A systematic review of non‐surgical treatments for lentigo maligna

Lentigo maligna (LM) is the most common melanocytic malignancy of the head and neck. If left untreated, LM can progress to lentigo maligna melanoma (LMM). Complete surgical excision is the gold standard for treatment, however, due to the location, size, and advanced age of patients, surgery is not always acceptable. As a result, there is ongoing interest in alternative, less invasive treatment modalities. The objective was to provide a structured review of key literature reporting the use of radiotherapy, imiquimod and laser therapy for the management of LM in patients where surgical resection is prohibited. An independent review was conducted following a comprehensive search of the National Library of Medicine using MEDLINE and PubMed, Embase, Scopus, ScienceDirect and Cochrane Library databases. Data were presented in tabular format, and crude data pooled to calculate mean recurrence rates for each therapy. 29 studies met the inclusion criteria: radiotherapy 10; topical imiquimod 10; laser therapies 9. Radiotherapy demostrated recurrence rates of up to 31% (mean 11.5%), with follow‐up durations of 1–96 months. Topical imiquimod recurrence rates were up to 50% (mean 24.5%), with follow‐up durations of 2–49 months. Laser therapy yielded recurrence rates of up to 100% (mean 34.4%), and follow‐up durations of 8–78 months. in each of the treatment series the I² value measuring statistical heterogeneity exceeded the accepted threshold of 50% and as such a meta‐analysis of included data were inappropriate. For non‐surgical patients with LM, radiotherapy and topical imiquimod were efficacious treatments. Radiotherapy produced superior complete response rates and fewer recurrences than imiquimod although both are promising non‐invasive modalities. There was no consistent body of evidence regarding laser therapy although response rates of up to 100% were reported in low quality studies. A prospective comparative trial is indicated and would provide accurate data on the long‐term efficacy and overall utility of these treatments.     

Topical and systemic retinoids for the treatment of cutaneous viral warts: A systematic review and meta‐analysis

Cutaneous viral warts (CVW), caused by human papillomavirus, often have a self‐limited course. However, some patients experience a recalcitrant disease despite treatment. Retinoids are considered the mainstay of therapy in many dermatologic diseases. Data on their use for viral warts are limited. To systematically review the published evidence on the efficacy and safety of retinoids for the treatment of CVW. A systematic review and meta‐analysis of topical or systemic retinoid treatment for CVW was performed in accordance with the PRISMA statement. The primary outcome was clinical response; secondary outcomes were recurrence rate and adverse events. Fourteen publications including 399 patients treated exclusively with retinoids (65% topical, 35% systemic) were evaluated. The complete response rate was 64% (95% CI, 46‐78%; I²=80%) for topical treatment and 61% (95% CI, 44‐76%; I²=69%) for systemic treatment. The most common side effects were irritant contact dermatitis and cheilitis, respectively. Relapse rates were 6% and 17%, respectively. The reviewed studies were considerably heterogenous and most lacked a control group. Both topical and systemic retinoids are effective and safe as monotherapy for CVW. Further studies are required to determine their exact role in this setting.     

Expanding the histologic findings in smallpox‐related post‐vaccinial non‐viral folliculitis

Post‐vaccinial non‐viral folliculitis has been recognized in the past decade as a new adverse cutaneous reaction to smallpox vaccination. Contrary to more serious smallpox vaccine reactions, post‐vaccinial non‐viral folliculitis has a benign course and resolves spontaneously within approximately 7 days. We describe additional histopathologic findings associated with post‐vaccinial non‐viral folliculitis, which has only been described once previously. New findings include the presence of a neutrophilic or lymphohistiocytic infiltrate that is concentrated around the hair follicles. We compare our findings to the follicular nature of varicella and herpes zoster infections, generating the hypothesis of deposition of vaccinia protein within folliculosebaceous units as a potential pathophysiologic mechanism behind post‐vaccinial non‐viral folliculitis.     

Occupational exposure to non‐artificial UV‐light and non‐melanocytic skin cancer – a systematic review concerning a new occupational disease

Background: Although UV exposure is the most important risk factor for cutaneous squamous cell carcinoma (SCC) and basal cell carcinoma (BCC), a systematic review analyzing the risk of occupational UV exposure is missing. Methods: Based on a systematic literature search in PubMed (until 05/2009) supplemented by hand search, the association between occupational UV exposure and SCC and BCC was analyzed. Literature search and data abstraction was done independently by 2 reviewers. The association between occupational UV exposure and cancer risk is presented as odds ratios (OR). Results: We identified 25 relevant epidemiologic studies (5 cohort studies, 17 case‐control studies, 3 cross‐sectional studies). 12 studies described a positive association between occupational UV exposure and risk of SCC with OR > 3 in 6 studies and OR 1.5–2.0 in another 6 studies. 3 studies did not find a relevant association (OR: 1.0–1.4). A significant positive association between occupational UV exposure and BCC was reported in 5 studies; 11 studies did not find a significant association. Conclusions: The association between occupational UV exposure and SCC is well and consistently documented epidemiologically (approximately 2‐fold increased risk), so that the criteria for a new occupational disease are fulfilled. The association with BCC is unclear due to significant methodological limitations in the published studies.     

Pulsed dye laser: what's new in non‐vascular lesions?

BACKGROUND AND OBJECTIVE: In dermatology, the pulsed dye laser (PDL) is the therapeutic instrument of choice for treating most superficial cutaneous vascular lesions. In addition, clinical experience over the last decade allowed us to treat patients with an ever increasing number of non-vascular indications. The purpose of this report is to summarize and critically appraise the scientific evidence that support the role of PDL in treating non-vascular skin lesions. METHODS: A literature-based study has been conducted, including the review of publications over the period January 1995 to December 2006, using the Medline Database. We also included our own experience in managing non-vascular lesions with the PDL. Four sets of preoperative and postoperative photos are presented. RESULTS: For viral skin lesions, PDL proved to be an alternative to other therapy options. This applies particularly to periungual warts and mollusca contagiosa. The mechanism of PDL with inflammatory dermatoses has not yet been elucidated. The effect seems to be better if there is a vascular component to the disease. With most of these indications (such as psoriasis and acne), PDL currently plays a rather minor or complementary role. Regarding collagen remodelling (hypertrophic scars, keloids, stretch marks, and skin rejuvenation), the question of whether a therapy makes sense or not has to be decided from case to case. CONCLUSION: With PDL, it is possible to achieve good results with numerous, partly less well-known indications (i.e. lupus erythematosus). With other diseases, PDL has so far been considered to be a complementary therapy method or to be in an experimental state.     

A new method of intralesional bleomycin therapy in the treatment of recalcitrant warts

We have used a new technique of hieomycin injection to treat intractable palmar, plantar and periungual warts. Tollowing local anaesthesia with topical EMLA? (lignocaine and prilocainel cream. 1 mg/ml bleomycin solution was dropped on to the wart and ‘pricked’ into tbe wart using a Monolet? needle. We acbieved 92% success rate which compares well with other authors whose success rales wilb inlralesional bleomycin vary between 33 and 92%. We conclude that tbis technique of intralesional bleomycin therapy is an effective, safe and generally well tolerated treatment for recalcitrant warts.     

Increased carbonyl protein level in the stratum corneum of inflammatory skin disorders: A non‐invasive approach

The stratum corneum (SC) is the interface of body and environment, and is continuously exposed to oxidative stress, resulting in carbonyl modification of proteins. We have developed a simple and non‐invasive method to assess carbonyl protein (CP) level in the SC, applied it to various kinds of skin, and revealed a link between the stratum corneum carbonylated protein (SCCP) level and water content in the SC. The purpose of the present study is to examine the SCCP level in inflammatory skin disorders associated with xerosis. Psoriasis vulgaris (PV) and atopic dermatitis (AD) are typical inflammatory skin disorders, of which the stratum corneum shows markedly low water content. SC samples were non‐invasively collected from the lesional and non‐lesional areas of PV and AD by adhesive tape stripping, and their carbonyl groups were determined by reaction with fluorescein‐5‐thiosemicarbazide. The average fluorescence intensity of the SC was calculated as SCCP level. Higher SCCP level was observed in the lesional area of PV as compared with non‐lesional area or healthy control. Lesional area of AD also exhibited higher SCCP level than corresponding non‐lesional area, of which SCCP level was slightly higher than the healthy control. These data suggest the involvement of oxidative modification of the SC protein, at least in part, in generation of xerotic skin in inflammatory skin disorders as well as dry skin in healthy subjects.