A refined surgical treatment modality for bromhidrosis: double w incision approach with tumescent technique.

BACKGROUND: Axillary bromhidrosis has a strong negative effect on one's social life. A high success rate and few complications are criteria for an ideal treatment method. OBJECTIVE: To evaluate a new surgical treatment modality for bromhidrosis: Double W incision with full-exposure excision under tumescent anesthesia. MATERIALS & METHODS: Twenty patients with bromhidrosis were treated. Patients were placed in a supine position with their treated arms abducted to 110 degrees . After injection of 60 mL of tumescent solution into each axilla, two small W incisions were made at the superior and inferior axillary poles of the hair-bearing area. The whole hair-bearing skin was undermined at the level of the superficial fat to obtain adequate skin eversion. The flaps were everted to offer full exposure of the apocrine glands, and meticulous excision of each gland was performed. Finally, the incisions were re-approximated, and bulky compressive dressings were applied to the area for 72 hours. RESULTS: Of the 40 axillae (20 patients), 32 (80.0%) showed excellent results, and eight (20.0%) had good results. Malodor was significantly decreased. There were no serious complications. CONCLUSION: This technique can produce excellent results with a lower complication rate than most other surgical modalities and can be performed without costly equipment.

Epidermoid cyst mimicry: report of seven cases and review of the literature.

Cysts are entities encountered frequently in dermatological clinics. Various types of cysts have been described and include trichilemmal cysts, epidermoid cysts, steatocystomas, and the myriad of developmental cysts (branchial cleft cyst, thyroglossal duct cysts, bronchogenic cysts). Moreover, not all lesions that appear clinically as cystic structures are, in fact, cysts. Increased awareness of these mimickers and a systematic approach to the evaluation of these cases is essential. The authors report seven cases, over the course of six years, presenting to their dermatology department, all of which were originally clinically diagnosed as "cysts" and referred to the authors for management. In this article, the authors review seven cyst mimickers and describe important aspects of these diagnoses to increase awareness of the importance of a preoperative biopsy and evaluation. It is important to have a thorough understanding of the wide differential diagnosis of cutaneous nodules and to consider other causes of lesions that appear to be cysts, particularly in the anatomical locations described.

Immune protective effect of a moisturizer with DNA repair ingredients.

Ultraviolet (UV) light damages DNA and impairs immune surveillance. The faulty repair of DNA after UV exposure is associated with immune suppression and facilitates photodamage that leads to photoaged skin and the growth of skin cancer. Sunscreens have been developed to filter UV light from entering the skin, but are not beneficial once DNA damage has occurred. Enhancing DNA repair after UV radiation may provide added advantage and prevent UV immunosuppression. This study was performed to determine whether a product with DNA repair ingredients prevents UV-induced suppression of contact hypersensitivity responses in vivo. Solar simulated radiation was delivered on skin with and without topical treatment with a moisturizer containing DNA repair enzymes (Advanced Night Repair Concentrate). Subjects were then sensitized to the hapten dinitrochlorobenzene, and the level of resultant contact hypersensitivity response was elicited 2 weeks later. Contact hypersensitivity response measured by skin fold thickness was significantly suppressed in untreated UV-irradiated subjects but not in subjects treated with DNA repair moisturizer after solar simulated radiation. Our results indicate that DNA repair ingredients significantly prevent UV-induced immune suppression.

UV protective effects of DNA repair enzymes and RNA lotion.

Solar UV radiation is known to cause immune suppression, believed to be a critical factor in cutaneous carcinogenesis. Although the mechanism is not entirely understood, DNA damage is clearly involved. Sunscreens function by attenuating the UV radiation that reaches the epidermis. However, once DNA damage ensues, repair mechanisms become essential for prevention of malignant transformation. DNA repair enzymes have shown efficacy in reducing cutaneous neoplasms among xeroderma pigmentosum patients. In vitro studies suggest that RNA fragments increase the resistance of human keratinocytes to UVB damage and enhance DNA repair but in vivo data are lacking. This study aimed to determine the effect of topical formulations containing either DNA repair enzymes (Micrococcus luteus) or RNA fragments (UVC-irradiated rabbit globin mRNA) on UV-induced local contact hypersensitivity (CHS) suppression in humans as measured in vivo using the contact allergen dinitrochlorobenzene. Immunohistochemistry was also employed in skin biopsies to evaluate the level of thymine dimers after UV. Eighty volunteers completed the CHS portion. A single 0.75 minimum erythema dose (MED) simulated solar radiation exposure resulted in 64% CHS suppression in unprotected subjects compared with unirradiated sensitized controls. In contrast, UV-induced CHS suppression was reduced to 19% with DNA repair enzymes, and 7% with RNA fragments. Sun protection factor (SPF) testing revealed an SPF of 1 for both formulations, indicating that the observed immune protection cannot be attributed to sunscreen effects. Biopsies from an additional nine volunteers showed an 18% decrease in thymine dimers by both DNA repair enzymes and RNA fragments, relative to unprotected UV-irradiated skin. These results suggest that RNA fragments may be useful as a photoprotective agent with in vivo effects comparable to DNA repair enzymes.

Apoptosis mechanisms related to the increased sensitivity of Jurkat T-cells vs A431 epidermoid cells to photodynamic therapy with the phthalocyanine Pc 4.

To examine the clinical applicability of Pc 4, a promising second-generation photosensitizer, for the photodynamic treatment of lymphocyte-mediated skin diseases, we studied the A431 and Jurkat cell lines, commonly used as surrogates for human keratinocyte-derived carcinomas and lymphocytes, respectively. As revealed by ethyl acetate extraction and absorption spectrophotometry, uptake of Pc 4 into the two cell lines was linear with Pc 4 concentration and similar on a per cell basis but greater in Jurkat cells on a per mass basis. Flow cytometry showed that uptake was linear at low doses; variations in the dose-response for uptake measured by fluorescence supported differential aggregation of Pc 4 in the two cell types. As detected by confocal microscopy, Pc 4 localized to mitochondria and endoplasmic reticulum in both cell lines. Jurkat cells were much more sensitive to the lethal effects of phthalocyanine photodynamic therapy (Pc 4-PDT) than were A431 cells, as measured by a tetrazolium dye reduction assay, and more readily underwent morphological apoptosis. In a search for molecular factors to explain the greater photosensitivity of Jurkat cells, the fate of important Bcl-2 family members was monitored. Jurkat cells were more sensitive to the induction of immediate photodamage to Bcl-2, but the difference was insufficient to account fully for their greater sensitivity. The antiapoptotic protein Mcl-1 was extensively cleaved in a dose- and caspase-dependent manner in Jurkat, but not in A431, cells exposed to Pc 4-PDT. Thus, the greater killing by Pc 4-PDT in Jurkat compared with A431 cells correlated with greater Bcl-2 photodamage and more strongly to the more extensive Mcl-1 degradation. Pc 4-PDT may offer therapeutic advantages in targeting inflammatory cells over normal keratinocytes in the treatment of T-cell-mediated skin diseases, such as cutaneous lymphomas, dermatitis, lichenoid tissue reactions and psoriasis, and it will be instructive to evaluate the role of Bcl-2 family proteins, especially Mcl-1, in the therapeutic response.

Optimal treatments for hyperpigmentation.

The current treatment of hyperpigmentation relies on multiple modalities to achieve satisfactory cosmetic results. Patients are savvy consumers who often present to physicians asking about the latest treatments and breakthroughs. By combining topical bleaching agents, chemical peels, laser therapy, and adequate photo-protection, many pigmentary disorders can be successfully treated. A review of recent trials and new technologies will be discussed.

Folliculotropic mycosis fungoides with central nervous system involvement: demonstration of tumor clonality in intrafollicular T cells using laser capture microdissection.

BACKGROUND: Folliculotropic mycosis fungoides (MF) is a rare variant of cutaneous T-cell lymphoma, MF type, characterized by atypical lymphocytes preferentially infiltrating the hair-follicle epithelium relative to the epidermis. OBSERVATIONS: We describe a rare case of folliculotropic MF involving the central nervous system. This is also the first case in which laser capture microdissection was used to show that the atypical lymphocytes within the hair-follicle epithelium were part of the same tumor clone present in other tissue compartments. CONCLUSIONS: In reviewing the literature describing atypical lymphocytes infiltrating hair-follicle epithelium relative to the epidermis, we encourage the use of the term folliculotropic mycosis fungoides. Our case also supports previous findings that central nervous system involvement can occur in advanced MF. The successful procurement and analysis of atypical lymphocytes from hair-follicle epithelium by laser capture microscopy ushers in a new era in molecular diagnostics.

Quantifying skin disease burden in mycosis fungoides-type cutaneous T-cell lymphomas: the severity-weighted assessment tool (SWAT).

OBJECTIVE: To develop a quantitative tool to assess severity of mycosis fungoides. DESIGN: Prospective analysis of a cohort. SETTING: University department of dermatology-based cutaneous lymphoma clinic. PATIENTS: From 1984 to 1995, 1186 visits from 323 referred patients seen in a multidisciplinary cutaneous lymphoma program. MAIN OUTCOME MEASURES: Severity-weighted assessment tool (SWAT) scores were obtained for patients at each visit. This score represents the product of the percentage total body surface area (%TBSA) involvement of each lesion type (patch, plaque, and tumor or ulceration), multiplied by a weighting factor: SWAT = (patch %TBSA x 1) + (plaque %TBSA x 2) + (tumor or ulcer %TBSA x 3). In addition, the standard measurements of TBSA involvement and physician global assessments were recorded for comparison. RESULTS: The SWAT score correlated well with %TBSA (r = 0.95, P<.001), physician global assessment (r = 0.60, P<.001), and time to complete remission during psoralen-UV-A therapy (r = 0.80, P<.001), therefore indicating validity against standard measures. Analysis of individual and subsets of patients demonstrated that the SWAT score more accurately quantified changes in skin disease burden, including mixed responses to treatment, than did %TBSA alone. CONCLUSIONS: The SWAT score is a useful clinical measurement for mycosis fungoides. The SWAT score captures overall physician impressions of disease status on a continuous dimensionless numerical scale, therefore providing a defined, objective, and sensitive quantitative measure. This tool is suitable for individual patient assessment, clinical trials, and outcome comparisons.