Treatment of toes as an integrated part of infection control for advanced lower limb lymphedema.

The aim of this study was to compare the incidence of infection and verrucous hyperkeratosis in patients who underwent surgery for advanced lymphedema according to the algorithm designed by the senior author, and were treated concurrently with/without toe treatment. A case series (Between 2004-2015) of 46 patients with unilateral advanced lower limb lymphedema was reviewed. Lymphoscintigraphy was used for evaluation of lymphedema severity. The ICG lymphography was used for staging. Fibrosis and skin induration were reflected by the tonicity. They were divided into two groups: (1) patients who underwent further treatment of toes according to the algorithm, and (2) patients who did not have toe-related treatment. Infection episodes and verrucous hyperkeratosis were recorded. There were 21 and 25 patients in Groups 1 and 2, respectively. All lymphoscintigrams showed severe dermal backflow with severe stagnation by 2.5 h after injection of Tc-99 colloid. All patients were stage IV or V. Tonicity values of skin were <60. Group 1 was reduced to an average of 0.6 episodes per year in the past year of follow-up, and Group 2 was reduced to an average of 1.5 episodes per year in the past year of follow-up (p <0.001). The average frequency of preoperative cellulitis was 3.6 episodes per year. The occurrence of verrucous hyperkeratosis was observed in 14.3% and 32% of Groups 1 and 2, respectively. The incidences of cellulitis and verrucous hyperkeratosis were significantly lower in Group 1 than in Group 2 (p <0.001). To achieve successful control of infection, they should be treated carefully according to the strategy described above.

Effect of a multi-sided concave liner barrel design on thickness and roughness of teat-end hyperkeratosis.

In a round liner barrel, the force of the closing liner is transferred by the two opposite sides of the liner wall to the teat apex. Liners with a multi-sided barrel shape close at three or more planes and distribute their force to a larger area of the teat apex. The objective of the study was to investigate effects of a liner with a multi-sided concave barrel design on the degree of teat-end hyperkeratosis, thickness and roughness, and on the time delay until thickness or roughness of teat-end hyperkeratosis responded to the experimental liner. The investigations were done on two dairy farms, one in USA and one in Germany. A split-udder arrangement of liners was used, and control treatment was a liner with round barrel shape. The test period comprised 14 weeks in the first study and 16 weeks in the second study. Thickness of teat-end hyperkeratosis was influenced by farm and test week. Roughness was influenced by farm, test week and treatment. In the first study, the incidence of rough teat-end hyperkeratosis was about 28 and 42% lower in teats milked with the experimental liner than in teats milked with the control liner by test weeks 11 and 14, respectively. In the second study, incidence of rough teat-end hyperkeratosis was rare in general, and in addition hardly occurred in teats milked with the experimental liner. The results indicate that the barrel design of the experimental liner causes similar effects on different farms but magnitude of the effect depends on initial incidence of teat end hyperkeratosis in the herd.

Phrynoderma and acquired acrodermatitis enteropathica in breastfeeding women after bariatric surgery.

BACKGROUND AND OBJECTIVES: Women who have undergone bariatric surgery are susceptible to nutritional deficiencies in subsequent pregnancies. We highlight the importance of dermatologists in the early recognition of cutaneous signs of malnutrition occurring in this specific clinical setting. PATIENTS AND METHODS: We compare clinical characteristics of two young women with dermatological signs of combined post-gestational nutritional deficiencies following Roux-en-Y gastric bypass surgery. RESULTS: Patient 1 exhibited follicular papules on the extremities, perianal eczema, perlèche, alopecia, and depigmentation of hair. Patient 2 showed erythematous plaques in genitoanal and acral areas, perlèche, diffuse alopecia, and depigmentation of hair. Based on clinical and histopathological findings, decreased vitamin A (patient 1) and zinc levels (patient 2), we diagnosed phrynoderma and acquired acrodermatitis enteropathica, respectively. Comparison of the two patients revealed that both (i) were lacking follow-up after gastric bypass surgery, (ii) developed skin lesions as primary symptoms with (iii) mixed clinical manifestations due to combined deficiencies, and (iv) experienced initial symptoms during lactation suggesting a causal relationship. CONCLUSIONS: Our observations highlight the potentially increased risk of women to develop post-gestational dermatological manifestations of malnutrition following bariatric surgery. The awareness of dermatologists with respect to this emerging, susceptible patient group may help avert damage to mother and child.

Systemic retinoids for the chemoprevention of cutaneous squamous cell carcinoma and verrucal keratosis in a cohort of patients on BRAF inhibitors.

BACKGROUND: The treatment of metastatic melanoma has changed greatly with the development of inhibitors targeted at the mutated BRAF kinase present in up to 50% of metastatic melanoma cases. These agents, vemurafenib and dabrafenib, have been shown to increase median survival. Unfortunately, they have also been associated with the development of verrucal keratosis (VK) and cutaneous squamous cell carcinoma (cuSCC). These lesions require surgical excision, and when a large number of these lesions need to be treated, it can significantly affect the patient's quality of life. OBJECTIVES: To determine if acitretin is suitable as a chemopreventative agent against the development of verrucal keratosis and cuSCC, in patients on BRAF inhibitors. METHODS: Patients treated with a BRAF inhibitor, vemurafenib or dabrafenib, for stage IV metastatic melanoma, who had undergone more than five surgical excisions to remove lesions suggestive of cuSCC, were offered the opportunity to commence acitretin as a chemopreventative agent. Patients were evaluated every 4 weeks. Clinical and histological data were collected. RESULTS: Eight patients, who had a total of 24 cuSCC removed, were included in the study. After commencement of acitretin, only five cuSCC were excised from two patients. The most significant reduction was in a patient who had developed 13 cuSCC over 10 months and only two cuSCC 3 months after commencing acitretin. No modifications in the dose of the BRAF inhibitor were made as a result of cuSCC in any of these patients. CONCLUSIONS: Acitretin should be considered as a chemopreventative agent for VK and cuSCC in patients taking BRAF inhibitors, before considering dosage reductions.

External auditory canal cholesteatoma and keratosis obturans: the role of imaging in preventing facial nerve injury.

We conducted a retrospective study to compare the clinical characteristics of external auditory canal cholesteatoma (EACC) with those of a similar entity, keratosis obturans (KO). We also sought to identify those aspects of each disease that may lead to complications. We identified 6 patients in each group. Imaging studies were reviewed for evidence of bony erosion and the proximity of disease to vital structures. All 6 patients in the EACC group had their diagnosis confirmed by computed tomography (CT), which demonstrated widening of the bony external auditory canal; 4 of these patients had critical erosion of bone adjacent to the facial nerve. Of the 6 patients with KO, only 2 had undergone CT, and neither exhibited any significant bony erosion or expansion; 1 of them developed osteomyelitis of the temporal bone and adjacent temporomandibular joint. Another patient manifested KO as part of a dermatophytid reaction. The essential component of treatment in all cases of EACC was microscopic debridement of the ear canal. We conclude that EACC may produce significant erosion of bone with exposure of vital structures, including the facial nerve. Because of the clinical similarity of EACC to KO, misdiagnosis is possible. Temporal bone imaging should be obtained prior to attempts at debridement of suspected EACC. Increased awareness of these uncommon conditions is warranted to prompt appropriate investigation and prevent iatrogenic complications such as facial nerve injury.

Dermatology and the community nurse: actinic (solar) keratosis.

Community nurses are in daily contact with patients and, in the course of their day's work, have every opportunity of recognizing those patients who are more vulnerable to the sun's rays, and noticing actual sun damage and actinic keratoses. They are then able to check other sun-exposed areas such as the face, ears, scalp, back and limbs to discover any other lesions or more serious problems of basal cell carcinoma, squamous cell carcinoma or malignant melanoma the would require referral, sometimes urgently, to a dermatologist for full assessment and treatment. In any case, sound advice about further protection from the sun, both for themselves and their families may help to reduce the likelihood of further problems.

Update on sunscreens.

Sunscreens have been around for more than 70 years. Designed originally to protect against sunburn, recognition of the various harmful effects of ultraviolet (UV) radiation has broadened the use of sunscreens. The addition of effective UVA sunscreen agents has enabled claims beyond protection against sunburn to include prevention of idiopathic photodermatosis, actinic keratoses, skin cancer, and photoaging. This article will review some of the recent advances in photoprotection, including the development of sunscreen formulations offering higher and broader protection against solar radiation.

Photodynamic therapy with methyl aminolevulinate for prevention of new skin lesions in transplant recipients: a randomized study.

BACKGROUND: Organ transplant recipients on long-term immunosuppressive therapy are at increased risk of non-melanoma skin lesions. Repeated field photodynamic therapy using topical methyl aminolevulinate (MAL) may have potential as a preventive treatment. METHODS: This open randomized, intrapatient, comparative, multicenter study included 81 transplant recipients with 889 lesions (90% actinic keratoses (AK)]. In each patient, the study treatment was initially administered to one 50 cm area on the face, scalp, neck, trunk, or extremities (n=476 lesions) twice (1 week apart), with additional single treatments at 3, 9, and 15 months. On each occasion, the area was debrided gently and MAL cream (160 mg/g) applied for 3 hr, before illumination with noncoherent red light (630 nm, 37 J/cm2). The control, 50 cm2 area (n=413 lesions) received lesion-specific treatment (83% cryotherapy) at baseline and 3, 9, and 15 months. Additionally, all visible lesions were given lesion-specific treatment 21 and 27 months in both treatment and control areas. RESULTS: At 3 months, MAL photodynamic therapy significantly reduced the occurrence of new lesions (65 vs. 103 lesions in the control area; P=0.01), mainly AK (46% reduction; 43 vs. 80; P=0.006). This effect was not significant at 27 months (253 vs. 312; P=0.06). Hypopigmentation, as assessed by the investigator, was less evident in the treatment than control areas (16% vs. 51% of patients; P<0.001) at 27 months. CONCLUSION: Our results suggest that repeated field photodynamic therapy using topical MAL may prevent new AK in transplant recipients although further studies are needed.

Actinic keratosis: an occupational and environmental disorder.

Solar ultraviolet light electromagnetic waves are a known environmental carcinogenic agent closely associated with the development of skin cancer in light-complexioned individuals. Outdoor workers have higher annual exposure to ultraviolet light. We will review the topic of actinic keratoses among these individuals as this common rudimentary form of superficial cutaneous squamous cell carcinoma is explored in greater detail.

Sociocultural aspects of arsenicosis in Bangladesh: community perspective.

This was a cross-sectional study under taken to explore the socioeconomic perspective of the arsenicosis problem, carried out in arsenic contaminated Upazillas where at least 100 arsenicosis patients had been identified. Two of the Upazillas with significant arsenic mitigation intervention and three of the Upazillas with limited interventions were selected for the study. Seven hundred fifty respondents were included in the study from 25 villages of the 5 Upazillas. Arsenicosis became a serious problem for the affected communities. Majority (71.31%) of respondents obtained their drinking water from tubewells, almost one third (29%) of the respondents still knowingly using arsenic contaminated water. Primary reason identified for this practice was distance of safe water source. Majority (58.6%) of the respondents said to face economic and 17.9% said to face social problem of varied range. Patients of lower income group were particularly more likely to face economic problems (P< .001) as well as social problem (P< .01). About half (50.7%) of the arsenicosis patients faced difficulty whilst receiving treatment, particularly female patients were more likely to face problem than male (P< .05). Several concerns also were surfaced regarding the heath care service provider particularly to the women patients, some of which are: long waiting time for receiving treatment (15%), discrimination in service delivery (10.7%) and inadequate separate facility for female patients (14.3%). Moreover the issues of financial burden raised by the respondents seem to have emerged as significant in terms of health care access. Access to Health service was particularly difficult for poor patients, as they often had to face problems associated with accessing service like, non availability of medicines in the hospitals (50.7%), traveling long distance (26.7%), purchasing medicine in most cases (32.4%) etc. Their dissatisfaction was compounded by negligent behavior of health care staff and nature of treatment provided. Furthermore length of time needed for reversal of symptoms led to loosing faith on efficacy of treatment, which cascades to negligence of patient's part in seeking health care. Women are less likely to get treatment for arsenicosis than men (P< .01). As there appear to be specific difficulties for women particularly for poor women in accessing health care, social and cultural values make it difficult for them to attend to their own health needs and to travel to service providers. Study findings suggest that a significant proportion (79.9%) of arsenicosis patient was found to access alternative health care. This includes; Homeopath, village doctors, Kabiraj and local pharmacists. Respondents in high intervention Upazillas were significantly more likely to get treatment (P< .05), to face fewer problems and to be satisfied with the facility (P< .001). Provision of safe water options, periodic screening of water source for arsenic, availability of trained doctor, regular availability of medicine, doorstep treatment, follow up on severe patients were the suggestions came from community for improvement.

The role of topical cyclo-oxygenase-2 inhibitors in skin cancer: treatment and prevention.

Cyclo-oxygenases (COXs) are rate-limiting enzymes in arachidonic acid metabolism and prostaglandin production. COX-2 is the main UV-responsive COX isoform in human skin and is involved in UV-induced skin inflammation and apoptosis. The topical NSAID diclofenac works as a nonspecific COX inhibitor and is an effective and well tolerated treatment for actinic keratosis, which is a principal precursor of cutaneous squamous cell carcinoma. Oral and topical COX-2 inhibitors have chemopreventive activity against chemically and UV light-induced skin cancer in animal models. The mechanism of action of COX inhibitors in skin tumorigenesis is complex and not completely understood. Clinical trials to evaluate whether topical administration of NSAIDs or specific COX-2 inhibitors can prevent skin cancer in high-risk patients are warranted.

Reliability of the histopathologic diagnosis of keratinocyte carcinomas.

OBJECTIVE: We sought to determine the interobserver reliability of the histopathologic diagnosis of basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) (keratinocyte carcinomas) in the setting of a Department of Veteran Affairs multicenter chemoprevention study. METHODS: Interobserver concordance was assessed by blinded review of histopathologic slides by study dermatopathologists. RESULTS: Overall interobserver agreement between the two dermatopathogists was kappa = 0.69 (95% confidence interval [CI] 0.67-0.69). The dermatopathologists' interobserver agreement was highest for basal cell carcinoma at kappa = 0.88 (95% CI 0.84-0.91) and for a diagnostic category in the SCC-actinic keratosis spectrum at kappa = 0.80 (95% CI 0.73-0.86). The largest disagreements between the two reference dermatopathologists were regarding the categories of invasive SCC at kappa = 0.62 (95% CI 0.52-0.72), SCC in situ at kappa = 0.42 (95% CI 0.29-0.56), and actinic keratosis at kappa = 0.51 (95% CI 0.40-0.62). Agreement between the local pathologists and central reference dermatopathologists were similar to the agreement between the central dermatopathologists. The morphea subtype of basal cell carcinoma was the only reliably diagnosed subtype (kappa = 0.79, 95% CI 0.51-1.00), and tumor depth was reliably measured. LIMITATIONS: A limitation of this study was the use of only two reference dermatopathologists. CONCLUSION: Because of the impact on physician decision making and patient care, researchers and clinicians need to be aware of reliability of histopathology results, particularly pertaining to the SCC and actinic keratosis spectrum.

Management of actinic keratosis patients: a qualitative study.

OBJECTIVES: In order to reinforce the appropriate UV-related behaviour of patients with actinic keratosis (AK), it is of importance to understand the underlying psychological aspects of having AK. MATERIALS AND METHODS: Open and systematic explorative interviews were conducted with 15 AK patients. Open, single interviews (n = 6) were made and summarized. Partly based on topics found by the single interviews, two qualitative group interviews (n = 7) with AK patients were performed. The topics of general importance were identified through analysis of the statements given at the group interviews. A third group interview (n = 2) was made to confirm the analytical results from the former interviews. RESULTS: Important topics for patients with AK were found to relate to the way to act in the sun (leisure time and outdoor work), a changed appearance, the seriousness of the AK diagnosis, control of the disease, and the sense of illness due to AK. Emotional reactions included worry, fear, irritation, doubt, guilt, and a relaxed attitude. CONCLUSION: It is suggested that the topics touched upon form psychological and pedagogical reference points for patient behaviour. Awareness of these topics is therefore recommended in the management of patient information related to AK.

Chemopreventative thoughts for photodynamic therapy.

The concept of skin cancer prevention with photodynamic therapy has evolved over the past few years to include large surface application of aminolevulinic acid or methyl aminolevulinate followed by light exposure to prevent the development of new lesions. Pre-clinical studies using various mouse models have shown that large surface photodynamic therapy can prevent the appearance of actinic keratoses, squamous cell carcinomas, and basal cell carcinomas. Recent clinical studies also suggest that large surface photodynamic therapy can prevent the development of actinic keratoses and possibly skin cancer.

Facial resurfacing for nonmelanoma skin cancer prophylaxis.

OBJECTIVE: To determine the effect of facial skin resurfacing for treatment of actinic keratoses (AKs) and prophylaxis against new primary basal and squamous cell carcinomas in individuals with previous nonmelanoma skin cancer (NMSC) or severe photodamage. DESIGN: Randomized, prospective 5-year trial. SETTING: Dermatology and otolaryngology clinics of a Veterans Affairs hospital. PATIENTS: Thirty-four patients with a history of facial or scalp AKs or basal or squamous cell carcinoma were enrolled. Five of 7 eligible patients who declined study-related treatment were used as controls. Twenty-seven patients were randomized to 3 treatment arms; 3 patients were discontinued from the study. INTERVENTIONS: Carbon dioxide laser resurfacing, 30% trichloroacetic acid peel, or 5% fluorouracil cream applied twice daily for 3 weeks. MAIN OUTCOME MEASURES: Reduction in the number of AKs was measured 3 months after treatment. The incidence of new NMSC in treated areas was assessed between January 1, 2001, and June 30, 2005. Times from baseline to diagnosis of first skin cancer were compared between the treatment and control groups. RESULTS: Treatment with fluorouracil, trichloroacetic acid, or carbon dioxide laser resulted in an 83% to 92% reduction in AKs (P< or =.03), a lower incidence of NMSC compared with the control group (P<.001), and a trend toward longer time to development of new skin cancer compared with the control group (P=.07). However, no significant differences were noted among the treatment groups. CONCLUSION: All 3 modalities demonstrated benefit for AK reduction and skin cancer prophylaxis compared with controls and warrant further study in a larger trial.

Topical photodynamic therapy for prevention of new skin lesions in renal transplant recipients.

Preclinical data suggest that topical methyl aminolevulinate photodynamic therapy may have potential in preventing new skin lesions in transplant recipients. An open intra-patient randomized study investigated the prevention potential of this treatment in 27 renal transplant patients with actinic keratoses and other skin lesions in two circular contralateral areas (5 cm diameter). The treatment area surface was debrided and methyl aminolevulinate cream (160 mg/g) was applied for 3 h prior to illumination by non-coherent red light (570-670 nm, light dose 75 J/cm2). The control area was not treated. The mean time to occurrence of the first new lesion was significantly longer in treated than control areas (9.6 vs 6.8 months, treatment difference 2.9 [95% confidence interval 0.2 to 5.5] months, p = 0.034). Over 12 months, 62% (16/26) of treated areas were free from new lesions compared with 35% (9/26) in control areas. These findings indicate that topical methyl aminolevulinate photodynamic therapy is a promising preventive treatment against new skin lesions in immunosuppressed patients.

Mechanisms of action of new treatment modalities for actinic keratosis.

Actinic keratosis (AK) constitutes the initial lesion in a disease continuum that can progress to invasive squamous cell carcinoma (SCC). In this article, we describe the mechanisms of action, tolerability, and efficacy of the most frequently used chemopreventative, chemotherapeutic, destructive, and novel immunologic methods for the control and treatment of actinic keratoses.

An overview of ultraviolet radiation, sunscreens, and photo-induced dermatoses.

The incidence of sunlight-induced skin aging and skin cancers, particularly melanoma skin cancer, has been increasing in many parts of the world. Authorities are recommending primary prevention programs to reduce cutaneous photodamage and skin carcinogenesis. An integral component of these programs is the use of protective clothing and effective sunscreens. Most modern sunscreens have highly efficient absorption or reflecting capabilities throughout ultraviolet B, partly ultraviolet A, and in some instances infrared wavelengths. Over the last several years, more efficient sunscreening ingredients have been developed for improved skin protection. More recently, direct evidence has demonstrated the effectiveness of sunscreens in their ability to reduce the incidence of solar keratoses. This article reviews the protectiveness of sunscreens and assays that predict their levels of protection.