Cartilage-like composition of keloid scar extracellular matrix suggests fibroblast mis-differentiation in disease.

Following wound damage to the skin, the scarring spectrum is wide-ranging, from a manageable normal scar through to pathological keloids. The question remains whether these fibrotic lesions represent simply a quantitative extreme, or alternatively, whether they are qualitatively distinct. A three-way comparison of the extracellular matrix (ECM) composition of normal skin, normal scar and keloids was performed using quantitative discovery-based proteomics. This approach identified 40 proteins that were significantly altered in keloids compared to normal scars, and strikingly, 23 keloid-unique proteins. The major alterations in keloids, when functionally grouped, showed many changes in proteins involved in ECM assembly and fibrillogenesis, but also a keloid-associated loss of proteases, and a unique cartilage-like composition, which was also evident histologically. The presence of Aggrecan and Collagen II in keloids suggest greater plasticity and mis-differentiation of the constituent cells. This study characterises the ECM of both scar types to a depth previously underappreciated. This thorough molecular description of keloid lesions relative to normal scars is an essential step towards our understanding of this debilitating clinical problem, and how best to treat it.

Carbon dioxide laser ablation for trichoepitheliomas: The largest reported series.

Trichoepitheliomas are benign cutaneous tumours often occurring on the face and can lead to considerable psychological distress to its sufferers. Treatment is often difficult, and surgery is limited by the obvious scars and multiple numbers of lesions. Carbon dioxide laser ablation can be used safely with good cosmetic outcome and low recurrence rate, and in this article, we describe our experience in the treatment of these tumours with the carbon dioxide laser. This is the largest reported series in the literature.

Laser Corrective Surgery with Fractional Carbon Dioxide Laser Following Full-thickness Skin Grafts.

Full-thickness skin grafts (FTSGs) are frequently used to treat patients with burn injuries and to repair defects rendered by excisional (including Mohs) surgery. The evidence for corrective laser surgery after scar formation is well established. With regard to laser treatment of FTSG, the evidence is sparse. Laser treatment after FTSG is a novel concept, with minimal literature. We present a case series, one of the first to our knowledge, of the treatment of FTSG with fractional CO2 laser in five patients after Mohs surgery.

Our experience of carbon dioxide laser ablation of angiofibromas: Case series and literature review.

Angiofibromas are one of the dermatological hallmarks of tuberous sclerosis. Various ablative treatments have been trialled and more recently topical rapamycin has been proposed. We present our experience of treatment of angiofibromas using carbon dioxide (CO2) laser ablation and provide a timely literature review. Nine patients were retrospectively identified as being treated with CO2 laser between 2009 and 2015. Three patients were male, six were female, median age at first treatment was 28 (range 15-49) years and the median number of treatments was two (range 1-17). Four of these patients could be contacted for a post-treatment telephone interview. All reported an improvement in appearance of angiofibromas following treatment and that they would recommend CO2 laser ablation to others. Three of the four reported recurrence of some lesions following treatment. The only side effect reported by one patient was transient hyperpigmentation. CO2 laser ablation appears to be a well-tolerated, efficacious treatment for angiofibromas with few long-term side effects.

The use of lasers in cutaneous sarcoid: Is there a role?

Sarcoid is a granulomatous disease that can affect the skin solely or as part of a systemic involvement. Cutaneous lesions of sarcoid may be difficult to treat and lasers are rarely used. In this article we report our case series and review the literature on the use of lasers in cutaneous sarcoid.

The use of lasers in Becker's naevus: An evidence-based review.

Becker's naevus is a hamartoma that often appears during puberty. Clinically this presents with a pigmented and often hairy patch most often on the shoulders. Treatment has always been challenging and lasers are often used with mixed results. This article reviews the evidence of all the laser treatments used in Becker's naevus and analyses the findings from the published studies and trials.

Photodynamic Therapy Followed by Mohs Micrographic Surgery Compared to Mohs Micrographic Surgery Alone for the Treatment of Basal Cell Carcinoma: Results of a Pilot Single-Blinded Randomised Controlled Trial.

INTRODUCTION: Basal cell carcinoma is a common cutaneous malignant tumour. Surgical excision is the "gold standard" treatment for most subtypes, with Mohs micrographic surgery (MMS) offering the highest cure rate. Other treatment modalities used include photodynamic therapy (PDT). BACKGROUND: We aimed to study the efficacy of combining MMS with PDT to see whether this would reduce the number of stages and final defect size when compared with MMS alone. MATERIALS AND METHODS: Our study was a single-centre, single-blinded, randomised and controlled pilot study involving a total of 19 patients. Nine patients were randomised to pre-treatment with PDT followed by MMS of whom two withdrew; the remaining 10 patients were randomised to the MMS alone. Follow-up visits were arranged at 3 and 6 months post-surgery. RESULTS: In the PDT arm, five out of the seven treated patients (71%) had their initial tumour size decreased following PDT treatment prior to MMS. The average number of stages in the PDT arm was 1.85, compared to 2.5 in the MMS arm. The average number of sections in the PDT arm was 4.2, in comparison to 5.2 in the MMS arm. CONCLUSION: Our pilot study showed a promising but limited role for PDT as an adjunct in MMS in the treatment of selected cases of basal cell carcinomas. Larger trials, preferably multi-centred are required to further examine the role of this combination therapy.

Lentigo maligna mimicking invasive melanoma in Mohs surgery: a case report.

Lentigo maligna is a lentiginous proliferation of atypical melanocytes confined to the epidermis, typically on chronically sun-damaged skin. Following biopsy and exclusion of invasive disease, therapy may involve Mohs surgery, topical treatment or radiotherapy. However, lentigo maligna often involves adnexal structures, creating histological difficulty in distinguishing these foci from invasive melanoma. We present a case in which, during Mohs excision, a nodule of severely atypical melanocytes appeared to lie within the dermis, potentially altering treatment and prognosis. The use of laminin-5 provided a means of resolving this diagnostic dilemma, facilitating continuation of Mohs surgery until tumour clearance was achieved.

Mohs micrographic surgery concordance between Mohs surgeons and dermatopathologists.

BACKGROUND: Mohs micrographic surgery (MMS) is the preferred treatment modality for high-risk nonmelanoma skin cancer because of the high cure rates and tissue-sparing effect. Its outcome is highly dependent on the expertise and accuracy of the Mohs surgeon in the interpretation of frozen sections. OBJECTIVE: This retrospective study evaluated the level of concordance between Mohs surgeons and dermatopathologists in reading histology slides from MMS procedures. METHODS AND MATERIALS: A Mohs surgeon read 170 randomly selected slides for a quality assurance audit during excision, and then a dermatopathologist blindly read them at a separate time. Absence or presence of tumour and the final diagnosis were recorded on a standardized form. RESULTS: An overall concordance of 99.4% was demonstrated. True discordance was recorded in only one of 170 cases. Intraepidermal atypia was the most challenging scenario for Mohs surgeons. CONCLUSIONS: The high rate of agreement in this study confirms that adequately trained MMS surgeons have sufficient expertise and training for accurate and precise frozen sections interpretation.

Birt-Hogg-Dubé syndrome with a renal angiomyolipoma: further evidence of a relationship between Birt-Hogg-Dubé syndrome and tuberous sclerosis complex.

Birt-Hogg-Dubé syndrome (BHDS) is an autosomal dominant condition caused by mutations in the gene which codes for folliculin (FLCN). It is characterised clinically by fibrofolliculomas, trichodiscomas, pulmonary cysts, spontaneous pneumothoraces and renal cancers. This case illustrates a patient with BHDS and a renal angiomyolipoma. Angiomyolipomas are not described as a feature of BHDS, but rather they can occur sporadically or in tuberous sclerosis complex (TSC). Recent studies suggest that clinical similarities between BHDS and TSC may be explained by FLCN and TSC proteins functioning on a common pathway, mammalian target of rapamycin. This case adds to the literature of cases with clinical similarities.

Cutaneous and subcutaneous metastases of gastrointestinal stromal tumors: a series of 5 cases with molecular analysis.

Gastrointestinal stromal tumors (GISTs) rarely metastasize to the skin. We describe 5 patients with GIST with subcutaneous and cutaneous metastases. The mean age at metastasis was 54 years (range 30-68 years) with a male predominance (4:1). Primary tumors occurred in the stomach (n = 3), small bowel (n = 1), and abdomen, not otherwise specified (n = 1). The average time from primary tumor resection to the resection of skin metastases was 59 months (range 11-155 months). The metastases occurred in the scalp (n = 2), cheek (n = 1), and abdomen (n = 2) with 3 patients presenting with solitary nodules and 2 patients with multiple nodules. The average size was 2 cm (range 0.6-4 cm). Histologically, 2 cases were spindled and 3 cases demonstrated mixed epithelioid and spindle cell morphology. All were confirmed to have CD117 reactivity. KIT genotyping was performed in 4 of 5 cases. Two cases harbored a mutation in exon 11, and the remaining 2 cases were wild type in exons 9, 11, 13, and 17. All 5 patients had multiple concurrent or subsequent abdominal and/or hepatic metastases. In 4 patients with an average follow-up of 32 months (range 6-75 months), after the resection of the metastases, 2 were alive with disease and 2 died of disease. Cutaneous metastases seem to be a late complication of GIST, but their presence does not necessarily herald a rapid demise of the patient.

A novel 2-hour method for rapid preparation of permanent paraffin sections when treating melanoma in situ with mohs micrographic surgery.

BACKGROUND: Distinguishing sun-induced melanocyte atypia from residual melanoma in situ (MIS) can be challenging, particularly when working with frozen sections. Immunostains such as melanoma-associated antigen recognized by T cells (MART-1) can assist, but paraffin sections provide an optimal means of analyzing melanocyte morphology. OBJECTIVE: To verify the effectiveness of a 2-hour paraffin processing technique that uses microwave technology in the preparation of MIS sections. METHODS: Twelve MIS debulk specimens were divided into 4 pieces with each piece processed 1 of 4 ways: our 2-hour paraffin technique with hematoxylin and eosin (H&E), conventional 24-hour paraffin processing with H&E, frozen sections with H&E, and frozen sections with MART-1 immunostaining. A Mohs surgeon and a dermatopathologist compared all specimens in a blinded fashion using a 3-point ranking scale to assess ease of visualizing normal melanocytes, ease of visualizing abnormal melanocytes, and overall ability to adequately visualize epidermal and dermal structures. RESULTS: A nonparametric signed rank test indicated no significant differences between our microwave technique and conventional paraffin processing in all 3 criteria (p=.29, .63, .75, respectively). Our microwave technique was significantly better than frozen H&E sections for all 3 criteria (p=.046, .004, .005, respectively). CONCLUSION: This rapid microwave tissue processing technique is comparable with conventional paraffin section processing.