Assessment of the efficacy of cryosurgery in the treatment of granuloma faciale

BACKGROUND: Granuloma faciale (GF) is an uncommon dermatosis of unknown pathogenesis. Multiple treatments have been proposed with varying results. We report nine cases treated successfully with cryosurgery and we review the literature. OBJECTIVES: To study the efficacy, tolerability and safety of cryosurgery techniques in the treatment of GF. METHODS: Nine immunocompetent adults with GF were treated by cryosurgery. The initiation of the therapy was preceded by a 60-day washout period in all subjects using other medication. Two different techniques were used (open-spray and contact cryo-probe). RESULTS: All patients were treated successfully. Apart from mild postinflammatory hypopigmentation in two patients that resolved within 4 months, no other adverse event was mentioned. During an average 24-month follow-up period after the integration of therapy, no recurrences were observed. CONCLUSIONS: Cryosurgery is an efficient, safe, inexpensive, easily used method for this uncommon dermatosis, which can be proposed as a treatment of first intention.     

Factors involved in the development of diaper‐area granuloma of the aged

An infant skin disease with clusters of nodules in the diaper contact area was reported as granuloma gluteale infantum. Recently, the number of elderly patients with this condition has increased, and it has been reported as diaper‐area granuloma of the aged. These lesions are presumably caused by irritation from feces and urine. We observed similar cutaneous symptoms in six elderly patients, five of whom revealed clusters of nodules arranged in a circular pattern in the gluteal region presenting a peculiar clinical picture. They were all bedridden and wore cloth diapers. We speculate that wearing a cloth diaper seems to be a major factor behind this condition. Another factor was sitting during the day. A subject had lesions with nodules on the scrotum. The distribution of nodules appeared to be related to the body position and vigorous movement of the patient. In all cases, topical steroid therapies were not effective. They were all positive for bacteriuria. Chronic urinary tract infection further irritates the skin. It is necessary to reduce urine contact and keep the lesion clean.     

Evolution of granuloma annulare to mid‐dermal elastolysis: report of a case and review of the literature

A 55‐year‐old healthy Caucasian female, on no medication, was seen by a dermatologist because of a patchy, slightly indurated and violaceous eruption involving her neck and trunk. The clinical impression was of granuloma annulare (GA). Over a period of several months the violaceous lesions became atrophic with loss of colour and eventual wrinkling of lesional skin. Sequential skin biopsies were obtained, which revealed a spectrum of changes. Those from early violaceous lesional zones displayed perivascular lymphocytic infiltrates and interstitial granulomatous inflammation, characteristic of interstitial GA. Samples from atrophic lesional areas appeared normal on routine sections but an Orcein–Giemsa (OG) stain, prompted by the clinical history of atrophy, revealed absence of elastic fibers in the mid‐reticular dermis. The combined clinicopathologic findings pointed to development of mid‐dermal elastolysis (MDE) at involutional sites of GA. Owing to consideration of a cutaneous T‐cell lymphoma in the differential diagnosis, genotyping in search of T‐cell monoclonality was performed and yielded a negative result. Our case supports the existing but scant evidence in the literature that the rare, enigmatic condition termed MDE is an end‐result of inflammatory destruction of dermal elastic fibers. GA is one form of dermatitis capable of culminating in this entity, but others have also been implicated.     

Perioperative management of tumor necrosis factor‐alpha blocker‐treated psoriatic patients: Case reports and review

Regarding appropriate timings of discontinuation and resumption of biologics for psoriasis patients before and after elective surgeries, an international consensus has yet to be reached. The Japanese Dermatological Association of Guideline and Safety Manual for the use of Biologic Agents in Psoriasis 2013 states that infliximab (IFX) and adalimumab (ADA) should be withheld at least 4 and 2 weeks, respectively, before surgery and can be restarted as neither postoperative infection nor delayed wound healing is recognized. We experienced three generalized pustular psoriasis (GPP) patients and one plaque‐type psoriasis patient undergoing surgeries during tumor necrosis factor (TNF)‐α blocker therapy. Three GPP cases experienced uneventful post‐surgical course. One psoriasis vulgaris patient on IFX had a wound healing delay with deterioration of psoriatic plaques which was restored by restarting IFX. The timing of suspension and resumption of TNF‐α blockers in all cases were determined following the Japanese guideline.     

It's time for Mohs: Micrographic surgery for the treatment of high‐risk basal cell carcinomas of the head and neck regions

Basal cell carcinoma (BCC) is the most common variety of non‐melanoma skin cancer and its incidence is increasing worldwide. The centrofacial sites (area H) are considered a high‐risk factor for BCC local recurrence. Mohs micrographic surgery (MMS) is a technique that allows intraoperative microscopic control of the surgical margins and is a good treatment option when tissue conservation is required for esthetic or functional reasons or for high‐risk lesions. The present study aimed to evaluate the recurrence rate of head and neck high‐risk BCCs comparing MMS vs conventional surgical excision. Clinical data of patients diagnosed from September 2014 to March 2017, referring to the Dermatology Unit of the Policlinico Sant'Orsola‐Malpighi, University of Bologna, were retrospectively evaluated (285 treated with MMS and 378 treated with traditional surgery). Of the 285 patients treated with MMS, 9 experienced a recurrence (3.1%). Of the 378 patients treated with traditional surgery, 53 relapsed (14%), 13 of whom presented residual tumor on the deep or lateral margins of the main surgical specimen. Our study confirms the trend reported in the literature that MMS represents the best treatment option for high‐risk BCCs arising in the head and neck region or presenting as a recurrence (P < .00001). Many more MMS centers and more trained dermatologists are needed worldwide in order to deal with the increasing number of BCC diagnosed every year.     

Surgical management of lipomas: Proposal of the Z‐incision design and surgical algorithm based on tumor size

Surgical excision is the treatment of choice for lipomas. However, linear incision methods or minimal extraction techniques often do not provide a sufficient surgical view. Therefore, removing large lipomas is often difficult. To present the Z‐incision and half Z‐incision designs for lipoma extraction, this retrospective study analyzed lipomas surgically excised at our institution between September 2015 and December 2018. The area of surgical field exposed by the Z‐incision versus that exposed by the linear incision was calculated using a schematic model. Cure rate, complications, and surgical field area were investigated. A total of 84 lipomas were included. A Z‐ or half Z‐incision was used to treat 30 lipomas, while a linear incision was used to treat 54 lipomas. The mean diameter of the mass in the Z‐ or half Z‐incision group was 47.7 mm (range, 15–160 mm), larger than that in the linear incision group (25.5 mm; range, 7–59 mm) (p < .001). The Z‐incision involved making rectangular windows by lifting 2 triangular flaps. According to our mathematical model, the Z‐incision provided a larger surgical field area than that provided by the linear incision based on stretched angles (1.81 times larger at 30° and 3.14 times larger at 15°). The Z‐ and half Z‐incisions were successfully performed in all but 1 lipoma (29 lipomas, 96.7%). There was 1 lipoma that resulted in postoperative complications (seroma, 3.3%). The Z‐incision design can be a useful alternative technique for the extirpation of lipomas, especially large lipomas. Here, we proposed a surgical algorithm for lipoma surgery based on tumor size.     

Adjuvant rituximab treatment for pemphigus: A retrospective study of 45 patients at a single center with long‐term follow up

To evaluate the long‐term outcomes of rituximab in the treatment of pemphigus and the influence of disease duration and different dose of rituximab on the clinical response, 45 patients with refractory pemphigus treated with at least one cycle of two infusions of rituximab (375 mg/m² per infusion weekly) were retrospectively studied. All patients were followed up for more than 2 years. All patients achieved complete or partial remission within 8 months of the first cycle. Thirty‐four (76%) patients relapsed at a median of 17 months. All patients who received additional cycles after relapse achieved new remissions. Early use of rituximab within 1 year of disease duration and high‐dose therapy induced better outcomes, although the results in early use were not statistically significant. Acute respiratory distress syndrome occurred in one patient. Rituximab is effective in treating pemphigus, but relapses are frequent during long‐term follow up, and additional cycles are beneficial in relapsed cases. Early and high‐dose rituximab therapy may be more effective.     

Cytoplasmic β‐catenin is lacking in a subset of melanoma‐associated naevi,but is detectable in naevus‐associated melanomas: potential implications for melanoma tumorigenesis?

Summary Background An excess of intracellular β‐catenin protein is triggered by various genetic alterations in melanoma cell lines, and has been suggested to play a role in melanoma tumorigenesis. Objectives To investigate the role played in vivo by β‐catenin in melanoma tumorigenesis, we compared the cytoplasmic detection of β‐catenin in benign melanocytic cells vs. malignant melanoma cells presumably generated from these benign melanocytic cells. For this purpose, melanocytic naevi occurring in association with melanoma, which were suggested to be melanoma precursors, were compared with their associated melanoma for β‐catenin cytoplasmic immunoreactivity. Methods Fifty‐seven consecutive cases of primary cutaneous melanoma were considered, and 15 of them were found to be associated with a melanocytic naevus portion. The naevus portion showed features of acquired melanocytic naevus (total 12 cases: five dysplastic, seven intradermal) or congenital growth pattern naevus (total three cases: one superficial, two deep). All specimens were immunohistochemically investigated for β‐catenin. Results Virtually all primary cutaneous melanomas, including those associated with a naevus portion, showed cytoplasmic β‐catenin positivity. However, the intradermal naevus portion was consistently cytoplasmic β‐catenin negative, while both the dysplastic and the congenital naevus portions were cytoplasmic β‐catenin positive. Conclusions β‐Catenin excess may play a role in melanoma tumorigenesis, because β‐catenin cytoplasmic reactivity was found in primary cutaneous melanoma but not in its associated intradermal naevus precursor. As, however, β‐catenin cytoplasmic reactivity was detected not only in primary cutaneous melanoma but also in its associated dysplastic/congenital naevus precursors, β‐catenin stabilization alone is not sufficient to play a decisive role for melanoma onset.     

A pilot methodology study for the photographic assessment of post‐inflammatory hyperpigmentation in patients treated with tretinoin

Background Post‐inflammatory hyperpigmentation (PIH) is a common occurrence in patients with acne vulgaris, particularly in those with skin of colour. Aims A previous study has demonstrated the benefit of tretinoin (retinoic acid) in the treatment of PIH; however, there is currently no standard protocol to evaluate change in PIH following treatment. Based on these findings, we performed a pilot, exploratory, blinded, intraindividual‐controlled methodology study that consisted of a photographic assessment protocol with facial mapping. Materials and methods The study was based on a secondary analysis of a phase 4, community‐based trial of 544 acne patients who were treated with tretinoin gel microsphere 0.04% or 0.1%. Only patients with Fitzpatrick types III–V (skin of colour) were included in the study; subjects with Fitzpatrick skin type VI were excluded because the photographic assessment did not allow for proper evaluation. Results Despite the small number of subjects evaluated (n = 25), the results revealed consistent assessment of improvement in PIH between two independent graders (weighted κ = 0.84). Conclusion Further study with a larger population is recommended to validate the accuracy of this method.     

Scedosporium apiospermum: An unreported cause of fungal sporotrichoid‐like lymphocutaneous infection in Australia and review of the literature

Scedosporium apiospermum is a fungus emerging as a rare but important cause of both localised and disseminated infections in immunocompromised patients. Most cutaneous lesions present as mycetoma, however a review of the literature revealed an increasing number of cases worldwide presenting with lymphocutaneous spread resembling sporotrichosis. An 85‐year‐old man with an extensive medical history including type II diabetes mellitus and meningioma presented with crusted haemorrhagic areas on the dorsum of his left foot and multiple crusted nodules extending proximally along his leg in a sporotrichoid‐like lymphocutaneous pattern. A mycological examination and culture of the cutaneous tissue found the fungus, Scedosporium apiospermum.     

Effectiveness and safety of a prevention‐of‐flare‐progression strategy with pimecrolimus cream 1% in the management of paediatric atopic dermatitis

Objective This study was performed to investigate the efficacy and safety of a prevention‐of‐flare‐progression strategy with pimecrolimus cream 1% in children and adolescents with atopic dermatitis (AD). Methods A 26‐week multi‐centre, randomized, double‐blind, vehicle‐controlled study was conducted in 521 patients aged 2–17 years, with a history of mild or moderate AD, who were clear/almost clear of disease before randomization to pimecrolimus cream 1% (n = 256) or vehicle cream (n = 265). Twice‐daily treatment with study medication was started at the first signs and/or symptoms of recurring AD. If, despite the application of study medication for at least 3 days, AD worsened (as confirmed by the investigator), treatment with a moderately potent topical corticosteroid (TCS) was allowed in both groups. The primary efficacy end point was the number of days on study without TCS use for a flare. Results The mean number of TCS‐free days was significantly higher (P < 0.0001) in the pimecrolimus cream 1% group (160.2 days) than in the control group (137.7 days). On average, patients on pimecrolimus cream 1% experienced 50% fewer flares requiring TCSs (0.84) than patients on vehicle cream (1.68) (P < 0.0001). Patients on pimecrolimus cream 1% also had fewer unscheduled visits (87) than patients on vehicle cream (246). Conclusions In children and adolescents with a history of mild or moderate AD but free/almost free of signs or symptoms of the disease, early treatment of subsequent AD exacerbations with pimecrolimus cream 1% prevented progression to flares requiring TCS, leading to fewer unscheduled visits and reducing corticosteroid exposure.     

Guide for medical professionals (i.e. dermatologists) for the management of Rhododenol‐induced leukoderma

Because some users develop depigmentation after the use of melanogenesis‐inhibiting products containing the quasi‐drug ingredient Rhododenol, Japanese Dermatological Association (JDA) established a Special Committee on the Safety of Cosmetics Containing Rhododenol on July 17, 2013 and management guide for dermatologists has been updated on the website in order to delineate the diagnostic criteria for Rhododenol‐induced leukoderma and provides a broad guide for standard treatment based on current knowledge. This guide is produced on the basis of the guide (version 7) updated on June 20, 2014 in the website. Rhododenol‐induced leukoderma refers to depigmentation of varying severity that develops after the use of cosmetics containing Rhododenol, mainly at the site of use. In most cases, repigmentation of part or all the affected area is evident after discontinuation. Histopathologically cellular infiltration around the hair follicles and melanophages are present in most cases. The number of melanocytes in the lesion is declined but not totally absent in most cases. Rhododenol itself is a good substrate for tyrosinase, resulting in the formation of Rhododenol metabolites (e.g., Rhododenol quinone). Melanocytes are damaged by Rhododenol metabolites during the subsequent metabolic process. The continued use of cosmetics containing Rhododenol thus induces tyrosinase activity‐dependent cytotoxicity in melanocytes in the epidermis at application sites, resulting in decreasing the amount of melanin produced by melanocytes; the addition of some other factor to this process is believed to subsequently cause the decrease or disappearance of melanocytes themselves from the epidermis.     

Evidence‐based guidelines for the prevention,identification and management of occupational contact dermatitis and urticaria*

Background: Occupational contact dermatitis is the most frequently reported work‐related skin disease in many countries. A systematic review was commissioned by the British Occupational Health Research Foundation in response to a House of Lords Science and Technology Committee recommendation. Objectives: The systematic review aims to improve the prevention, identification and management of occupational contact dermatitis and urticaria by providing evidence‐based recommendations. Methods: The literature was searched systematically using Medline and Embase for English‐language articles published up to the end of September 2009. Evidence‐based statements and recommendations were graded using the Royal College of General Practitioner's three‐star system and the revised Scottish Intercollegiate Guidelines Network grading system. Results: Three thousand one hundred and fifty‐five abstracts were identified and screened. From these, 786 full papers were obtained and appraised. One hundred and nineteen of these studies were used to produce 36 graded evidence statements and 10 key recommendations. Conclusions: This evidence review and its recommendations focus on interventions and outcomes to provide a robust approach to the prevention, identification and occupational management of occupational contact dermatitis and urticaria, based on and using the best available medical evidence.