Radiodermatitis prevention with sucralfate in breast cancer: fundamental and clinical studies.

BACKGROUND: Acute radiodermatitis induced by radiotherapy may affect the quality of life and in some cases requires withholding treatment. The present study concerns the protective effect of a 1% sucralfate lotion. We propose joint fundamental and clinical points of view. METHODS: The free radical scavenging capacity of sucralfate was measured with electron spin resonance and was supported by theoretical calculations. The clinical effects of sucralfate lotion were evaluated on 21 women treated for breast cancer. Breast skin response was evaluated at 0, 10, 20, 30, 40, and 50 Gy, according to (1) the radiation therapy oncology group (RTOG) acute toxicity scale and (2) spectrophotometry data obtained with X-Rite SP60. RESULTS AND CONCLUSIONS: Sucralfate appeared as a relatively poor free radical scavenger (compared to reference compounds such as vitamin E). The sucralfate-containing lotion used in the present study did not provide systematic radiodermatitis prevention. Spectrophotometric evaluation of the skin response to irradiation appeared to be a very effective and more sensitive technique than the RTOG scale. Its use should be recommended to study cutaneous radioprotective action.

A three-year-analysis of fixed drug eruptions in hospital settings in France.

Fixed drug eruption (FDE) is one of the most typical cutaneous drug adverse reactions. This localized drug-induced reaction is characterized by its relapse at the same sites. Few large series of FDE are reported. The aim of this study was to retrospectively collect and analyse well informed cases observed in a hospital setting. This study involved 17 academic clinical centers. A French nation-wide retrospective multicentric study was carried out on a 3-year-period from 2005 to 2007 by collecting data in seventeen departments of dermatology in France. Diagnosis of FDE was based essentially on clinical findings, at times confirmed by pathological data and patch-testing. Records were reviewed for demographics, causative drugs, localization, severity, and patch-tests, when available. Fifty nine cases were analysed. Patients were 59-years-old on average, with a female predilection. The most common drug was paracetamol, followed by the non-steroidal anti inflammatory drugs. The time between drug intake and skin symptoms was, on average, two days. Beside these classical characteristics, some original findings were found including, a frequent non pigmentation course and a sex-dependent pattern of distribution. Women often had lesions on the hands and feet, and men on the genitalia. Given the fact that skin pigmentation is an inconstant feature of FDE, its French name (erythème pigmenté fixe) should be reconsidered. The sex-dependent distribution could help our understanding of the pathophysiology of fixed drug eruption.

The contribution of large genomic deletions at the CDKN2A locus to the burden of familial melanoma.

Mutations in two genes encoding cell cycle regulatory proteins have been shown to cause familial cutaneous malignant melanoma (CMM). About 20% of melanoma-prone families bear a point mutation in the CDKN2A locus at 9p21, which encodes two unrelated proteins, p16(INK4a) and p14(ARF). Rare mutations in CDK4 have also been linked to the disease. Although the CDKN2A gene has been shown to be the major melanoma predisposing gene, there remains a significant proportion of melanoma kindreds linked to 9p21 in which germline mutations of CDKN2A have not been identified through direct exon sequencing. The purpose of this study was to assess the contribution of large rearrangements in CDKN2A to the disease in melanoma-prone families using multiplex ligation-dependent probe amplification. We examined 214 patients from independent pedigrees with at least two CMM cases. All had been tested for CDKN2A and CDK4 point mutation, and 47 were found positive. Among the remaining 167 negative patients, one carried a novel genomic deletion of CDKN2A exon 2. Overall, genomic deletions represented 2.1% of total mutations in this series (1 of 48), confirming that they explain a very small proportion of CMM susceptibility. In addition, we excluded a new gene on 9p21, KLHL9, as being a major CMM gene.

Predictive clinical features of eczema craquelé associated with internal malignancy.

OBJECTIVE: To describe a series of hospitalized patients with eczema craquelé (EC) and the possible correlations between clinical features of EC and cancer in an open prospective observational study. PATIENTS AND INTERVENTIONS: The study population comprised 68 consecutive patients included between January 1, 1999 and December 31, 2000 who were followed up through December 2004. All patients who had localized or generalized EC were included. Patients underwent complete clinical examinations, routine laboratory tests, chest x-rays, abdominal ultrasound, and cutaneous biopsies performed on EC. MAIN OUTCOME MEASURES AND RESULTS: Rates of EC associated with cancer, clinical features of eczema, rate of recalcitrant eczema, relationship to other clinical prognostic factors, and paraneoplastic evolution were evaluated. Cancer was diagnosed in 32 patients (47%). We observed a significant difference in the presenting clinical signs of EC between patients with malignant tumors and patients without cancer. In patients with malignancies, EC was widespread on the trunk and we noted deep red and inflammatory fissures. In all cases, EC led to the discovery of malignancy or recurrence of cancer. CONCLUSION: Widespread EC, topical corticosteroid resistance, and deep red and inflammatory fissures were significantly correlated with neoplasia.

Treatment of cutaneous calcinosis in CREST syndrome by extracorporeal shock wave lithotripsy.

We describe the unusual case of a 78-year-old woman consulting for extensive and painful wound leg ulcerations and calcifications secondary to CREST syndrome that was treated by extracorporeal shock wave lithotripsy. This treatment was considered because of the severity of our patient's symptoms and her failure to respond to various medical and surgical treatment.

Leg ulcerations: a clinical appraisal.

Leg ulcerations are frequent and often require dermatological advice. Many typical ulcerations may be recognized quite easily by inspection. Through a series of clinical examples, clinical diseases that may have ulceration of the leg as an initial presentation are illustrated. The figures of the article may be looked at first, without reading the legend, so the reader may suggest diagnostic hypotheses before discovering the true diagnosis.

Treatment of refractory pemphigus vulgaris with rituximab (anti-CD20 monoclonal antibody).

BACKGROUND: Pemphigus vulgaris (PV) is a severe antibody-mediated autoimmune blistering disease. Because some patients with PV do not enter into remission, despite the use of high-dose corticosteroid therapy and immunosuppressive adjuvant treatments, new effective and safer agents are warranted to treat refractory PV. Rituximab, a monoclonal anti-CD20 antibody, induces depletion of B cells in vivo and has shown efficacy in patients with refractory antibody-mediated autoimmune disorders. We describe herein 3 patients treated with rituximab for severe PV. OBSERVATIONS: Three patients with refractory PV were treated with rituximab, resulting in a clinical response in all patients, which was complete in 2 patients. A decline in titers of circulating antiepidermis autoantibodies paralleled disease activity, while circulating B cells remained undetectable for 6 to 10 months. Two patients experienced bacterial infection in the weeks following the rituximab course. A clinical relapse occurred in 2 patients, at 6 and 10 months. A second course of rituximab controlled the disease in one of them. CONCLUSION: These patients' response suggests that rituximab may be a valuable treatment for refractory PV and warrants further studies to evaluate the risk-benefit ratio in patients with PV showing resistance to classic therapy.

Routine vs extensive malignancy search for adult dermatomyositis and polymyositis: a study of 40 patients.

OBJECTIVE: To identify potential risk factors and the yield of routine screens for early detection of malignancy associated with dermatomyositis (DM) and polymyositis (PM). DESIGN: Retrospective study of malignancies in all patients with DM or PM followed up between the years 1981 and 2000 and a review of the relationship of DM and PM to malignancy, the usefulness of various tests or examinations for malignancy search, and the patients' course. SETTING: Departments of internal medicine and dermatology in a teaching hospital. PATIENTS: Forty consecutive adult patients with DM (33 cases) or PM (7 cases). MAIN OUTCOME MEASURES: (1) Rate of false-negative results of routine workup and yield (percentage of positive results) of blind malignancy search and (2) comparison of 16 characteristics in patients with malignancy vs those without. RESULTS: Malignancy occurred in 16 patients: 13 with DM and 3 with PM. In all cases, the diagnosis of malignancy was made concurrently with or shortly after the diagnosis of DM or PM. Factors associated with malignancy were recruitment in the internal medicine department (P =.02), constitutional symptoms (P<.01), a rapid onset of DM or PM (P =.02), the lack of Raynaud phenomenon (P<.01), and a higher mean erythrocyte sedimentation rate (P<.01) and creatine kinase level (P<.01). Initial routine search failed to discover 4 malignancies, 3 of which were discovered at an advanced stage by more extensive investigations. The positive result yield of blind malignancy search was only 13% (11 of 87), but reached 28% (5 of 18) for blind abdominal-pelvic and thoracic computed tomographic scans. CONCLUSION: Extensive search for malignancy, particularly computed tomographic scans, may be warranted in at least a subset of patients with DM or PM and risk factors of malignancy.

Erysipelas: recognition and management.

Erysipelas is an acute bacterial infection of the dermis and hypodermis that is associated with clinical inflammation. It is a specific clinical type of cellulitis and, as such, it should be studied as a specific entity. Erysipelas is generally caused by group A streptococci; it is highly probable that streptococcal toxins also play a role, which could, in part, help explain the clinical inflammation. Erysipelas of the leg is the main clinical type encountered. The face, arm, and upper thigh are the other most common sites for the occurrence of erysipelas. After a sudden onset, areas of erythema and edema characteristically enlarge with well-defined margins. Athlete's foot is the most common portal of entry for the disease. Erysipelas is generally associated with high fever, and adenopathy and lymphangitis are sometimes present. At the time of diagnosis, it is important to look for clinical markers of severity (local signs and symptoms, general signs and symptoms, co-morbidity, social context) which would necessitate hospitalization. There are many differential diagnoses, particularly in the case of atypical dermo-hypodermitis. Some bacterial infections may have specific clinical aspects or may lead to a diagnosis of cellulitis. Necrotizing cellulitis or fasciitis are life-threatening diseases and a rapid diagnosis is important. Other noninfectious types of cellulitis have been reported in many diseases, both localized or generalized. The biology of typical erysipelas is of little value in diagnosis and a laboratory workup is usually not required. There are few local complications associated with erysipelas; abscess can occur in some patients and septicemia is rare. Recurrence is the more distressing complication. Treatment of patients with erysipelas has been evaluated in a small number of studies. In most of them, erysipelas has been included in therapeutic studies of 'severe cutaneous infections'. This is not justified as in fact erysipelas is usually sensitive to penicillin G. Amoxicillin and macrolides are also effective. However, comparative, cost-analysis studies need to be performed to determine the best therapeutic option. Bed rest with the leg elevated is also important. Anticoagulants are indicated in patients at risk of venous thromboembolism. The portal of entry will also require treatment. Long-term antibacterial therapy is required for patients with recurrence.

[Onychomatricoma, a rare lesion of the nail]. / L'onychomatricome, une lésion rare de l'ongle.

Onychomatricoma is a rare fibroepithelial lesion of the nail matrix with peculiar clinical and histological features. Clinically, it is characterized by a longitudinal band of yellow thickening of the nail plate with transverse overcurvature and splinter hemorrhages. Nail avulsion exposes a villous tumor of the matrix with filamentous digitations extending into multiple holes of the nail plate. Histologically, a thick keratogenous zone forms a thickened nail plate. The lesion in its proximal portion is characterized by deep epithelial invaginations and by a stroma organized in two layers. The distal zone corresponds to multiple fibroepithelial projections extending into the nail plate. The diagnosis can be difficult in the presence of misleading clinical features or when the specimen is incomplete or examined with an improper orientation. Surgical resection is the recommended treatment.

Photodynamic treatment induces cell death by apoptosis or autophagy depending on the melanin content in two B16 melanoma cell lines.

Photodynamic therapy (PDT) is now a well-established treatment modality for cutaneous carcinomas and is based on the administration of a light-activated drug followed by illumination of the pathological area. The treatment of metastatic melanoma remains a therapeutic challenge. To define the possible role of melanin in relative phototoxicity of 5-aminolevulinic acid (5-ALA), a photosensitizer used in PDT in vivo, we studied cell death in two variants (with or without melanin, B16F10 and B16G4F cells, respectively) of a melanoma cell line. Concentrations of 5-Ala up to 10 mM induced similar cytostatic effects in the B16G4F and B16F10 cells. PDT and high 5-ALA concentrations induced photocytotoxicity in both melanoma cell lines (at 10 mM for B16F10 cells and at 5 mM for B16G4F cells). Cell death corresponded to p53-dependent apoptotic signaling in pigmented B16F10 cells, whereas an autophagic response leading to a caspase-independent death was detected in non-pigmented B16G4F cells. Therefore, the PDT-induced cell death pathway appeared to correlate with melanin synthesis capacity in melanoma cells. To reduce the cytotoxicity of 5-ALA without irradiation, a low drug concentration could be used. Consequently, in combination with current therapeutics, a moderate concentration of 5-ALA and PDT may constitute a supplementary promising approach to eliminate metastatic melanoma.

Photodynamic therapy can improve warts' discomfort in renal transplant patients prospective multicenter study.

Many studies have been conducted showing that aminolevulinic acid (ALA)-photodynamic therapy (PDT) can be an alternative treatment for recalcitrant warts. Recently, we performed a study evaluating methyl-aminolevulinic acid (MAL)-PDT for the treatment of hand warts in a population of renal transplant patients. Two symmetrical targets were selected on each hand and randomly assigned to chemical keratolytic treatment followed by three cycles of ALA-PDT (75 J cm(-2) red light). Patients were evaluated after 3 months and a second run of PDT was performed if the total area and number of warts decreased less than 50%, with evaluation every 3 months for 1 year. Twenty patients were included and 16 were evaluable (9 M, 7 F). After 6 months the reduction of warts' area was 48.4% on the treated side versus 18.4% in the control area (P = 0.021). The decrease in the total number of warts was 41%versus 19.4% (P = NS). The global tolerance of the treatment was good with acceptable pain during irradiation. These results suggest that ALA-PDT is a safe and efficient treatment for transplanted patient warts. The improvement between treated and control zone is 20% due to the decrease in untreated warts' area and number.

Serum neurotrophin profile in systemic sclerosis.

BACKGROUND: Neurotrophins (NTs) are able to activate lymphocytes and fibroblasts; they can modulate angiogenesis and sympathic vascular function. Thus, they can be implicated in the three pathogenic processes of systemic sclerosis (SSc). The aims of this study are to determine blood levels of Nerve Growth Factor (NGF), Brain-Derived Neurotrophic Factor (BDNF) and Neurotrophin-3 (NT-3) in SSc and to correlate them with clinical and biological data. METHODS: Serum samples were obtained from 55 SSc patients and 32 control subjects to measure NTs levels by ELISA and to determine their relationships with SSc profiles. FINDINGS: Serum NGF levels were higher in SSc patients (288.26 ± 170.34 pg/mL) than in control subjects (170.34 ± 50.8 pg/mL, p<0.001) and correlated with gammaglobulins levels and the presence of both anti-cardiolipin and anti-Scl-70 antibodies (p<0.05). In contrast, BDNF levels were lower in SSc patients than in controls (1121.9 ± 158.1 vs 1372.9 ± 190.9 pg/mL, p<0.0001), especially in pulmonary arterial hypertension and diffuse SSc as compared to limited forms (all p<0.05). NT-3 levels were similar in SSc and in the control group (2657.2 ± 2296 vs 2959.3 ± 2555 pg/mL, NS). BDNF levels correlated negatively with increased NGF levels in the SSc group (and not in controls). CONCLUSION: Low BDNF serum levels were not previously documented in SSc, particularly in the diffuse SSc subset and in patients with pulmonary hypertension or anti-Scl-70 antibodies. The negative correlation between NGF and BDNF levels observed in SSc and not in healthy controls could be implicated in sympathic vascular dysfunction in SSc.

Blue light is phototoxic for B16F10 murine melanoma and bovine endothelial cell lines by direct cytocidal effect.

UNLABELLED: The large number of studies devoted to the effect of ultraviolet light on biological systems, contrasts with the lack of experimental data concerning the direct effects of visible light. It has been shown that blue light inhibited the growth of B16F10 melanoma cell lines and reduced the percentage of S phase cells. Yet these effects are poorly understood. MATERIALS AND METHODS: Two cell lines and irradiation with blue light were used. Cell mortality and a possible mechanism of action were investigated. RESULTS: Exposure of B16F10 melanoma and bovine endothelial cells to blue light (wavelength 450 nm, 10 J/cm(2) from a Waldman lamp) induced a rapid and large reduction in viability followed by the death of virtually all the irradiated cells within 24 h. These results led us to expose a patient with haemorrhagic cutaneous melanoma metastasis to blue light. Irradiation led to an immediate arrest of haemorrhage, an inhibition of tumour growth and extensive tumour necrosis 24h after irradiation. CONCLUSION: Exposure to blue light may offer new approaches to the treatment of superficial skin carcinomas in humans.

Generalized eczema craquele as a presenting feature of systemic lymphoma: report of seven cases.

Eczema craquele, or asteatotic eczema, has been associated with malignant lymphoma although this is rare. Since 1986, we have observed seven patients, six men and one woman, mean age 71.5 years (range 43-86 years), with systemic lymphoma and concurrent eczema craquele. Five patients had T-cell lymphoma, one had a B-cell lymphoma and one had Hodgkin's disease. All patients shared several characteristics: (1) a synchronous onset of eczema craquele and lymphoma, (2) generalized eczema, (3) absence of alternative disease or conditions that could favour the onset of eczema craquele, and (4) eczema refractory to topical corticosteroids and emollients, but which resolved upon lymphoma remission and invariably recurred with the lymphoma relapse. All the patients except one died within 1 year, most with active lymphoma. The finding of recalcitrant generalized eczema craquele should prompt a search for lymphoma, particularly in older men. Lymphoma-associated eczema craquele has most characteristics of paraneoplastic syndromes and may be a hallmark of aggressive lymphoma.