Adalimumab: a treatment option for pyoderma gangrenosum after failure of systemic standard therapies.

BACKGROUND: Pyoderma gangrenosum (PG) belongs to a group of neutrophilic dermatoses and is often associated with systemic disorders. The authors present a patient with a recalcitrant PG that did not respond to systemic standard therapies, and discuss further treatment options with impact on quality of life. CASE REPORT: A 42-year-old woman with recurrent PG since 2005 was presented to the dermatology department in April 2010. Systemic standard therapies including azathioprine, corticosteroids, mycophenolate mofetil, and cyclophosphamide in combination with intensive topical treatment showed to be ineffective. Hence, in October 2010 the authors discontinued any previous systemic therapies and implemented a subcutaneously-administered therapy with adalimumab starting with 80 mg in week 0 and 40 mg in week 1, followed by 40 mg every second week. Under this therapy the ulceration got steadily smaller and healed nearly completely within 64 weeks. However, treatment with adalimumab is still ongoing, with the intent of consolidation and treatment success, but application intervals have been extended to 4-week intervals. Therapy with adalimumab was well tolerated without any side effects and led to an increased quality of life measured with the Dermatology Life Quality Index. DISCUSSION: An immune-modulatory monotherapy with adalimumab is a viable treatment option for recalcitrant PG. Thanks to the easy administration, rare side effects, and good healing action it is a convincing therapeutic strategy.

Successful treatment of Rowell syndrome using oral cyclosporine A.

BACKGROUND: To present and discuss successful treatment of Rowell syndrome with low dose orally administered cyclosporine in a male patient with refractory course of disease. METHODS: A 63-year-old male patient presented with a five-week history of widespread, severely pruritic erythematous skin changes that were first seen on the back. Within a few weeks, skin rashes extended to the whole body recessing the face. Because treatment with topical and orally administered corticosteroids was ineffective, we began an immunosuppressive therapy using cyclosporine. Treatment was initiated with an orally administered dosage of 100mg/day and subsequent dose reduction to 50mg/day after 14 days. RESULT: After four weeks of treatment, all clinical signs were resolved; only postinflammatory hyperpigmentation persisted for several weeks. Treatment-related side effects included arterial hypertension that could be controlled with antihypertensive drugs. CONCLUSION: Primarily described in 1963, Rowell syndrome represents the combination of cutaneous lupus erythematosus and erythema multiforme in a single individual. Controversial discussion concerning the genuine character of the disease is still going on, and even the existence of this entity remains unclear. Several therapeutic regimes are known, including corticosteroids, methotrexate, or dapsone. To the best of our knowledge, this is the first report of successful treatment of Rowell syndrome with low doses of cyclosporine. Orally administered low-dose cyclosporine seems to be a potent alternative treatment option for patients with Rowell syndrome refractory to standard therapies.

Giant melanoma of the scalp--discussion of a rare clinical presentation.

An 84-year-old woman presented with ulcerated scalp lesions that had been mistreated as acute haemorrhagic eczema for several months. Examination showed confluent purple-blue-grey macules, papules and nodules covering a great portion of the parietofrontotemporal scalp with focal areas of ulceration. Dermatopathologic examination of two 5 mm punch biopsies confirmed an invasive malignant melanoma (Breslow thickness of 5 mm, clark level V). In addition, lymphangiosis melanomatosa, intravascular tumour growth and a diffuse infiltration of the subcutaneous tissue were seen. Possible treatment options (eg, surgery, irradiation, intralesional treatment) were discussed with the patient, but declined. It is important that clinicians are aware that melanomas may be large and biopsies are mandatory to avoid delayed diagnosis. Thus, a dermatologist has a pre-eminent position in diagnostic procedure.

Rowell syndrome--case report with discussion of significance of diagnostic accuracy.

Rowell syndrome is a very controversial condition and though defining diagnosing criteria exist, many previously published cases lack one or more of these criteria. It represents the combination of cutaneous lupus erythematosus and erythema multiforme in one single individual. In order to discuss relevance of diagnostic and defining criteria the authors use a case seen in our outpatient service that was primarily diagnosed as Rowell syndrome. But due to lacking criteria, the authors rediagnosed this patient as an unusual variation of lupus erythematosus.

Frequency of local recurrence following segmentectomy of stage IA non-small cell lung cancer is influenced by segment localisation and width of resection margins--implications for patient selection for segmentectomy.

OBJECTIVE: Segmentectomy has recently been suggested as alternative to lobectomy for curative treatment of early-stage non-small cell lung cancer (NSCLC). This study was performed to investigate if localisation of the resected segment or width of resection margins influence local recurrence following complete segmentectomy of stage IA NSCLC. METHODS: Between 1987 and 2002, 49 segmentectomies and 150 lobectomies were performed in patients with pT1pN0cM0-NSCLC in our institution. Indications for segmentectomy were a limited pulmonary function or severe comorbidity. The median follow-up duration was 54 months. Local recurrence was distinguished from secondary primary lung cancer and was defined as tumour within the same lung or in the ipsilateral mediastinum. Segment localisation, width of resection margins, tumour size, tumour type, grading and age were analysed concerning their influence on local recurrence. RESULTS: Local recurrence occurred in 16% of patients with segmentectomy and was significantly more frequent than in patients with lobectomy (5%; p=0.005; log-rank test). Segmentectomy in the S1-3 region tended more frequently to local recurrence than segmentectomy in the remaining segments (p=0.08; log-rank test): There was no recurrence following segmentectomy in the S7-10 region (n=6) or of S4-5 (n=5). Recurrence occurred in 7 (23%) out of 30 patients with segmentectomy in the S1-3 region and in 1 (12%) out of 8 patients with S6-segmentectomy. Also, resection margins < or = 1cm tended to be associated with local recurrence (p=0.06; log-rank test). CONCLUSIONS: The frequency of local recurrence following segmentectomy might be influenced by segment localisation and width of resection margins. Segmentectomy within the S1-3 region should be avoided whenever possible.