Topical therapy with imiquimod for eyelid lesion.

Herein a case of clinically diagnosed lower eyelid lesion treated with topical imiquimod is reported. Macroscopic resolution of the lesion occurred 4 weeks after treatment with good cosmetic result. This is the first reported successful case of using this drug in treating eyelid lesion involving the lid margin.

The Australian Mohs database: periocular squamous cell carcinoma.

OBJECTIVE: To present the results of all patients with periocular squamous cell carcinoma (SCC) treated with Mohs' micrographic surgery (MMS) in Australia between 1993 and 1999. DESIGN: Prospective, noncomparative, multicenter, interventional case series. PARTICIPANTS: Seventy-nine patients undergoing MMS for periocular SCC over a 7-year period (1993-1999). MAIN OUTCOME MEASURES: Recurrence after MMS, site, size, prior recurrence, defect size, histologic subtype, and presence of perineural invasion (PNI). RESULTS: Seventy-nine patients had 54 (68%) lower eyelid, 19 (24%) medial canthus, and 6 (7.6%) upper eyelid SCCs. The most common histologic subtypes were well differentiated (48.7%) and moderately differentiated (35.1%) SCC. Seventy-three percent were primary tumors and 27% were recurrent tumors. Three (4.3%) cases had histologically confirmed PNI. Two of the 3 cases with PNI were recurrent (P = 0.1355), and surgical excision was the most frequent prior treatment (P = 0.0192), with up to 3 prior excisions in 1 case. None of the patients with PNI received adjunctive radiotherapy, and none have recurred with follow-ups to date of 4, 5, and 6 years, respectively. A median follow-up of 73 months (mean, 77.3; range, 42-117) was available in 56 (71%) cases, of which 2 (3.64%; exact 95% confidence interval, 0.44%-12.53%) recurred. Both cases were primary, moderately differentiated SCCs. CONCLUSION: This is the largest reported prospective series of periocular SCC managed by MMS, with a median follow-up of over 5 years. It demonstrates that MMS has the lowest reported recurrence rate (3.64%) of any treatment modality for periocular SCC. That there were no recurrences for cases with PNI further emphasizes the importance of margin-controlled excision for periocular SCC.

The Australian Mohs database, part I: periocular basal cell carcinoma experience over 7 years.

OBJECTIVE: To present the findings of all patients with periocular basal cell carcinoma (BCC) treated with Mohs' micrographic surgery (MMS) in Australia between 1993 and 1999. DESIGN: Prospective, noncomparative, multicenter, interventional case series. METHODS: Prospective series of 1295 patients undergoing MMS for periocular BCC over a 7-year period (1993-1999). INCLUSION CRITERIA: Periocular BCC referred for MMS. MAIN OUTCOME MEASURES: Site, tumor size, prior occurrence, defect size, histologic subtype, and presence of perineural invasion. RESULTS: Twelve hundred ninety-five patients had 615 (47.5%) lower eyelid, 626 (48.3%) medial canthus, and 51 (3.9%) upper eyelid BCCs. The most common histologic subtypes were nodulocystic (39.5%) and infiltrating (34.8%) (P = 0.0008). Sixty-eight percent were primary and 32% were recurrent tumors. Previously recurrent BCCs were larger (P<0.0001), with larger defects (P<0.0001) than primary BCCs, and had more subclinical extension (P<0.0001) requiring more levels for complete excision (P<0.0001). Furthermore, superficial BCCs were more likely to have a prior occurrence (P<0.0001). In this series, perineural invasion was found in 1% of cases, with greater subclinical tumor extension in such cases (P = 0.0657). CONCLUSION: The Australian MMS database is the largest prospective, nationwide series of high-risk periocular BCC managed by MMS. Almost 50% of tumors were at the medial canthus, with nodulocystic and infiltrating being the most common histologic subtypes. Recurrent BCCs comprised a third of tumors and were larger, with larger defects and more subclinical extension than primary BCCs. Perineural invasion was found in 1% of cases and also had greater subclinical extension.

The Australian Mohs database, part II: periocular basal cell carcinoma outcome at 5-year follow-up.

OBJECTIVE: To report the outcome with 5-year strict follow-up (only cases where 5-year follow-up is available) of all patients with periocular basal cell carcinoma (BCC) treated with Mohs' micrographic surgery (MMS) in Australia between 1993 and 1996. DESIGN: Prospective, noncomparative, multicenter, interventional case series. METHODS: A prospective series of 819 patients, undergoing MMS for periocular BCC over a 3-year period (1993-1996). INCLUSION CRITERIA: Periocular BCC referred for MMS. MAIN OUTCOME MEASURES: Recurrence, site, size, prior occurrence, defect size, histologic subtype, and presence of perineural invasion. RESULTS: Eight hundred nineteen patients had 257 (54%) lower eyelid, 195 (41%) medial canthus, and 22 (5%) upper eyelid BCCs. The most common histologic subtypes were nodulocystic (43%) and infiltrating (30%) (P = 0.0003). Sixty-eight percent were primary and 32% were recurrent tumors. Five-year follow-ups for cases between 1993 and 1996 were available in 347 (42%) cases. There were 7 recurrences (2.0%; exact 95% confidence interval [CI]: 0.82%-4.1%), 5 of which were at the medial canthus and all of which were previously recurrent, with up to 3 recurrences before MMS. Previous recurrence (P<0.0001), infiltrating (5) or superficial (2) histologic subtype (P = 0.0882), and medial canthal site were the main predictors of recurrence after MMS. There were no recurrences for primary BCC, and the 5-year recurrence for previously recurrent BCC was 7.8% (exact 95% CI: 3.2%-15.4%). CONCLUSION: The Australian MMS database is the largest prospective nationwide series of periocular BCC managed by MMS. The strict 5-year recurrence rates of 0% and 7.8% for primary and recurrent tumors, respectively, confirm MMS as the treatment of choice for periocular BCC.

Transmembrane T-cell receptor peptides inhibit B- and natural killer-cell function.

A synthetic hydrophobic peptide (core peptide; CP) containing two positively charged amino acids, lysine and arginine was derived from the transmembrane sequence of the T-cell receptor (TCR) alpha chain and has been shown to inhibit T-cell-mediated inflammation. In this study, we investigated the specificity of CP (10 microm) on lymphocyte function and found that it significantly inhibited interleukin-2 production in T cells and natural killer cytotoxicity by 46-58% compared to positive control. CP had no effects on B-cell proliferative responses when used at these concentrations; however, it suppressed B-cell proliferation at higher concentrations (50 microm). Inhibition by CP was not the result of membrane pore formation or cytotoxicity when examined by trypan blue, propidium iodide staining or transmission electron microscopy. CP analogues, with both lysine and arginine replaced by neutral or negatively charged amino acids, or by randomly distributing charges in the peptide sequence, had no effect on lymphocyte function. These results suggest that peptide inhibition is affected by its structure and charge interactions, and may involve common signalling molecules in T, B and natural killer cells. The potential of the immuno-inhibitory effects of CP as a novel anti-inflammatory peptide in therapy should be further explored.

Survey of phototherapy practice by dermatologists in Australia.

A postal survey was sent to all dermatologists in Australia to determine current phototherapy practices. Questionnaires were returned by 158 (57%) of 277 dermatologists, of whom 112 (71%) provided phototherapy. Large variations existed in attitudes and practice, including indications, contraindications, dosage schedules, equipment maintenance, response to adverse events, and follow-up arrangements. Cumulative ultraviolet (UV) doses for psoralen and UVA (PUVA) were not calculated by 21%, while 30% did not calculate cumulative doses for UVB. Written informed consent was not obtained by 32%. Phototherapist dermatologists reported 25 patients developing melanoma following PUVA. Only 30% of Australian dermatologists organize regular follow up of patients after phototherapy. Australians have the highest rates of melanoma and non-melanoma skin cancers in the world, because of their ancestry and high solar exposure. This makes it inappropriate for Australian dermatologists to rely entirely on foreign safety data when assessing the risks and benefits of phototherapy in Australian patients. There is a need for standardized Australian guidelines that can be prospectively assessed to ensure phototherapy is used to maximize efficacy and minimize risks in Australian patients, given their unique ancestral mix and outdoor lifestyle.

Scrubbing for cutaneous procedures can be hazardous.

Office-based minor cutaneous surgery is a service provided by many medical practitioners. In New South Wales, Australia, it is a legal requirement for practitioners to surgically scrub before donning sterile gloves for all forms of invasive surgery, including minor cutaneous procedures. Frequent scrubbing causes altered skin barrier function, irritant dermatitis and a potential risk of latex sensitization. These adverse effects are associated with significant morbidity and cost. Better tolerated alternatives, including alcohol-based hand rubs, should be considered in preference to traditional surgical scrubs in order to reduce these occupational risks for minor proceduralists. Well-controlled, prospective studies should explore what extent of hand washing is necessary for donning sterile gloves for minor cutaneous surgery.

Basal cell carcinoma of the lip treated with radiotherapy.

Basal cell carcinoma (BCC) of the lip is uncommon relative to other cutaneous sites for BCC, such as the central face or scalp. A female predisposition and predilection for the upper lip have been previously documented. A retrospective analysis of patients treated for BCC of the lip was undertaken within the department of Radiation Oncology, Westmead Hospital, Sydney. Twenty patients were identified; 12 women and 8 men. The majority (15/20) had T1 lesions of the upper lip (17/20). Eleven patients were referred for radiotherapy alone and nine for adjuvant radiotherapy following either incomplete excision or local recurrence. With a mean follow up of 36 months no patient has recurred following either definitive or adjuvant radiotherapy. Despite the majority of BCCs of the lip being amenable to surgery fractionated external beam radiotherapy remains an option especially when functional and/or cosmetic concerns are an issue. We present the findings from this small case series and use our findings to illustrate the role of radiotherapy in treating BCC of the lip.

Merkel cell carcinoma and multiple cutaneous squamous cell carcinomas in a patient with pityriasis rubra pilaris.

A 79-year-old female was diagnosed with Merkel cell carcinoma (MCC) and multiple cutaneous squamous cell carcinomas (SCC) occurring on a background of pityriasis rubra pilaris. At the time of initial diagnosis and treatment for upper limb MCC, axillary nodal metastases were clinically evident. In the ensuing months, she developed multiple rapidly progressing SCC and eventually a left arm soft tissue deposit of metastatic MCC. Treatment involved multiple courses of fractionated radiotherapy. The salient clinical features and supporting evidence for this case are presented.