Risk factors for incomplete excision of basal cell carcinomas

Incomplete excision of basal cell carcinomas (BCCs) may be followed by recurrence of the tumor. In order to detect risk factors for incomplete excision of BCCs we performed a cross-sectional study of 1278 patients who underwent a primary excision of BCCs, during a four-year period, within an ambulatory and hospital plastic surgery department setting. Incomplete excision occurred in 159 of 1478 primary excisions of BCCs (10.8%) and was significantly associated with location of the tumors in the eyelids (OR 3.64, 95% CI 1.96-6.71), ears (OR 2.51, 95% CI 1.25-4.94), naso-labial folds (OR 2.26, 95% CI 0.99-5.04) and nose (OR 1.88, 95% CI 1.30-2.71). There was an inverse association with location of the tumors in the upper limbs (OR 0.44, 95% CI 0.21-0.90), back (OR 0.12, 95% CI 0.02-0.48) or chest (OR 0.09, 95% CI 0.00-0.57). Baso-squamous differentiation was associated with incomplete excision of BCCs (p = 0.03). No association was observed between incomplete excision of BCCs and gender, age, setting of the operation (ambulatory vs. hospital), clinical appearance of the lesion (suspected BCCs vs. other diagnoses) or diameter of the lesions. In conclusion, incomplete excision of BCCs was associated with location of the tumors in the eyelids, ears, naso-labial folds and nose. We recommend that in patients with BCCs located in these sites, surgeons should commence particular surgical measures to avoid inadequate excisions of the tumors.     

Epidemiologic risk factors of basal cell carcinoma development and age at onset in a Southern European population from Greece

Background: Basal cell carcinoma (BCC) is the most common form of skin cancer with increasing incidence rates worldwide. Methods: To assess the association of BCC with epidemiologic risk factors in a Southern European population from Greece, we conducted a hospital‐based case–control study of 199 patients with BCC and 200 controls. Results: In the multivariate analysis, fair skin colour was associated with increased risk of BCC (OR: 4.9, 95% CI: 2.4–10.0). However, darker skin phototypes III/IV (patient’s reported sun sensitivity/tanning ability) showed a higher BCC risk (OR: 3.9, 95% CI: 1.8–8.5). Persons with occupational UV exposure of 5 years or more had a 2.7‐fold increased risk (95% CI:1.4–5.3). There was an increased risk of BCC related to the number of sunburns after the age of 20 years (OR: 3.2, 95% CI: 1.4–7.3) and solar lentigines (OR: 6.8, 95% CI: 3.6–12.8). Subgroup analysis showed that different risk factors are associated with early onset BCC including the presence of dysplastic nevi (OR: 6.4, 95% CI: 1.5–27.2), the number of weeks per year spent at the beach during childhood (OR: 8.9, 95% CI: 3.3–24.1) and the history of sunburns during childhood (OR:5.0, 95% CI: 1.3–19.1). Conclusions: Fair skin colour was significantly associated with BCC risk. The relation of sunburns during adulthood with BCC underlies the importance of sunburn prevention throughout life time. Early onset BCCs seem to have a different pathogenetic background and were associated with dysplastic nevi as well as intermittent sun exposure and sunburns during the early years of life.     

Occupational ultraviolet light exposure increases the risk for the development of cutaneous squamous cell carcinoma: a systematic review and meta-analysis

Background Despite the fact that ultraviolet (UV) light exposure is the most important risk factor for cutaneous squamous cell carcinoma (SCC) there is an ongoing debate concerning the relationship between cumulative work‐related UV exposure and SCC occurrence. Objectives To analyse comprehensively the relationship between work‐related UV exposure and SCC risk. Methods We conducted a systematic electronic literature search in PubMed (up to 5 May 2010) supplemented by a hand search, which identified 18 relevant studies that were included in the review. Data abstraction and study quality assessment was done independently by two reviewers. Maximally adjusted odds ratios (ORs) and corresponding 95% confidence intervals (CIs) of all included studies were pooled in a random‐effects meta‐analysis. Sensitivity analysis included meta‐regression on study‐specific covariates to explore the robustness of the results and to identify sources of heterogeneity between studies. Eighteen studies (six cohort studies, 12 case–control studies) met the eligibility criteria and were included in the systematic review. Results Sixteen studies (89%) found an increased risk of SCC in individuals with occupational UV light exposure compared with individuals without occupational UV light exposure, reaching statistical significance in 12 studies. Two studies found no association between occupational UV light exposure and SCC occurrence. The pooled OR (95% CI) was 1·77 (1·40–2·22) and did not differ significantly between cohort studies [OR (95% CI): 1·68 (1·08–2·63)] and case–control studies [OR (95% CI): 1·77 (1·37–2·30)]. Meta‐regression analyses suggested an increasing strength of the association between occupational UV light exposure and SCC risk with decreasing latitude. Conclusions In summary, there is consistent epidemiological evidence for a positive association between occupational UV light exposure and SCC risk.     

Lack of evidence for a protective effect of prolonged breastfeeding on childhood eczema: lessons from the International Study of Asthma and Allergies in Childhood (ISAAC) Phase Two

Summary Background Exclusive breastfeeding for at least 4 months is recommended by many governments and allergy organizations to prevent allergic disease. Objectives To investigate whether exclusive breastfeeding protects against childhood eczema. Methods Study subjects comprised 51 119 randomly selected 8‐ to 12‐year‐old schoolchildren in 21 countries. Information on eczema and breastfeeding was gathered by parental questionnaire. Children were also examined for flexural eczema and underwent skin prick testing. Odds ratios (ORs) were calculated for each study centre and then pooled across populations. Results There was a small increase in the risk of reported ‘eczema ever’ in association with ‘breastfeeding ever’ and breastfeeding < 6 months [pooled adjusted OR 1·11, 95% confidence interval (CI) 1·00–1·22 and OR 1·10, 95% CI 1·02–1·20, respectively]. There was no significant association between reported ‘eczema ever’ and breastfeeding > 6 months (pooled adjusted OR 1·09, 95% CI 0·94–1·26). Risk estimates were very similar for exclusive breastfeeding < 2 months, 2–4 months and > 4 months and for eczema symptoms in the past 12 months and eczema on skin examination. As for more severe eczema, breastfeeding per se conveyed a risk reduction on sleep disturbed eczema (pooled adjusted OR 0·71, 95% CI 0·53–0·96), but this effect was lost where children had been exclusively breastfed for > 4 months (pooled adjusted OR 1·02, 95% CI 0·67–1·54). Allergic sensitization and a history of maternal allergic disease did not modify any of these findings. Conclusions Although there was a protective effect of ever having been breastfed on more severe disease, we found no evidence that exclusive breastfeeding for 4 months or longer protects against eczema. Our results are consistent with findings from a recent systematic review of prospective studies. The U.K. breastfeeding guidelines with regard to eczema should be reviewed. Intervention studies are now required to explore how and when solids should be introduced alongside breastfeeding to aid protection against eczema and other allergic diseases.     

Five–year results of curettage–cryosurgery of selected large primary basal cell carcinomas on the nose: an alternative treatment in a geographical area underserved by Mohs' surgery

Mohs' micrographic surgery (MMS) is the recommended treatment for large basal cell carcinomas (BCCs) of the nose. This 5–year follow–up study attempts to evaluate whether curettage–cryosurgery (CC) could be an alternative therapy in a country where optimal resources for MMS are lacking. All patients with a primary nasal or perinasal BCC, 10 mm or larger in diameter, were assessed at a skin tumour clinic. Sixty–one BCCs of non–morphoeiform type were treated with CC. Most of the tumour was removed by careful curettage with different sized curettes. The tumour area was then frozen with liquid nitrogen in a double freeze–thaw cycle. Fifty patients were followed for at least 5 years with only one recurrence. The cosmetic result was good or acceptable in all patients. A thorough curettage followed by cryosurgery could be a safe and inexpensive alternative therapy even for large primary non–morphoeiform BCCs of the nose.     

Comparison of NB-UVB combination therapy regimens for vitiligo: A systematic review and network meta-analysis

Background

Vitiligo was an autoimmune disease and some guidelines for the management of vitiligo encouraged the use of NB-UVB combination therapies to enhance repigmentation.

Objectives

To compare the effectiveness of current NB-UVB combination regimen at the improvement in repigmentation through a systematic review and network meta-analysis.

Methods

We searched the electronic databases for randomized controlled trials related to NB-UVB combination therapy for vitiligo till October 2022. STATA15.0 software was applied to carrying out data analysis.

Results

A total of 28 eligible studies involving 1194 participants were enrolled in the analysis. The NMA results revealed that compared with NB-UVB, carboxytherapy [OR = 32.35, 95% CI (1.79, 586.05)], Er: YAG laser+ topical 5% 5-FU [OR = 10.74, 95% CI (4.05, 28.49)], needling/micro-needling [OR = 3.42, 95% CI (1.18, 9.88)], betamethasone intramuscular injection [OR = 3.08, 95% CI (1.17, 8.13)], topical tacrolimus [OR = 2.54, 95% CI (1.30, 4.94)], and oral Chinese herbal medicine compound [OR = 2.51, 95% CI (1.40, 4.50)] integrated with NB-UVB were more efficacious in excellent to complete repigmentation response rate (≥75%). Besides, NB-UVB+ Er: YAG laser+ topical 5% 5-FU [OR = 0.17, 95% CI (0.04, 0.67)] and NB-UVB+ needling/micro-needling [OR = 0.24, 95% CI (0.06, 0.88)] were less likely evaluated as ineffective repigmentation response (≤25%).

Conclusions

All combination therapies ranked higher than NB-UVB monotherapy in inducing successful repigmentation and avoiding failed treatment in patients with vitiligo. Comprehensive consideration, NB-UVB+ Er: YAG laser+ topical 5% 5-FU and NB-UVB+ needling/microneedling would be the preferred therapeutic approaches.     

Margin involvement and clinical pattern of basal cell carcinoma with mixed histology

Background Mixed basal cell carcinoma (BCC) has not been sufficiently and specifically studied. Objective The aim of this study was to estimate in adults the prevalence of mixed cases observed among primary BCCs and to compare clinical and anatomical features of mixed vs. single BCCs, with focus on the incomplete excision. Patients and methods A total of 3636 histologically confirmed primary BCCs were examined. Data on gender, age, histological subtype, anatomical location and margin involvement were collected. Mixed type was defined as a combination of two or more single subtypes. Results Prevalence of single and mixed BCCs was 82.2% and 17.8% respectively. Prevalence of BCCs on the upper limbs was higher in mixed than single cases (8.8% vs. 4.0%; P < 0.001) while prevalence on the back was lower (16.9% vs. 23.7%; P < 0.001). Tumour was aggressive in 59.1% of mixed vs. 16.0% of single BCCs (P < 0.001). Margin involvement was more prevalent in mixed than in single BCCs (16.7% vs. 9.6%; P < 0.0001). At multivariate analysis being mixed vs. single BCC was associated with aggressiveness of tumour (OR = 8.5, 95% CI, 6.9–10.4), lateral margin involvement (OR = 1.98, 95% CI, 1.42–2.76) and subject being man (OR = 1.31, 95% CI, 1.10–1.60) but not with deep involvement of margin or anatomical location. Conclusion Among BCCs, the mixed type may be observed in adults with relatively high rate and may represent a complex and individual subset of BCCs with potential aggressive behaviour.     

[Translated article] Risk of a Second Skin Cancer in a Cohort of Patients With Nonmelanoma Skin Cancer – Basal Cell Carcinoma or Squamous Cell Carcinoma – Treated With Mohs Micrographic Surgery: A National Prospective Cohort Study

ObjectivePatients with nonmelanoma skin cancer (NMSC)—ie, basal cell carcinoma (BCC) or squamous cell carcinoma (SCC)—have an increased risk of developing a second skin cancer. The aim of this study was to describe the frequency, incidence per 1000 person-years, and predictors of a second skin cancer in a cohort of patients with NMSC treated with Mohs micrographic surgery (MMS).Material and methodsProspective study of a national cohort of patients with NMSC who underwent MMS at 22 Spanish hospitals between July 2013 and February 2020; case data were recorded in the REGESMOHS registry. The study variables included demographic characteristics, frequency and incidence per 1000 person-years of second skin cancers diagnosed during the study period, and risk factors identified using mixed-effects logistic regression.ResultsWe analyzed data for 4768 patients who underwent MMS; 4397 (92%) had BCC and 371 (8%) had SCC. Mean follow-up was 2.4 years. Overall, 1201 patients (25%) developed a second skin cancer during follow-up; 1013 of the tumors were BCCs (21%), 154 were SCCs (3%), and 20 were melanomas (0.4%). The incidence was 107 per 1000 person-years (95% CI, 101–113) for any cancer, 90 per 1000 person-years (95% CI, 85–96) for BCC, 14 (95% CI, 12–16) per 1000 person-years for SCC, and 2 (95% CI, 1–3) per 1000 person-years for melanoma. More men than women developed a subsequent skin cancer (738 [61%] vs 463 [39%]). The main risk factors were a history of multiple tumors before diagnosis (relative risk [RR], 4.6; 95% CI, 2.9–7.1), immunosuppression (RR, 2.1; 95% CI, 1.4–3.1), and male sex (RR, 1.6; 95% CI, 1.4–1.9).ConclusionPatients have an increased risk of developing a second tumor after MMS treatment of NMSC. Risk factors are a history of multiple tumors at diagnosis, immunosuppression, and male sex.     

Psychological distress and investment in one’s appearance in patients with pemphigus

Background Pemphigus vulgaris is a chronic disease not currently curable. Physical involvement and the impact of chronic therapies can lead patients to changes in psychological and relational areas. Objectives To provide a measure of psychological distress, dysfunctional investment in one's appearance, and their relationship. Methods Self‐administered questionnaires (ASI, HADS) were given to 74 pemphigus inpatients. Results Strong associations between psychological distress and dysfunctional investment in one's appearance were observed [adjusted odds ratio (OR) = 7.36, 95% confidence intervals (CI) 1.20–45.11; OR 5.38, 95% CI 0.81–35.87, respectively, for appearance stereotyping and body‐image vulnerability], together with a perceived high disease severity (OR 6.03, 95% CI 1.90–23.46). Conclusions Our results are compatible with the idea that some forms of psychological distress could be in part due to one's perception of his/her own body image.     

Vitamin D‐binding protein polymorphisms are not associated with development of (multiple) basal cell carcinomas

Abstract: Vitamin D‐binding protein (VDBP) single nucleotide polymorphisms (SNP) may affect skin carcinogenesis. The objective was to test the association between two functional VDBP SNPs and the susceptibility to (multiple) basal cell carcinomas (BCCs). Of the 7983 participants, 5790 (72.5%) and 5823 (72.9%) participants were genotyped for rs7041 and rs4588, respectively, and three haplotypes (Gc1s, Gc2 and Gc1f) were analysed. Two hundred and thirty‐three persons developed a BCC of whom 122 (52.4%) developed multiple BCCs during a mean follow‐up of 11.6 years. The VDBP genotype was not associated with (multiple) BCC development using Cox proportional hazards and Andersen‐Gill analyses, respectively. Stratifying age groups demonstrated that in the youngest age‐group, the A/T variant of rs7041 was associated with BCC development [adjusted hazard ratio (HR) = 1.88 (95%CI 1.10–3.20)], while homozygote Gc1s carriers had a significantly lower BCC risk [adjusted HR = 0.53 (95%CI 0.31–0.91)]. In conclusion, the VDBP polymorphisms were not associated with susceptibility to (multiple) BCCs, but age–gene interactions were observed.     

Risk assessment for nickel contact allergy

Nickel is one of the most common allergens causing allergic contact dermatitis worldwide. The aim of the study was to evaluate the contributing factors to nickel contact allergy (NiCA) in Asians who have a unique culture and lifestyle. We randomly selected 324 previously patch‐tested patients, 162 nickel patch test (PT)‐positive patients and 162 nickel PT‐negative patients. The patients were telephone interviewed for their lifestyle information. Most of the nickel PT‐positive patients (93.2%) were female with a mean age of 38.9 ± 13.3 years compared with the other group of nickel PT‐negative patients who had a smaller proportion of females (76.5%) with an older mean age of 44.1 ± 14.9 years (P = 0.001). Multivariate analysis was able to establish that the significant risk factors for NiCA were female sex (odds ratio [OR], 6.38; 95% confidence interval [CI], 2.15–18.94), young age (OR, 0.98; 95% CI, 0.96–1.00), occupation with long periods of exposure to metal (OR, 3.08; 95% CI, 1.18–8.02), seafood (OR, 1.96; 95% CI, 1.17–3.27) and canned food consumption (OR, 3.12; 95% CI, 1.17–8.33) (P < 0.05). The adjusted factors found to associate with NiCA were female sex, young age, occupation with long periods of exposure to metal, seafood and canned food consumption.     

Subclinical Infiltration of Basal Cell Carcinoma in Asian Patients: Assessment after Mohs Micrographic Surgery

Background

Several differences in basal cell carcinomas (BCCs) were found, according to the ethnic group; for example, pigmented BCCs was more common in Asian or Hispanic patients. However, there are few reports on the subclinical extension of the BCC in Asian patients.

Objective

The aim of this study was to evaluate the subclinical infiltration of the basal cell carcinoma in Asian patients.

Methods

All patients with BCC who visited the department of dermatology at Korea University Ansan Hospital were treated with Mohs micrographic surgery. In 81 patients, 83 tumors of BCC were completely eradicated by Mohs micrographic surgery (MMS) from April 2001 to August 2008, and were reviewed in this study. Information recorded included the total margin and the number of stages of Mohs micrographic surgery, anatomic location, tumor size, presence of pigmentation, clinical type, and pathological subtype. We divided the clinical types into nodular, ulcerated, and pigmented, and the pathological types into nodular, micronodular, morpheaform, and adenoid. The BCC was of pigmented type if pigmentation covered more than 25% of the tumor, regardless of whether pigmentation was distinct, or if there was apparent pigmentation that covered more than 10% of the tumor.

Results

The nose and cheek were the most common sites requiring more than one stage of surgery. In tumors smaller than 1 cm, 91.7% required only one stage of excision, compared with 60.6% in tumors larger than 1 cm. More than two Mohs stages were required in 25% of non-ulcerated BCCs and in 46.2% of ulcerated BCCs. Sixty eight percent of pigmented BCCs required only one stage of Mohs micrographic surgery. In cases of non-pigmented BCCs, only 45% required one Mohs stage. More than one Mohs stage was required in 19.2% of non-aggressive BCCs and in 42.9% of aggressive BCCs.

Conclusion

Subclinical infiltration differed between the two groups according to the size of the BCC (1 cm threshold) and most of the BCCs were located in the head and neck area. Considering this result, indication for MMS can be extended for BCCs larger than 1 cm in Asian patients. Ulcerated BCCs required more Mohs stages than non-ulcerated BCCs. Pigmented BCCs might show lesser subclinical infiltration than non-pigmented BCCs. Aggressive pathological subtypes showed more subclinical infiltration than the non-aggressive types; however, after evaluation of the border that was excised with MMS, mixed histologic types were found to be more frequent than generally accepted. Therefore, we consider that, when planning surgery, dermatologists should not place too much confidence in the pathologic subtypes identified by biopsy.     

Do the health‐care workers gain protection against herpes zoster infection? A 6‐year population‐based study in Taiwan

Varicella zoster virus (VZV) causes varicella, and may reactivate to cause herpes zoster later in the life of the host. It has been previously observed that exposure to VZV may boost the host’s latent immunity. Health‐care workers who are frequently exposed to ill patients ought to receive a protective effect. We investigated the incidence of herpes zoster among health‐care workers and the general population in Taiwan to see whether such a protective effect exists among health‐care workers against herpes zoster. This nationwide population‐based retrospective cohort study was based on data obtained from the Taiwan National Health Insurance Database. In total, 7744 health‐care workers, including 168 dermatologists and pediatricians, and 695 188 general adults were recruited for the study. Health‐care workers in the age groups 20–29, 30–39 and 40–49 years were found to have a significant higher herpes zoster incidence compared to the general adults (P < 0.001, 0.011 and <0.001, respectively). Both logistic regression and Cox regression showed that dermatologists, pediatricians, and other medical professionals have a higher herpes zoster incidence than the general population (odds ratio [OR] = 1.36, 95% confidence interval [95% CI] = 0.63–2.90, hazards ratio [HR] = 1.35, 95% CI = 0.64–2.82 in dermatologist and pediatrician groups, and OR = 1.39, 95% CI = 1.23–1.58, HR = 1.38, 95% CI = 1.22–1.56 in other medical professionals). The incidence of herpes zoster is higher among health‐care workers and it can be clearly concluded that no protective effect against herpes zoster exists for health‐care workers in Taiwan.     

Relationship of treatment delay with surgical defect size from keratinocyte carcinoma (basal cell carcinoma and squamous cell carcinoma of the skin)

Larger keratinocyte carcinoma (KC) lesions are associated with higher morbidity. This study examined the association of potentially modifiable characteristics, including treatment delay, with KC defect size after Mohs micrographic surgery (MMS). A stratified random sample of patients treated for KC with MMS were selected for telephone interview. Two hundred and nineteen interviews were completed (refusal rate 24%). Regression models were used to examine the predictors to defect size and delay. Anatomic site, age, histology, and gender predicted defect size (R(2) = 0.39) and were used as control variables. Self-reported delay between initial physician examination and MMS predicted defect size (p = 0.0004), with greater than 1 y delay being associated with a doubling of defect size (adjusted odds ratio (OR) 2.0; 95% confidence interval (CI) 1.3-3.1). Delays of this duration were associated with initial examination by a primary provider (unadjusted OR 3.9; 95% CI 1.7-8.8), misdiagnosis (unadjusted OR 6.8; 95% CI 2.5-18.7), being treated without biopsy (unadjusted OR 23.3; 95% CI 6.5-83.7), and multiple surgical removals (unadjusted OR 6.2; 95% CI 2.5-15.5). All but provider specialty were independent predictors of delay. Attention to processes of care delivery for KC may have a greater impact on morbidity than efforts are earlier detection by the public.     

Time to recurrence after surgical excision of atypical fibroxanthoma-updated systematic review and meta-analysis

Atypical fibroxanthoma (AFX) remains a rare cutaneous dermally based fibrohistiocytic tumour with high rates of local recurrence. Mohs micrographic surgery (MMS) and wide local excision (WLE) with margins 1–2 cm are two surgical options. It is unclear whether timing of recurrence following surgical excision of AFX differs according to technique. A systematic review and meta-analysis were performed according to PRISMA guidelines. There was a total of 188 MMS cases and 783 WLE cases. The pooled proportion of MMS cases of recurrence is 6.6% (95% CI 3.6–11.9%), compared with WLE 11.3% (95% CI 7.1–16.5%), which was not significantly different (P = 0.12) Pooled time to recurrence of MMS for AFX to be 14.2 (95% CI 11.6–16.8%) months, compared to 13.3 (95% CI 9.99–16.6%) months (P = 0.86). Our findings suggest that recurrence rates are similar between MMS and WLE techniques and that timing of recurrence is similar regardless of surgical technique employed.     

Abstract No. 3Is there a skin cancer risk with narrowband ultraviolet B phototherapy? Preliminary data from the second phase of the Dundee follow‐up study

We do not know whether narrowband ultraviolet B (NB‐UVB, TL‐01) phototherapy carries any increased risk of skin cancers. Follow‐up of 126 patients treated with NB‐UVB in Germany (Weischer M, Blum A, Eberhard F et al. No evidence for increased skin cancer risk in psoriasis patients treated with broadband or narrowband UVB phototherapy: a first retrospective study. Acta Derm Venereol (Stockh) 2004; 84 : 370–4) did not detect any increased skin cancer risk. Our follow‐up study (with linkage to Scottish Cancer Registry data complete to 1998) showed greater than expected (compared with age‐ and sex‐matched Scottish population) numbers of basal cell carcinomas (BCCs) in those treated with NB‐UVB (Man I, Crombie IK, Dawe RS et al. The photocarcinogenic risk of narrowband UVB (TL‐01) phototherapy: early follow‐up data. Br J Dermatol 2005; 152 : 755–7). Whether the modestly increased standardized incidence rate (SIR) of 213 (95% confidence interval, CI 102–391) was due to treatment or factors such as ascertainment bias was not clear. Analysis of data from the next phase of this follow‐up study, with linkage to the Scottish Cancer Registry complete to December 2002, is ongoing. The summary phototherapy records of 4050 patients treated with NB‐UVB between 1985 and 2002 were examined. The median duration of follow‐up was 5·8 years (up to 16·7) from end of first NB‐UVB course. We now have 26 633 person‐years of follow‐up data. The most frequent primary diagnoses were: psoriasis (55%), atopic dermatitis (15·4%), polymorphic light eruption (7·7%) and chronic urticaria (3·9%). Indirect standardization, adjusting for age and sex, was used to compare numbers of skin tumours identified with numbers expected in the general Scottish population. We did not find significantly more melanomas [SIR 164 (95% CI 60–357), P = 0·16] nor squamous cell carcinomas [SIR 173 (95% CI 79–329), P = 0·08] than expected. More BCCs than expected were registered in patients who had received NB‐UVB and psoralen plus ultraviolet A [SIR 184 (95% CI 128–255), P = 0·0007] and who had received only NB‐UVB [SIR 211 (95% CI 135–314), P = 0·0007, n = 3082]. So far, these findings are reassuring. A possible explanation for the excess BCCs is a causative association between NB‐UVB exposure and BCC development. Alternatively, more BCCs may have been registered in our treated patients because of careful surveillance leading to more BCCs being detected earlier and treated with modalities leading to a histopathological diagnosis (and, therefore, registration). However, only with more prolonged follow‐up of patients who have received high cumulative numbers of treatments might a definite skin cancer risk become detectable. Therefore, we should remain cautious as we cannot dismiss the possibility that NB‐UVB is carcinogenic in humans.     

Psoriasis is independently associated with psychiatric morbidity and adverse cardiovascular risk factors,but not with cardiovascular events in a population‐based sample

Background Psoriasis may significantly reduce quality of life. Previous studies reported an association of psoriasis and cardiovascular risk factors and cardiovascular events. The extent to which psoriasis is associated with psychiatric morbidity and the role of psychiatric comorbidity as a potential confounder of the association between psoriasis and cardiovascular morbidity require further investigation. Objectives To study the association between psoriasis, psychiatric morbidity and cardiovascular morbidity. Methods Case–control study utilizing an interdisciplinary administrative outpatient database from Germany. Patients with confirmed diagnosis of prevalent psoriasis within the study period (2003–2004) (n = 3147, mean age 57 years) were individually matched for age and gender with 3147 controls without psoriasis. The relationship of psoriasis with psychiatric morbidities (depression, stress‐related disorders, behaviour disorders and schizophrenic disorders), cardiovascular risk factors (diabetes, hypertension, obesity and dyslipidaemia) and cardiovascular events [myocardial infarction (MI), stroke] was investigated using logistic and linear regression models. Results Crude analyses suggested an association of psoriasis with depression, stress‐related disorders, behaviour disorders and cardiovascular risk factors, but not with MI [odds ratio (OR) 1.14; 95% confidence interval (95% CI) 0.81–1.62] or stroke (OR 0.97; 95% CI 0.61–1.54). Multivariate models controlling for age, gender and consulting behaviour indicated that psoriasis is independently associated with depression (OR 1.49; 95% CI 1.20–1.86), stress‐related disorders (OR 1.41; 95% CI 1.22–1.62), behaviour disorders (OR 1.58; 95% CI 1.05–2.39), diabetes (OR 1.21 95% CI 1.04–1.40), hypertension (OR 1.34; 95% CI 1.18–1.51), dyslipidaemia (OR 1.29; 95% CI 1.07–1.55), and obesity (OR 1.63; 95% CI 1.39–1.90). For each psychiatric condition, the likelihood of being affected significantly increased with each physician visit due to psoriasis, suggesting that the risk of psychiatric comorbidity increases with the severity of psoriasis. Conclusion Psoriasis appears to be independently associated with major psychiatric disorders and with cardiovascular risk factors, but not with cardiovascular events.     

Efficacy and safety of tofacitinib for moderate‐to‐severe plaque psoriasis: a systematic review and meta‐analysis of randomized controlled trials

The effects of tofacitinib in treating moderate‐to‐severe plaque psoriasis were unclear. We aimed to assess the effects of tofacitinib in treating moderate‐to‐severe plaque psoriasis. We searched PubMed, Cochrane Central Register of Controlled Trials and EMBASE for relevant randomized controlled trials (RCTs) and conducted a systematic review and meta‐analysis. Four RCTs with 2724 participants were included. Compared to placebo, tofacitinib significantly improved psoriasis {≥75% reduction in the Psoriasis Area and Severity Index score: 5 mg BID: risk difference (RD) 0.32 [95% confidence interval (CI) 0.28–0.35], 10 mg BID: RD 0.51 (95% CI 0.43–0.58); ≥90% reduction in the Psoriasis Area and Severity Index score: 5 mg BID: RD 0.19 (95% CI 0.17–0.22), 10 mg BID: RD 0.36 (95% CI 0.31–0.42); Physician's Global Assessment 0/1: 5 mg BID: RD 0.31 (95% CI 0.27–0.35), 10 mg BID: RD 0.48 (95% CI 0.44–0.53)} and participants’ life quality [Dermatology Life Quality Index 0/1: 5 mg BID: RD 0.24 (95% CI 0.20–0.2), 10 mg BID: RD 0.36 (95% CI 0.33–0.40)]. Tofacitinib was associated with an increase in minor adverse events [upper respiratory tract infection: 5 mg BID: RD 0.02 (95% CI 0.00–0.03), 10 mg BID: RD 0.02 (95% CI 0.00–0.04); hypercholesterolaemia: 5 mg BID: RD 0.02 (95% CI 0.01–0.04), 10 mg BID: RD 0.02 (95% CI 0.01–0.04)]. In conclusion, tofacitinib may be a treatment option for moderate‐to‐severe plaque psoriasis that is unresponsive to other therapies and patients who are intolerable to other therapies or prefer oral medications.     

Treatment of 208 extensive basal cell carcinomas with Mohs micrographic surgery

Aim With the rapidly increasing number of basal cell carcinomas in Europe, a close look at Mohs Micrographic Surgery (MMS) is timely. Subject We report the results of MMS in the Netherlands, as treatment for extensive basal cell carcinomas. Methods Patients (n= 198) with extensive basal cell carcinoma (n= 208) were treated with MMS. The mean follow up period was 6.4 years. Results Four of 208 BCCs recurred. Conclusions Considering a recurrence rate of only 2% for the treatment of extensive and mainly recurrent basal cell carcinomas, we suggest that MMS provides the best prospect for total tumour removal.     

Risk factors for nonpurulent leg cellulitis: a systematic review and meta‐analysis

Nonpurulent cellulitis is an acute bacterial infection of the dermal and subdermal tissues that is not associated with purulent drainage, discharge or abscess. The objectives of this systematic review and meta‐analysis were to identify and appraise all controlled observational studies that have examined risk factors for the development of nonpurulent cellulitis of the leg (NPLC). A systematic literature search of electronic databases and grey literature sources was performed in July 2015. The Newcastle–Ottawa Scale (NOS) was used to assess methodological quality of included studies. Of 3059 potentially eligible studies retrieved and screened, six case–control studies were included. An increased risk of developing NPLC was associated with previous cellulitis [odds ratio (OR) 40·3, 95% confidence interval (CI) 22·6–72·0], wound (OR 19·1, 95% CI 9·1–40·0), current leg ulcers (OR 13·7, 95% CI 7·9–23·6), lymphoedema/chronic leg oedema (OR 6·8, 95% CI 3·5–13·3), excoriating skin diseases (OR 4·4, 95% CI 2·7–7·1), tinea pedis (OR 3·2, 95% CI 1·9–5·3) and body mass index > 30 kg m⁻² (OR 2·4, 95% CI 1·4–4·0). Diabetes, smoking and alcohol consumption were not associated with NPLC. Although diabetics may have been underrepresented in the included studies, local risk factors appear to play a more significant role in the development of NPLC than do systemic risk factors. Clinicians should consider the treatment of modifiable risk factors including leg oedema, wounds, ulcers, areas of skin breakdown and toe‐web intertrigo while administering antibiotic treatment for NPLC.