The keystone flap and its simplified version for malignant skin tumor defects of the lower limbs: A review of 25 cases.

BACKGROUND: Skin tumors commonly occur on the legs and are treated in first line by surgery. Several techniques are available to repair lower limb defects: secondary-intention healing, partial closure, primary closure with or without an s-plasty, or a skin graft. The lack of tissue laxity of the surrounding skin does not allow several local flaps (advancement, rotation, or transposition). Closing large skin defects at this site may be challenging. PATIENTS AND METHODS: We retrospectively reviewed a series of consecutive patients undergoing malignant tumor wide excision on lower limbs, with a keystone flap or its simplified technique (releasing incision) for closure of a skin defect. RESULTS: Twenty-five patients, 17 women and 8 men, ranging from 19 to 95 years old (mean age: 70 years) were included. Keystone flap reconstruction on the lower limbs was performed in 19 cases and the simplified technique in 6. The excised tumors were as follows: squamous cell carcinoma (n=6), basal cell carcinoma (n=9), melanoma (n=9) and Bowen's disease (n=1). Three local complications were observed. No cases of recurrence were observed. CONCLUSION: Keystone flap is a reliable surgical method for reconstruction of lower limb skin defects. Aesthetic results are better than when a skin graft is used, complications are uncommon, and prolonged operative time is avoided.

[Haemorrhagic complications following ibrutinib intake after dermatological surgery]. / Complication hémorragique secondaire à la prise d'ibrutinib après chirurgie dermatologique.

INTRODUCTION: Ibrutinib is a selective oral inhibitor of Bruton's tyrosine kinase. It is used in haematology to treat lymphoid B disorders. Haemorrhagic complications in dermatological surgery are occasionally associated with the use of anti-platelet and/or anticoagulant medication. Herein, we report a case of haemorrhage under ibrutinib following skin surgery. PATIENTS AND METHODS: A 70-year-old male patient began treatment with ibrutinib for chronic lymphocytic leukaemia had 2 basal cell carcinomas of the face. The next day he had a persistent haemorrhage lasting more than 48h, with no effects on the final scarring result. DISCUSSION: Ibrutinib is a tyrosine kinase inhibitor whose mechanism of action plays a role in platelet adhesion. It is known to cause haemorrhaging, either spontaneously or following invasive procedures, especially at the beginning of treatment. In the case of low-risk haemorrhagic procedures in which bleeding may be controlled by mechanical haemostasis, ibrutinib should be discontinued 3 days before and after surgery. In the event of recent initiation of ibrutinib and in the absence of urgent dermatological management, it is preferable to schedule any surgical procedures 3 months after the start of ibrutinib.

[Introduction to tissue movements - Principles of flaps]. / Introduction aux mouvements tissulaires ­ Principes des lambeaux.

The practice of surgical dermatology allows the dermatologist to take overall management of patients, particularly in the domain of skin cancer. It is the dermatologist who makes a diagnosis based on his expertise and his understanding, determines the tumour edges and the surgical margins to be applied, carries out the excision and repair procedures, and performs monitoring. Such comprehensive management requires knowledge of fundamental principles that allow for repair procedures suited to specific sites. Normally, simple repair involving direct suture can be performed using the intrinsic elasticity and plasticity of skin. However, depending on the site and the extent of substance loss, it may be necessary to perform a more complex repair by recruiting adjoining skin to create a flap. Skin flaps follow certain shared general rules. Their primary purpose is to fill in for surgically removed tissue that cannot be corrected by suturing by simply moving them from their current anatomical placement, creating a second and different shaped tissue loss at a point where simple wound closure may be effected thanks to looseness of the skin. In this article, we lay the groundwork for reflection on the practice of autoplasty, we set out the rules required to ensure optimal results, and we explain the various types of flaps using a classification based on tissue mobilization including advancement, rotation and transposition flaps.

[Vemurafenib-induced radiation recall dermatitis]. / Dermite de rappel induite par le vémurafénib.

INTRODUCTION: Radiation recall dermatitis is an uncommon inflammatory reaction of the skin appearing after several days to several years at the site of previous irradiation; it is precipitated by the use of triggering drugs, although rarely by BRAF or MEK inhibitors. PATIENTS AND METHODS: We report an unusual case of recall dermatitis induced 3 months after initiation of vemurafenib and cobimetinib therapy. DISCUSSION: Radiation recall dermatitis is a cutaneous reaction that must be known and which in rare cases such as ours may occur a long time after the end of radiotherapy.

[Superficial temporal artery pseudoaneurysm: 2 cases]. / Pseudo-anévrisme de l'artère temporale superficielle : deux cas.

BACKGROUND: Pseudoaneurysm of the superficial temporal artery causes tumefaction in the temporal region. Herein, we report two cases. PATIENTS AND METHODS: Case 1 : a 32-year-old man presented with a slightly pulsatile nodular formation measuring 2 cm in the right temporal region that had appeared nine months after traumatic injury. A diagnosis of superficial temporal artery pseudoaneurysm was considered. Excision was performed with ligation of the afferent and efferent artery. The clinical diagnosis was confirmed by histopathology. Case 2 : a 24-year-old man presented with a nonpulsatile subcutaneous tumefaction on his left temple. Surgery was proposed based on a supposed epidermal cyst. However, the perioperative aspect suggested a lesion of arterial origin and excision was performed following ligation of the afferent and efferent artery. CONCLUSION: Pseudoaneurysm of the superficial temporal artery must be considered for all temporal cutaneous formations, particularly when there is a history of trauma. The clinical diagnosis may be confirmed by Doppler ultrasound. Surgery is the treatment of reference.

[Advancement cheek flap for nasal sidewall defects]. / Lambeau d'avancement-rotation jugal pour pertes de substance latéronasale et paranasale moyenne.

BACKGROUND: The nasal sidewall and adjacent cheek are frequent sites of cutaneous tumour. The aim of this study is to present an advancement-rotation cheek flap technique for nasal sidewall and paranasal cheek defects. PATIENTS AND METHODS: This is a retrospective, non-comparative study of patients undergoing a cheek advancement-rotation flap for nasal sidewall and paranasal cheek defects between September 2008 and October 2012. Sex, age, histological type of the excised lesion, method of anaesthesia, size of the defects, any occurrence of complications and results were compiled from the medical record. RESULTS: Eleven patients with a mean age of 66 years were included. For 10 patients, the tumour was a basal cell carcinoma and in one case was a squamous cell carcinoma. The defects were located in the nasal sidewall and paranasal cheek in four cases, the paranasal cheek/lower eyelid in five cases and in the nasal sidewall, anterior cheek and lower eyelid in two cases. All but one had surgery under a local anaesthetic. No patients presented post-surgical complications. One patient had a subcutaneous granuloma which subsequently subsided completely. The aesthetic result was good: two of the 11 patients had a marked nasolabial fold, one patient had a mild cutaneous deformity due to flap movement under eyelid. No recurrence of carcinoma was observed during follow-up of between 14 and 40 months. CONCLUSION: This flap should be considered for defects measuring under 3 cm on all or part of the nasal sidewall, paranasal cheek and lower eyelid fold.

[Vemurafenib-induced toxic epidermal necrolysis]. / Nécrolyse épidermique toxique au vemurafenib.

BACKGROUND: Herein we report the first case of toxic epidermal necrolysis (TEN) occurring with use of vemurafenib. PATIENTS AND METHODS: A 75-year-old female patient was being treated with vemurafenib for stage IV melanoma with BRAF V600E mutation. She suddenly presented fever, diffuse pruriginous maculopapular erythema, palpebral edema, palmar bulla, conjunctivitis, cheilitis and mucosal ulceration. The condition progressed towards detachment affecting 50% of the skin area. Cutaneous biopsy revealed lichenoid dermatosis, chiefly vesicular with numerous eosinophils. Direct immunofluorescence (IFD) was negative. Vemurafenib was the only drug to which the reaction was ascribable and we concluded on vemurafenib-induced TEN. DISCUSSION: To our knowledge, this is the first reported case of vemurafenib-induced TEN, but this adverse effect, although already described in the BRIM-3 study, appears rare in clinical practice. Other severe skin reactions have been described in the literature. These include a case of Stevens-Johnson syndrome in a female patient treated with vemurafenib and previously receiving ipilimumab. A more common occurrence is cutaneous reactions involving efflorescence of benign hyperkeratotic lesions, occasionally accompanied by authentic epidermal carcinoma or keratoacanthoma, and requiring regular dermatological monitoring of patients treated with vemurafenib. CONCLUSION: If maculopapular exanthema occurs under vemurafenib, continuation of this treatment should be reassessed since the risk of progression to a more serious condition such as TEN, as seen in the present case, cannot be ruled out.

[Blastic plasmacytoid dendritic cell neoplasm revealed by ecchymotic lesions on the face]. / Tumeur à cellules plasmocytoïdes dendritiques blastiques révélée par des lésions ecchymotiques du visage.

BACKGROUND: Cutaneous CD4+CD56+ malignant tumor proliferation was previously called "CD4/CD56 hematodermic neoplasm". However, the most recent studies have shown that the disease develops from plasmacytoid dendritic cells and the tumor has been renamed "Blastic Plasmacytoid Dendritic Cell Neoplasm" (BPDCN). It is an aggressive disease with a poor prognosis and behaves like acute leukemia in the short to moderate term. PATIENTS AND METHODS: A 65-year-old man with no particular history consulted for a left laterocervical lesion of ecchymotic aspect that had appeared one year earlier. Topical corticosteroid therapy had been unsuccessful. Examination of biopsies with lymphocyte typing enabled a diagnosis of BPDCN to be made. At the histopathological level, biopsy showed an infiltrate comprising medium to large cells. Immunohistochemical examination was remarkable for the absence of expression of markers of T- and B-cell lines. However, these tumor cells expressed CD4, CD56 and TCL1. Staging of the disease was normal. Treatment with chemotherapy was initiated in collaboration with a team of hematologists. Autologous bone marrow transplant was then performed. DISCUSSION: BPDCN is a rare malignant blood dyscrasia. It is distinguished by inaugural skin involvement, with systemic manifestations occurring much later. Histopathological examination of a skin biopsy with immunostaining establishes the diagnosis. In terms of phenotype, the tumor population is highly characteristic. The cells are negative for antigens of T- and B- cell lines. However, these cells express CD4, CD56 and TCL1, which are markers of plasmacytoid dendritic cells. The disease carries a poor prognosis and evolves in the short to middle term in the same way as acute leukemia. First-line treatment consists of the chemotherapy regimens used in aggressive lymphoma or acute leukemia. A bone marrow graft is sometimes performed at the time of initial relapse. Average survival is 12 months for chemotherapy alone and 30 months for transplant after first relapse. Early bone marrow transplantation has been shown to improve survival.

[Efficacy of acitretin in IgA pemphigus]. / Pemphigus à IgA: efficacité de l'acitrétine.

BACKGROUND: IgA pemphigus is a particular entity among autoimmune blistering intraepidermal diseases. IgA pemphigus is subdivided into two types: intraepidermal neutrophilic IgA dermatosis and subcorneal pustular dermatosis. PATIENTS AND METHODS: We report the case of an 82-year-old woman with intraepidermal neutrophilic IgA pemphigus associated with IgA gammopathy. The histopathological findings were unusual, with numerous large subcorneal pustules, a few pustules in the stratum spinosum, and basal IgA deposition. A favourable outcome was achieved with acitretin. DISCUSSION: This observation is significant in that it highlights the difficulty of classification of IgA pemphigus, which is currently based on clinical and histopathological findings. There is currently no therapeutic consensus attitude but simply a set of empirical data.

[Use of a rhomboid flap to repair temporal and frontotemporal cutaneous defects: 11 cases]. / Réparation de pertes de substance temporales et frontotemporales par un lambeau de transposition de type rhomboïdal : 11 observations.

BACKGROUND: Temporal and frontotemporal skin defects can be repaired using various reconstruction procedures: temporojugal rotation-advancement flaps, frontotemporal advancement flaps, skin grafts, etc. We propose an alternative method using a rhomboid transposition flap, thus extending the possibilities for repair in this region. MATERIALS AND METHODS: This is a retrospective, non-comparative study of patients in whom a rhomboid transposition flap of the temporal or frontotemporal region was created between February 2008 and March 2010. Sex, age, hospitalization, histological type of the excised lesion, type of anaesthesia, defect size, possible occurrence of complications and outcome were compiled from the medical records. RESULTS: Eleven patients (five women and six men) of average age 76 years were included. The lesions were due in all cases to basal cell carcinoma. Five patients were ambulatory and seven were hospitalized. All patients underwent surgery under local anaesthesia in a single session. Hospitalized patients had more extensive cutaneous defects, were older and had more comorbidities. One patient presented incomplete lateral resection. The most frequent complication was bruising on the lower eyelid (5/11), and two more severe complications occurred: distal flap necrosis and haematoma. The aesthetic result was good for all patients after a mean 20months of follow-up. CONCLUSION: Rhomboid transposition flaps appear to be a reconstruction option that warrants consideration in cutaneous defects in the temporal or frontotemporal region.

[Cutaneous manifestations during treatment with TNF-alpha blockers: 11 cases]. / Manifestations cutanées observées au cours d'un traitement par anti-TNF alpha: 11 observations.

BACKGROUND: TNFalpha blockers have recently extended the therapeutic arsenal available in dermatology. However, dermatologists must be informed of their potential adverse dermatological effects. While the chief adverse effect of TNFalpha blockers is risk of infection, cutaneous adverse effects have not yet been clearly elucidated and publications on this topic are few and far between. The aim of our study is to report various dermatological problems noted during treatment with TNFalpha blockers. PATIENTS AND METHODS: This was a retrospective study of patient files. The study population comprised patients receiving TNFalpha blockers and presenting cutaneous reaction, and seen in the dermatology department between August 2001 and December 2004. RESULTS: Eleven patients were included. The following cutaneous reactions were seen: delayed skin rash (1 case), lupus syndrome (1 case), cutaneous vasculitis (2 cases), palmoplantar pustulosis (2 cases), psoriasis vulgaris (1 case), atopic dermatitis (1 case), lichenoid rash (1 case), purpuric capillaritis (1 case) and melanoma (1 case). DISCUSSION: The cutaneous manifestations seen represented a wide range of different clinical pictures. Dermatologists must be aware of these potential adverse effects. Future improvement of knowledge of the physiopathological mechanisms as well as the institution of prospective cohort studies should provide clearer guidance on the management of such symptoms.

[Invasive fungal dermatitis in extremely premature newborns: a specific clinical form of systemic candidiasis]. / La candidose cutanée invasive du grand prématuré, une forme clinique particulière de candidose systémique.

BACKGROUND: Fungal agents, chiefly Candida albicans, are the cause of rising morbidity and mortality in newborn infants weighing less than 1500 g. We studied the particular cutaneous effects during the course of these infections. PATIENTS AND METHODS: This was a retrospective 3-year study in premature infants weighing less than 1500 g and hospitalized in the neonatal department of the Lille University Teaching Hospital. The patients included in the study presented sepsis with isolation of Candida in blood and/or urine culture. RESULTS: Twelve infants were included (1.8%). The risk factors seen are those described in literature (broad-spectrum antibiotics, prolonged mechanical ventilation and parenteral nutrition, corticosteroids and central venous catheters). Infection occurred early (mean: D12) and affected extremely premature infants (mean: 25 weeks' amenorrhea) of low birth weight (mean: 758 g) generally born by vaginal delivery (9 of 12 infants). The sole fungal agent isolated was Candida albicans. In 10 of the 12 patients, a characteristic skin disorder was observed (erythema with erosion and desquamation). In 10 of the 12 patients, too, Candida was isolated from skin and/or mucosal samples. DISCUSSION: Although it is now universally accepted that antifungal treatment should be initiated without delay for candidemia in septic newborn infants at risk, diagnosis of systemic candidiasis remains delicate. However, a specific pattern of skin involvement is very commonly seen that is atypical for candidiasis, but which in addition to its diagnostic value indicates early colonization with Candida (first 2 weeks of life). In this setting of immaturity of the skin and immune system, colonization and proliferation in skin and/or mucosa appear to constitute the first stage of systemic infection and we may speak of invasive cutaneous-mucosal candidiasis in extremely premature infants and initiate treatment designed to prevent the disease becoming systemic..

[Pneumomediastinum complicating the anti-synthetase syndrome]. / Pneumomédiastin compliquant un syndrome des anti-synthétases.

INTRODUCTION: Pneumomediastinum is a rare but classical complication of dermatomyositis. Its development is a serious matter and necessitates prompt recourse to aggressive treatment with corticosteroids combined with immuno-suppressants or intravenous human immunoglobulin. CASE REPORT: We report the case of a 63 year old woman presenting with pulmonary infiltration, in the presence of dermatomyositis, as a clinical manifestation of the anti-synthetase syndrome. The progress was rapidly unfavourable with pneumomediastinum and acute respiratory distress despite initial treatment with corticosteroids followed by human immunoglobulin and immunosuppressants. CONCLUSION: The identification of cutaneous or muscular signs in the initial investigation of a pulmonary infiltrate should lead to a search for anti-synthetase antibodies in order to determine the optimal clinical management as quickly as possible.

[Giant primitive neuroendocrine cutaneous carcinoma of the leg]. / Carcinome neuroendocrine cutané primitif géant de la jambe.

INTRODUCTION: Primitive cutaneous neuroendocrine carcinoma or Merkel cell carcinoma is a tumor characterized by rapid evolution. The size at the time of diagnosis is a mean of 2 to 3 centimeters. We report a case of a particular clinical and anatomopathological presentation. OBSERVATION: A 76 year-old woman had a voluminous tumoral plaque on the left leg with multiple ulcero-necrotic lesions involving the bone structure without palpable, inguinal lymphadenopathy. The histological and immunocytochemistry examination led to the diagnosis of cutaneous neuroendocrine carcinoma. The normality of the chest, abdominal and pelvis investigations confirmed the primitive cutaneous origin. The patient died a few months later without lymph involvement. DISCUSSION: To the best of our knowledge, such a presentation of primitive cutaneous neuroendocrine carcinoma has never been reported. The absence of lymphadenopathy despite the tumor volume and extensive skin involvement suggest the hypothesis of a non lymphophilic form of primitive cutaneous neuroendocrine carcinoma. This case report shows that lymphophily depends neither on the tumoral size nor to the degree of differentiation of tumoral cell proliferation, but on biological factors that require specification.