Ultraviolet A1 phototherapy: One center's experience.

BACKGROUND: Ultraviolet A1(UVA1) phototherapy is increasingly being used in the treatment of morphea, atopic dermatitis, lupus and some other recalcitrant dermatoses. We present a retrospective review of our experience with this modality. AIM: To evaluate the treatment response rates for various dermatoses and adverse effects of UVA1 phototherapy. METHODS: We reviewed phototherapy notes along with electronic and/or paper case records for all patients treated with UVA1 phototherapy from October 1996 to December 2008. RESULTS: A total of 269 patients (outcomes available for 247) had 361 treatment courses (treatment data available for 317 courses) over this period. We found phototherapy to be beneficial in 28 (53%) of 53 patients with atopic dermatitis and 19 (51%) of 37 patients with morphea. A beneficial outcome was recorded in all six (100%) cases of urticaria and six (85.7%) of seven patients treated for a polymorphic light eruption. Benefit was also recorded in systemic lupus erythematosus (8 (44.4%) of 18), lichen sclerosus (6 (42.9%) of 14), mastocytosis (2 (33.3%) of 6), necrobiosis lipoidica (4 (30.8%) of 13), granuloma annulare (2 (25%) of 8), scleroderma (2 (22.2%) of 9) and keloids (1 (7.7%) of 13). Overall, treatment was well tolerated with no patients having to stop treatment due to adverse effects. LIMITATIONS: This is a retrospective study with no control group. Subjective/recall bias is quite possible as a number of patients were followed up over the phone. CONCLUSIONS: Our data suggest that ultraviolet A1 can be considered for the treatment of selected dermatoses. However, long-term malignancy risk is as yet unknown.

Anatomical segmentations in all forms of vitiligo: A new dimension to the etiopathogenesis.

BACKGROUND: We have reported segmented lesions in acral vitiligo as well as in generalized vitiligo and thereby proposed somatic mosaicism as a predisposing feature in all forms of vitiligo. This study is a further attempt to characterize and understand such segmented lesions by screening a large series of patients. METHODS: We searched our electronic archives (from 2002 to 2014) and identified/reviewed the photos of 615 vitiligo patients inclusive of all clinical types. Over 3500 photographs were screened for patterns that were repeatedly seen in two or more patients and a composite picture of these were marked on a body map. RESULTS: Similar unilateral/bilateral segmented lesions were identified among all forms of vitiligo during relatively stable phases of the disease. These appeared to be related to small and large anatomical divisions of the body. In rapidly evolving disease on the trunk, the lesions conformed to Blaschkoid patterns. Several instances of stable mirror image lesions, symmetric incremental progressions and regressions were also recorded. LIMITATIONS: These are observations of a retrospective, single-center review which need to be substantiated further in larger prospective studies. CONCLUSION: Similar unilateral/bilateral segmented patterns delineating major/minor anatomical divisions of the body may indicate a preexisting developmental defect (such as mosaicism).

Acral Vitiligo and Lichen Sclerosus - Association or a Distinct Pattern?: A Clinical and Histopathological Review of 15 Cases.

BACKGROUND: Acral or acrofacial vitiligo (AFV) with bilateral lesions over the extremities and face is considered as a transitional form that may progress to generalized vitiligo. Oral and genital mucosal lesions are often integral to this pattern. Lichen sclerosus (LS) in a milder expression, results in oral and genital vitiligoid depigmentation without textural changes and thus needs to be differentiated from AFV. MATERIALS AND METHODS: We reviewed 217 cases of AFV recorded over a period of 12 years. RESULTS: One hundred and sixteen cases had associated oral/genital lesions. Among these, 15 patients demonstrated typical clinical as well as histological features of LS. DISCUSSION: Coexistence of typical LS essentially among oral and genital lesions of acral vitiligo suggests that acral vitiligo might be a distinct sub-group of NSV. Since both the diseases have an autoimmune basis, the co-existence may be explained by epitope spreading, as a result of interface dermatitis seen in vitiligo. In addition, the possibility of a common genetic predisposition needs to be explored.

Segmental and generalized vitiligo: both forms demonstrate inflammatory histopathological features and clinical mosaicism.

BACKGROUND: Segmental vitiligo (SV) and generalized vitiligo (GV) are perceived to evolve by different mechanisms, the former with unspecified neural mechanisms and the latter by melanocyte specific autoimmune mechanisms. However, the two diverse mechanisms are difficult to reconcile in cases of "mixed vitiligo". To test the possibility of a common pathogenesis, we reviewed clinical and histopathological features of SV and GV. MATERIALS AND METHODS: As part of an ongoing histopathological study on vitiligo and vitiligo like lesions, over a 10 year period from 2002 to 2011, biopsies were taken routinely from evolving or recently evolved lesions. 50 cases of SV with quasi-dermatomal distribution and 154 cases of GV were identified and the clinical and histopathological features were compared. RESULTS: Mild clinical inflammation was recorded in 33 of 154 GV cases but, none among 50 SV had such features. In addition to bilateral symmetrical involvement, mirror image lesions with unusual segmentation were observed in nine cases of GV. SV with a few bilateral lesions (4) and GV with quasi-dermatomal lesions (3), i.e., mixed vitiligo, were included in their corresponding groups for analytical purposes. Focal lichenoid inflammation of varying degrees around epidermal/adnexal melanocytes was identified as a common feature in evolving lesions of both SV (78%) and GV (70%). CONCLUSIONS: SV and GV demonstrated a similar inflammatory histopathological spectrum. "Segmentation/mosaicism", identified for the first time in GV is another unifying factor. Cutaneous mosaicism harboring fragile melanocyte populations, which are susceptible to external as well as auto-inflammatory mechanisms, is an attractive hypothesis to pursue in the causation of vitiligo.

Malignant tumours of the hand and wrist.

Malignant tumours are rare in the hand and wrist. The clinical presentation may be similar to that of a benign lesion and a high index of suspicion is necessary so that such lesions are not missed by the treating surgeon. Out of a total of 657 tumours/tumour-like lesions of the hand and wrist seen in a tertiary referral centre in a 10-year period, a total of 39 tumours were identified as malignant (5.9%) and of which majority had origin from the skin (53.8%). The management of these tumours is primarily surgical. Limb salvage surgery may be applied when appropriate, though eradication of disease should be the primary goal rather than preservation of function. A multimodal approach is necessary for appropriate management including chemotherapy and radiotherapy.

A review of pain experienced during topical photodynamic therapy--our experience in Dundee.

BACKGROUND: Topical photodynamic therapy (PDT) using 5-aminolaevulinic acid (ALA) and its methylated ester, methyl aminolevulinate (MAL) is widely used to treat superficial non-melanoma skin cancer (NMSC). It has been proposed that ALA PDT is more painful than MAL PDT. The aim of this paper was to compare pain scores of MAL PDT with ALA PDT in our patients and to analyse the relationship between various parameters and pain during PDT. METHODS: We retrospectively reviewed case notes and electronic records for all patients with superficial NMSC treated with PDT from June 2007 to March 2009. RESULTS: On univariate analysis of patients with single lesions only, we observed no association between pain and lesion diameter or pro-drug or dose or diagnosis. Pre-treatment PpIX fluorescence was significantly associated with pain. However on univariate analysis of all patients (whether single or multiple lesions) treated with PDT, MAL was associated with significantly less pain than ALA. When all the recorded variables were taken into account (multivariate analysis), diagnosis, pre-treatment PpIX fluorescence and lesion diameter were associated with pain. CONCLUSIONS: Our data lends some support to previous published reports suggesting that the MAL PDT regime is less painful than that for ALA PDT. However, PDT pain is multifactorial and choice of photosensitiser is probably not a major pain determining factor. A prospective randomised study, with the same incubation periods for each pro-drug, is needed to definitively answer the question as to whether or not MAL PDT causes less pain than ALA PDT.

Lichen sclerosus of lips: a clinical and histopathologic study of 27 cases.

BACKGROUND & METHODS: Oral lichen sclerosus (LS) has been considered uncommon and involvement of lips extremely rare. We reviewed the clinical and histologic features of 72 cases of LS with oral/genital involvement, seen in our institute from 2002 to 2007. RESULTS: Lichen sclerosus was diagnosed with exclusive genital lesions in 45, exclusive lip involvement in 20, and orogenital involvement in seven cases. Fifteen of 27 histologically confirmed lip LS lesions were considered as early inflammatory or presclerotic, eight were intermediate/progressive, and four as late resolved lesions. Lip LS presented as asymptomatic vitiligoid lesions in 70% and dermal sclerosis was demonstrable in only 44%, which was limited to the papillary layer. This was in contrast with genital LS lesions which were asymptomatic in only 12% and demonstrated both papillary and reticular dermal sclerosis in 69%. CONCLUSION: Lip LS is far less symptomatic and destructive with limited dermal sclerosis compared with genital LS. Greater awareness and histologic assessment are essential for diagnosis because of the misleading vitiligoid appearance. "Vitiligoid LS" a superficial variant proposed by Borda can be aptly applied to lip LS. Dermatologists need to be aware of this rarely reported manifestation of LS as it adds to the spectrum of oral lichenoid lesions and lichenoid dysplasia, which are suspected to have a malignant potential.

How we treat Bowen's disease with topical photodynamic therapy in Dundee.

We have more than 10 years experience in the Photobiology Unit, in the use of topical photodynamic therapy (PDT) for non-melanoma skin cancer and other skin diseases. During this time we have undertaken approximately 5000 treatments and this article details the practical aspects of how we treat Bowen's disease with topical PDT.

Lichenoid inflammation in vitiligo--a clinical and histopathologic review of 210 cases.

BACKGROUND: '"Inflammatory vitiligo" cases with clear lichenoid infiltrates have been reported. However, the inflammatory nature of common vitiligo has not gained wide acceptance because of its benign appearance and scanty cellular infiltrates. We have observed in our patients a few lesions with mild erythema, scaling and marginal hyperpigmentation which were suspected to be inflammatory. This study was conducted to assess the histological features and prevalence of such marginally active lesions, in comparison with common vitiligo. METHODS: Two hundred and ten consecutive new cases of vitiligo seeking treatment for the first time were included in this study. Clinical lesions were carefully examined and biopsies were taken in all cases. Biopsies were also taken from pigmented skin 3 cm away from the vitiligo lesion in 20 cases and normal pigmented skin over the contralateral side in 20. RESULTS: Marginally active lesions with erythema, scaling and hyperpigmentation were identified in 27 patients (13%). Lymphocytic infiltration of dermo-epidermal interface was observed in 89% of these cases which was clearly lichenoid in 59%. Similar lichenoid infiltrates were also seen in 50% of pigmented skin samples 3 cm away from the lesion and 23% of common macular vitiligo lesions. CONCLUSIONS: Vitiligo is an inflammatory disease that with development involves a lichenoid tissue reaction.

Vitiligoid lichen sclerosus: a reappraisal.

BACKGROUND: Many case studies of lichen sclerosus (LS) have reported an association of vitiligo. However, such an association is not reported from larger case studies of vitiligo, which happens to be a common disease. Autoimmune etiology suspected in both LS and vitiligo has been considered as the reason for their association in some patients. It has also been suggested that lichenoid inflammation in LS may trigger an autoimmune reaction against melanocytes. AIMS: To test this association, we reviewed clinical and histological features of 266 cases of vitiligo and 74 cases of LS in a concurrent study of both diseases. METHODS: All outpatients seen in our department between 2003 and 2006 and who were diagnosed as having LS or vitiligo on the basis of clinical and pathologic features were included in the study. RESULTS: Vitiligoid lesions were seen along with stereotypical LS lesions in three patients but all the three lesions had histological features of LS. Oral/genital areas were affected in 57 out of the 74 LS cases and of those, 15 were initially suspected to have vitiligo. These cases with a clinical appearance of vitiligo and histological features of LS were considered as 'vitiligoid LS', a superficial variant proposed by J. M. Borda in 1968. Association of LS was not observed in the 266 cases of vitiligo. CONCLUSION: Exclusive oral/genital depigmentation is a common problem and histological evaluation is essential to differentiate vitiligoid LS from true vitiligo. The association of vitiligo with LS may have been documented due to the clinical misdiagnosis of vitiligoid LS lesions as vitiligo as histological investigations were not undertaken in any of the reported cases.

Keratoacanthoma centrifugum marginatum arising in vitiligo: a case report.

Keratoacanthoma centrifugam marginatum (KCM) is a rare variant of the Keratoacanthoma (KA) form of squamous cell carcinoma with only 30 cases reported to date. We report a case of KCM arising in a long-standing vitiligo lesion chronically exposed to sunlight. Over years, the vitiligo lesions gradually evolved into sclerotic plaques and subsequently KCM developed in one of the plaques.