Decreased skin cancer after cessation of therapy with transplant-associated immunosuppressants.

BACKGROUND: Immunosuppression for solid organ transplantation is associated with increased incidence of internal and cutaneous malignant tumors, among which skin cancer is the most common. OBJECTIVE: To determine the effects on cutaneous carcinogenesis when stopping therapy with immunosuppressive medications. OBSERVATIONS: We followed the clinical course of 6 solid organ transplant recipients after therapy with immunosuppressant medications was stopped because of allograft failure or unacceptable cutaneous carcinogenesis. Generally, we found that stopping therapy with immunosuppressive medications resulted in deceleration of cutaneous carcinogenesis, resolution of cutaneous verrucae vulgaris, and qualitative improvements in skin condition. Four patients experienced marked improvement; 2 did not. CONCLUSIONS: Cessation of transplant-associated therapy with immunosuppressive medications for patients in whom cutaneous carcinomas developed after transplantation may lead to deceleration of cutaneous carcinogenesis, decreased verrucae, and improved skin quality within 1 to 2 years. Because of the natural variation in skin cancer development and the small number of cases in this series, definitive conclusions require further study.

Ozone depletion update.

BACKGROUND: Stratospheric ozone depletion due to chlorofluorocarbons an d increased ultraviolet radiation penetration has long been predicted. OBJECTIVE: To determine if predictions of ozone depletion are correct and, if so, the significance of this depletion. METHODS: Review of the English literature regarding ozone depletion and solar ultraviolet radiation. RESULTS: The ozone layer is showing definite thinning. Recently, significantly increased ultraviolet radiation transmission has been detected at ground level at several metering stations. It appears that man-made aerosols (air pollution) block increased UVB transmission in urban areas. Recent satellite measurements of stratospheric fluorine levels more directly implicate chlorofluorocarbons as a major source of catalytic stratospheric chlorine, although natural sources may account for up to 40% of stratospheric chlorine. CONCLUSIONS: Stratospheric chlorine concentrations, and resultant increased ozone destruction, will be enhanced for at least the next 70 years. The potential for increased transmission of ultraviolet radiation will exist for the next several hundred years. While little damage due to increased ultraviolet radiation has occurred so far, the potential for long-term problems is great.

Delayed full-thickness grafting of lower leg defects following removal of skin malignancies.

BACKGROUND: Closure of wounds on the lower leg can be difficult. If primary closure of local flap repair cannot be accomplished, grafting is usually the next option. Full-thickness grafts are, generally superior to split-thickness grafts, but may not survive immediate postoperative grafting on the lower leg. OBJECTIVE: The purpose of this report is to demonstrate another approach to treatment of lower leg wounds. METHODS: Thirteen patients with lower leg wounds were successfully closed with a delayed full-thickness skin graft. CONCLUSION: This study demonstrates that delayed full-thickness grafting of the lower extremities may have advantages over other methods.

Thinning of the ozone layer: facts and consequences.

The ozone layer is showing small but definite signs of depletion. Despite this, significantly increased UV radiation transmission at ground level has been found only in the Antarctic and Arctic regions. The potential for increased transmission of UV radiation will exist for the next several hundred years. Although little damage from increased UV radiation has occurred so far, the potential for long-term problems is great. The natural history of ozone and the causes and consequences of, and possible solutions to ozone depletion are examined in this article.

Foreign-body granuloma due to an unsuspected wooden thorn.

Foreign bodies occasionally cause a chronic granulomatous reaction that may be mistaken for a plantar wart or even a skin malignancy. This possibility should be considered when lesions on the foot become progressively larger and more tender. Diagnosis may require surgical excision.

The surgical management of chondrodermatitis nodularis chronica helicis.

Surgical management of chondrodermatitis nodularis chronica helicis by curettage is described. The curet directs the dissection. The necrotic cartilage is soft and is removed easily. The endpoint is reached when the curet is repelled by firm, elastic cartilage. Contours remain normal because the skin is tented over the defect supported by the remaining cartilage.

Surgical treatment of extramammary Paget's disease. A report of six cases and a reexamination of Mohs micrographic surgery compared with conventional surgical excision.

Extramammary Paget's disease (EMPD) is a rare cutaneous malignancy, usually on the genitalia, that almost always extends beyond clinically apparent margins. Recurrences after standard methods of surgical excision are notoriously frequent; effective treatment with Mohs micrographic surgery was first reported in 1979. It has since been suggested this malignancy may be multifocal, and reports of recurrences after resection with micrographic surgery have appeared. The authors report six cases treated with Mohs surgery, two of which recurred. They also present data on 42 additional cases obtained from a written survey of members of the American College of Mohs Micrographic Surgery and comparison cases selected from the literature. The recurrence rate after micrographic surgery appears to be at least as low as that after conventional surgical excision with vertical frozen section or paraffin section margin control. Mohs micrographic surgery allows for maximal tissue sparing of critical anatomic structures and is performed under local anesthesia as an outpatient; because of this, it may be superior to conventional surgical excision. A scheme for management of this malignancy is presented. Surgeons should be aware radical excision is not needed for most cases of extramammary Paget's disease and very long-term patient follow-up is required.

Cutaneous phaeohyphomycosis caused by a rare fungal pathogen, Hormonema dematioides: successful treatment with ketoconazole.

Annular, fungating, ulcerated lesions developed on both hands of a 64-year-old immunocompetent man 2 months after he was cut with barbed wire. A dematiaceous mold, Hormonema dematioides, heretofore not definitively associated with human disease, was grown from two separate tissue specimens during a period of 9 days. Histopathologic examination demonstrated rare small, periodic acid-Schiff-positive, hyaline, yeastlike organisms in tissue. Twelve weeks of empiric therapy with ketoconazole, 400 mg/day, was curative.

Mycobacterium avium-Mycobacterium intracellulare infection limited to the skin and lymph nodes in patients with AIDS.

Three patients with AIDS who were taking 3'-azido-3'-deoxythymidine (AZT) developed cutaneous abscesses from which Mycobacterium avium-Mycobacterium intracellulare was isolated. Culture of multiple blood samples and bone marrow aspirate from all three patients revealed that the infection was not disseminated. This is a rare form of presentation for this infection in AIDS patients. We speculate that the antiviral drug AZT was responsible for the localization of disease.

Prevalence and clinical spectrum of skin disease in patients infected with human immunodeficiency virus.

We examined 100 serial patients who were receiving care in a county outpatient immunodeficiency clinic and whose serum was positive by Western blot test for the human immunodeficiency virus (HIV). Skin disorders were found in 92% of these HIV-infected patients, with little difference in prevalence or severity in three clinical categories: patients with the acquired immunodeficiency syndrome, patients with acquired immunodeficiency syndrome-related complex, and those who were asymptomatic. Patients positive for HIV antibodies had significantly more skin disease, with the exception of dermatophytosis, than did a historical control population. A strong association was observed between the use of zidovudine and the absence of infection with Candida albicans. We conclude that there is a high prevalence of skin disease in HIV-positive patients who seek medical care, and that specialists in skin disease should be included in these patients' initial evaluation and continuing care.

Common penile lesions.

We have briefly summarized some of the most common and confusing penile lesions likely to be seen by the urologist. We have discussed the clinical features, differential diagnosis, and treatment from the dermatologist's point of view. We have included the latest possible references, as many disorders discussed here are rapidly becoming better understood.