Micrographic surgery (Tubingen torte technique) for the treatment of an invasive dermatofibrosarcoma protuberans with muscular involvement.

Dermatofibrosarcoma protuberans (DFSP) is an uncommon skin tumour characterized by a slow, infiltrative growth and marked tendency towards local recurrences. Wide surgical excision of 3-5 cm from the margins including the fascia is the recommended treatment. Mohs Micrographic Surgery has been shown to afford lower rates of recurrence. The Mohs-Tübingen technique is a variant indicated for very large excisions that allows a complete eradication of the tumour, preserving healthy tissues. We report the case of a 45 year-old man affected by DFSP of the right shoulder deeply infiltrating the muscles, referred to us for a recurrence after a large excision. We submitted the patient to Mohs-Tübingen surgery in collaboration with an orthopaedic surgeon due to the presence of muscular involvement of DFSP. Two surgical operations were necessary to obtain negative histology as the tumor was deeply infiltrating the prescapular muscles. After three years of follow-up, the patient did not have any recurrence and the normal mobility of the shoulder was preserved. Precocious diagnosis and adequate therapy are necessary for DFSP as not only the margins, but also the deep invasion of the tumor have to be carefully controlled.

Bath PUVA and psoriasis: is a milder treatment a worse treatment?

BACKGROUND/AIM: The guidelines of the British Photodermatology Group for topical treatment with psoralen and ultraviolet light (PUVA) recommend starting UVA doses between 0.2 and 0.5 J/cm(2), according to the phototype. Our purpose was to evaluate the therapeutic efficacy and tolerability of bath PUVA, with 8-methoxypsoralen (8-MOP), by using lower UVA doses, regardless of phototype. METHODS: We compared 2 groups of patients (group 1: n = 10, group 2: n = 20) with chronic plaque-type psoriasis. Group 1 was treated with the usual starting dose and dose progression; group 2 was treated by using a lower first dose, a slower dose progression and reaching a lower maximum dose. The Psoriasis Area and Severity Index (PASI) score was assessed at the initial stages, and every month until the end of the treatment. RESULTS: In group 1, the median baseline PASI score decreased from 15.2 to 4.5 (p < 0.005, Student's paired t test), while in group 2, it fell from 13.7 to 4.1 (p < 0.005). No statistical difference between the groups is detectable. Severe phototoxic reactions were observed only in 2 patients of group 1. Side effects were not observed in group 2. CONCLUSIONS: Our data indicate that an aggressive bath PUVA treatment is not substantially more effective in clearing chronic plaque-type psoriasis than a milder therapeutic approach.