Simple modification to the punch biopsy technique to minimize handling and crush artefact.

A number of techniques have been described to retrieve the tissue core after punch biopsy. We describe a simple modification to the punch-biopsy technique that minimizes instrumentation, handling and the subsequent risk of crush artefact. Our technique is simple, quick and economical and essentially involves rotation of the punch through 90 degrees then lateral extraction with a degree of upward traction, which usually leaves the tissue core deposited beside the skin defect. At this point it can be easily grasped with a square of gauze or detached if required using scissors or a scalpel blade.

Tumid lupus erythematosus occurring following highly active antiretroviral therapy for HIV infection: a manifestation of immune restoration.

Tumid lupus erythematosus (LE) is a relatively rare and only recently recognized subset of chronic cutaneous lupus. We report a case occurring in a male with HIV infection whereby his rash was only unmasked by immune restoration following highly active antiretroviral therapy (HAART). The phenomenon of latent inflammatory or autoimmune disease appearing following HAART is now recognized as the "immune restoration syndrome" and tumid LE has not been reported in this setting previously. Fortunately this variant of lupus does not result in scarring and is responsive to anti-malarials, allowing continuation of HAART in this patient.

Paraneoplastic immunobullous disease with an epidermolysis bullosa acquisita phenotype: two cases demonstrating remission with treatment of gynaecological malignancy.

Two cases of paraneoplastic immunobullous disease occurring in women with gynaecological malignancies are reported. Both cases demonstrated mechanobullous mucocutaneous blistering as is typically seen in epidermolysis bullosa acquisita. Their immunopathology, however, favoured a dermal-binding mucous membrane pemphigoid (MMP) (or possibly bullous pemphigoid) for patient 1 and laminin-5 MMP for patient 2. Both patients showed resolution of blistering within 1 year of treatment of their malignancies; uterine and ovarian carcinoma, respectively. These cases are of interest because of their paraneoplastic nature; as well as overlapping clinicoimmunopathological features. In addition, patient 2 is, as far as we are aware, the first report of ovarian-carcinoma-associated laminin-5 MMP.

Nodular melanoma. No longer as simple as ABC.

BACKGROUND: Malignant melanoma is the fourth most commonly diagnosed malignancy in Australia. Nodular melanoma (NM) comprise less than 15% of all melanoma but account for up to 70% of those thicker than 3 mm. OBJECTIVE: This article describes the clinical features of NM, its prognosis and management. DISCUSSION: Nodular melanoma presents very differently from superficial spreading melanoma, and does not meet the 'ABCD' criteria used to alert doctors and patients to the possibility of this diagnosis. Due to their rapidly developing depth of invasion, urgent referral and wide excision are advised.

Successful palliation and significant remission of cutaneous calcinosis in CREST syndrome with carbon dioxide laser.

BACKGROUND: There are few satisfactory medical or surgical therapies for cutaneous calcinosis in connective tissue disorders. OBJECTIVE: Carbon dioxide laser vaporization allows precise ablation of superficial dystrophic calcification. This treatment modality was considered because of the severity of our patient's symptoms and failure to respond to various medical therapies. METHODS: Over a 5-year period, six affected digits received a single treatment with carbon dioxide laser vaporization. RESULTS: Treated digits healed over a 6-week period and led to a significant remission in symptoms. The average remission time for affected digits to date is at least 3 years and has allowed our patient to remain in full-time employment. CONCLUSION: Carbon dioxide laser vaporization may offer effective remission of symptoms in cutaneous calcinosis of CREST syndrome (including cutaneous calcinosis, Raynaud's phenomenon, sclerodactyly, and telangiectasia).

Pachydermodactyly: a forme fruste of knuckle pads?

A 16-year-old boy presented with painless swellings localized to the radial and ulnar aspects of his second through to the fifth fingers on the left hand, with more subtle changes affecting two fingers on the opposite hand. This had developed in the absence of mechanical trauma. Investigations for an arthropathy were negative, while a biopsy showed marked epidermal hyperplasia and an expanded dermis. These features are typical of pachydermodactyly, a benign dermatosis of uncertain aetiology. The interesting feature of this case is the presence of knuckle pads in the father of the patient, which raises the possibility that these two similar entities are related.

Nodular melanoma: patients' perceptions of presenting features and implications for earlier detection.

BACKGROUND: The incidence of thick melanoma and related mortality is largely static despite advances in early detection during the last 20 years. Nodular melanoma (NM) accounts for the majority of thick lesions and is difficult to recognize in the early stages of its evolution. OBJECTIVE: The purpose of this study was to identify historic or clinical features that may facilitate earlier detection of NM. METHODS: A questionnaire was administered to 125 patients attending the Victorian Melanoma Service between 1998 and 2000 with superficial spreading melanoma or NM. Parameters were compared by tumor type and thickness. RESULTS: NMs are more often symmetric, elevated, uniform in color, and nonpigmented. Color change is uncommon. CONCLUSION: NM often fails to fulfill the ABCD diagnostic criteria. Biopsy after a set period of observation should aid differentiation from inflammatory lesions and enable earlier detection of this subtype.

Photodynamic therapy: is it a valuable treatment option for actinic keratoses?

Photodynamic therapy (PDT) is proposed as an effective therapy with a good safety profile for patients with actinic keratoses. PDT involves the application of a photosensitizer to dysplastic or neoplastic tissue such that when exposed to light of an appropriate wavelength, the target tissue undergoes a cytotoxic reaction. Studies to date have demonstrated that PDT for the treatment of patients with actinic keratoses achieves clearance of lesions with minimal morbidity, maintenance of functional integrity of underlying tissues, and excellent cosmetic results. We present a review of the treatment of patients with actinic keratoses and the role of PDT in this context.

Methods of evaluating hair growth.

For decades, scientists and clinicians have examined methods of measuring scalp hair growth. With the development of drugs that stem or even reverse the miniaturization of androgenetic alopecia, there has been a greater need for reliable, economical and minimally invasive means of measuring hair growth and, specifically, response to therapy. We review the various methods of measurement described to date, their limitations and value to the clinician. In our opinion, the potential of computer-assisted technology in this field is yet to be maximized and the currently available tools are less than ideal. The most valuable means of measurement at the present time are global photography and phototrichogram-based techniques (with digital image analysis) such as the 'TrichoScan'. Subjective scoring systems are also of value in the overall assessment of response to therapy and these are under-utilized and merit further refinement.

Nodular type and older age as the most significant associations of thick melanoma in Victoria, Australia.

OBJECTIVES: To explore the clinical associations of thick melanoma and to compare the clinicopathological variables of nodular and superficial spreading types. DESIGN: Cross-sectional study of all invasive primary melanomas recorded by the Victorian Cancer Registry for 1998 and those reviewed by the Victorian Melanoma Service between October 1, 1994, and April 31, 1999. SETTING: Population-based cancer registry and public hospital-based multidisciplinary melanoma clinic. PATIENTS: This study included 1422 patients recorded by the Victorian Cancer Registry and 674 patients who had attended the Victorian Melanoma Service; unclassifiable tumor types were excluded, leaving 1144 and 645 patients, respectively, eligible for analysis. MAIN OUTCOME MEASURES: Melanomas were categorized by thickness into thin (< or =1 mm), intermediate (>1-3 mm), and thick (>3 mm) and compared according to patient age, sex, and tumor type and site. Superficial spreading and nodular types were also compared in this manner. Use of the Victorian Melanoma Service database enabled a more comprehensive analysis of historical and phenotypic characteristics. RESULTS: Thick melanoma was predominantly nodular, occurring in older men, mostly on the head and neck and associated with fewer nevi. Nodular melanoma was thicker and found mostly on the lower limbs or head and neck; it had a greater association with a history of solar keratoses than did superficial spreading melanoma. CONCLUSION: Nodular type and older age are the most significant associations of thick melanoma.