Current management of actinic keratoses.

An actinic keratosis (AK) is a pre-malignant cutaneous lesion that frequently manifests in sun-exposed areas of the skin as a small, rough, scaly erythematous papule. They are one of the most common presenting complaints for dermatologists. AKs should be treated due to their potential to progress into a squamous cell carcinoma (SCC). There are numerous treatments available for managing AKs including those broadly categorized as destructive, topical field, and procedural field therapies. The topical field therapies include 5-fluorouracil, imiquimod, and diclofenac gel. Recently, imiquimod 3.75% (Zyclara TM) has been approved for the treatment AKs on the face and scalp. It is a reasonable alternative to imiquimod 5%, as the approved indication includes a larger surface area for treatment, shorter duration course, and the potential for less severe local skin reactions. There is no widely accepted algorithm for the treatment of AKs, as comparative data is unavailable between all approaches. Therapy choices are guided by efficacy, adverse effects, cosmetic results, and patient compliance.

Hepatitis in disseminated bacillus Calmette-Guérin infection.

Local immunotherapy with an attenuated live strain of Mycobacterium bovis, bacillus Calmette-Guérin (BCG), is an effective and frequently used treatment for in situ transitional cell carcinoma (TCC) of the bladder. Success rates are high, and serious side effects are infrequent but can affect every organ system. A 79-year-old patient with recently diagnosed TCC who was treated with intravesical BCG for a recurrence after initial surgical treatment is reported. After unsuccessful attempts at bladder catheterization with the creation of a false passage for his third treatment, BCG was instilled via a suprapubic catheter the same day and again a week later. Two weeks after the third BCG instillation, the patient presented with profound lethargy and weakness to the point of not being able to get up out of a chair. He was febrile, anorexic, icteric and had hepatosplenomegaly. Disseminated BCG infection was suspected on the basis of history, clinical examination and a liver biopsy that showed noncaseating granulomatous hepatitis. Empirical treatment was started with antituberculous combination therapy. A short course of an oral corticosteroid was given. Clinical improvement was marked and sustained so that the patient could be discharged home for the full six-month course of his treatment. Disseminated BCG infection with granulomatous hepatitis can be severe and life-threatening in cases where a large intravascular inoculum of BCG may have been given inadvertently.

Detection of artificial changes in mole size by skin self-examination.

BACKGROUND: The efficacy of the skin self-examination (SSE) to detect artificial changes in the size of nevi has not been evaluated in a controlled setting. OBJECTIVE: Our purpose was to determine the sensitivity and specificity of the SSE in detecting artificial changes in mole size in patients at high risk for melanoma. METHODS: In a single-center, single-blinded cross-over study, patients who had been performing the SSE confidently for at least 1 year examined their backs after the diameter of an existing mole was increased artificially in random order by 0, 2, or 4 mm. RESULTS: The specificity of the SSE was 62% (95% confidence interval [CI], 53%-72%) (N = 103). The sensitivity of the 2 mm change was 58% (95% CI, 49%-68%) and that of the 4 mm change was 75% (95% CI, 66%-83%). SSE performance was not related to perceived risk, number of moles, gender, age, or frequency of self-examination. CONCLUSION: Even in our highly motivated and selected group of high-risk patients, 25% could not detect an obvious increase in the diameter of an existing nevus, whereas 38% incorrectly identified a change when none was made. The SSE is only a moderately effective tool for the detection of acute, large, changes in mole size. The usefulness of the SSE in detection of new lesions or changes in existing lesions is likely due to a combination of factors or due to factors other than size, such as color, border irregularity, and texture, among others.