consider local factors affecting the success of closures. OBJECTIVE: Large facial neoplasms can be removed serially with Mohs micrographic surgery. Serial excision facilitates recruitment of adjacent normal skin for replacement of lesional skin, minimizing the risks of necrosis. METHODS: A large morpheaform basal cell carcinoma was excised serially. The initial defect was closed with an O to L advancement flap. The final excision and repair 2 months later consisted of a combination of primary closure with marsupialization and pursestring closure. A full-thickness skin graft was used to close the final defect. RESULTS: The patient had optimal cosmesis at 2-year follow-up. CONCLUSION: Large facial neoplasms can be excised serially. This technique, performed in the setting of Mohs micrographic surgery, takes advantage of "mechanical and biologic creep," resulting in excellent cosmesis and function.