Epithelioid sarcoma on the foot masquerading as an intractable wound for > 18 years

Slow‐growing sarcomas may give rise to intractable wounds, which may be attributed to commoner causes. A 57‐year‐old man with diabetes mellitus presented with a 24‐year history of a chronic wound that originated on his left great toe. Because of the long history, the nonspecific histological findings and the complication of ulcerative colitis, we misdiagnosed his ulcer as pyoderma gangrenosum. The wound was eventually diagnosed correctly by histological examination of a skin biopsy and the use of immunohistochemistry to detect cytokeratin, epithelial membrane antigen and vimentin. Specimens obtained 16 years earlier showed the same staining pattern. Radiological examinations revealed no metastasis. The patient received a below‐knee amputation without further chemotherapy or radiotherapy. When patients have intractable ulcers, appropriate biopsies and immunohistochemical examinations are sometimes necessary to exclude a malignancy even if the history and symptoms do not suggest a diagnosis of sarcoma.     

Streptococcus pyogenes and β‐lactam antibiotics

Letters to the Editor are welcomed for publication (subject to editing). Letters must be signed by all authors, typewritten double spaced, and must not exceed two pages of text including references. Two copies of all letters should be submitted along with one copy on disk. Letters should not duplicate material submitted or published in other journals. Prepublication proofs will not be provided.     

Comparison of clinical and cost‐effectiveness of psoralen + ultraviolet A versus psoralen + sunlight in the treatment of chronic plaque psoriasis in a developing economy

Psoralen + ultraviolet A (PUVA) therapy is an established modality for psoriasis. As India is a tropical country that has good availability of natural sunlight psoralen + sunlight (PUVAsol) may be a more convenient option. To compare the efficacy and cost‐effectiveness of PUVA versus PUVAsol in chronic plaque psoriasis. Cases of chronic plaque psoriasis with body surface area ≥10% or Psoriasis Area and Severity Index (PASI) ≥10, excluding erythrodermic or pustular psoriasis, were randomized to receive either PUVA or PUVAsol, with endpoint being the achievement of PASI 90 or completion of 12 weeks treatment, whichever is earlier. Cost analysis was also undertaken. Thirty‐six cases (16 in PUVA and 20 in PUVAsol group) completed treatment. In the PUVA group, 15 cases (93.75%) responded to therapy while in the PUVAsol group, 15 (75%) responded (P = 0.29). Mean baseline PASI in the PUVA and PUVAsol groups was 16 and 14.4, respectively, and at endpoint was 1.62 and 3.77. There was a significantly greater reduction in PASI in the PUVA group at 2 and 4 weeks but at 8 and 12 weeks and endpoint, it was comparable. Treatment failure occurred in 6.25% and 25% of cases respectively (P = 0.29). Side effects were higher with PUVA. Total cost of therapy was significantly higher in the PUVA group (P = 0.002). Cost‐effectiveness ratio was US$0.72 with PUVA and US$0.37 with PUVAsol. Both PUVA and PUVAsol were equally efficacious, with PUVAsol being twice as cost effective. Hence, PUVAsol may be recommended as treatment for psoriasis in a developing economy such as India.     

Pre‐operative ultrasound with a 12–15 MHz linear probe reliably differentiates between melanoma thicker and thinner than 1 mm

Background Pre‐operative determination of primary melanoma thickness could be a tool to identify those patients who could be treated with radical primary tumour excision and sentinel lymph node biopsy in a single procedure. An excellent correlation between sonographic and histological measurement of maximal tumour thickness has been achieved using 20‐MHz transducers. Objective To show that widely available high resolution ultrasound with 12–15 MHz linear probe could also reliably assess the thickness of primary melanoma. Methods Sixty‐nine patients underwent ultrasound evaluation of 70 clinically and dermoscopically suspicious pigmented skin lesions before surgical excision. Results The sensitivity, specificity, positive and negative predictive values of ultrasound to detect melanoma > 1 mm were 92%, 92%, 95% and 81% respectively. The correlation between ultrasound and histological tumour thickness was very good [Pearson’s correlating index 0.823 (P < 0.001)]. Mean difference between sonographic and histological measurements was 0.045 mm with limits of agreement estimated at ?1.4 and +1.49, and a bias between two methods 45 μm. Conclusion Ultrasound examination with a 12–15 MHz linear transducer can reliably differentiate primary melanoma > 1 mm from those ≤ 1 mm.     

Pyoderma gangrenosum – a review of 24 cases observed over 10 years

Background and objectives Pyoderma gangrenosum (PG) is a disorder, included in the spectrum of neutrophilic and auto‐inflammatory dermatoses, whose clinical aspects and outcome we intend to characterize. Materials and methods In a retrospective study based on files of patients diagnosed during a 10‐year period (2000–2009), we evaluated demographic data, anatomic locations, number of lesions, clinical variants, associated diseases, treatment regimens, healing time, and recurrence. Results A total of 24 patients were included, 19 women and five men (F/M = 3.8/1), aged between 17 and 89 years (mean 58.3 ± 24.6 years) with a diagnosis of PG. Lesions, single in 15 patients (62.5%) and multiple in nine (37.5%), were localized in the lower limbs in 19 patients (79.2%), upper limbs (4), abdomen (4), face (2) and genital area (1). Clinical variants observed were ulcerative (17 patients), pustular (4), bullous (2) and superficial granulomatous (1). Associated systemic diseases were observed in 18 patients (75%), gastrointestinal in seven patients (29.2%), hematological in seven (25%), autoimmune inflammatory in three (12%), and solid tumors in two (8.3%). Systemic steroids were used in the treatment, either alone in 10 patients (41.7%) or combined with cyclosporine in eight (33.3%). Complete healing was achieved in 20 patients, on average five months after diagnosis, but lesions recurred one or more times in four patients (16.7%). Conclusions As reported in the literature, PG is a rare disorder, more common in females, frequently associated with systemic disease, which compromises the prognosis.     

15 % Azelainsäuregel in der Behandlung der Akne. Zwei doppelblinde klinische Vergleichsstudien

Background: Topical measures are still the mainstay in the therapy of mild‐to‐moderate acne vulgaris. Azelaic acid 20 % in a cream formulation has been established as an efficacious and safe topical drug for 15 years. A new non‐alcoholic hydrogel formulation containing 15 % azelaic acid was clinically tested against two standard drugs – 5 % benzoyl peroxide (BPO) and 1 % clindamycin. Patients and Methods: In two independent, randomized, blinded comparative trials 15 % azelaic acid gel was clinically tested against 5 % benzoyl peroxide (BPO) gel in 351 patients and against 1 % clindamycin gel in 229 patients. The drugs were applied b. i. d. for 4 months. Results: Azelaic acid 15 % gel proved to be as effective as BPO and clindamycin with median % reduction of the inflamed lesion (papules and pustules) of 70 %, and 71 % respectively. The azelaic acid gel was well‐tolerated, the side effects (local burning and irritation) were distinctly less than with BPO but more pronounced than with clindamycin. Despite these side effects, the treatment was well‐accepted by the majority of patients. Conclusions: Azelaic acid gel is an effective topical monotherapy for mild‐to‐moderate acne vulgaris; its new gel form is an enrichment of acne therapy.     

High‐concentration (20 μg g−1) tacalcitol ointment in the treatment of facial psoriasis: an 8‐week open‐label clinical trial

Background Facial psoriasis gives rise to considerable concern because of associated cosmetic problems and psychosocial distress. It requires a treatment approach other than topical corticosteroids, which bear a risk of cutaneous adverse reactions. Recently, topical tacalcitol has been shown to be effective in psoriasis. Objectives The aim of this open‐label single‐centre study is to investigate the efficacy and safety of high‐concentration (20 μg g^?1) tacalcitol ointment (Bonalfa‐high^®, Teijin Pharma, Tokyo, Japan) in patients with facial psoriasis and to evaluate clinical response according to the distribution of facial psoriatic lesions. Patients and methods Thirty‐seven patients were enrolled to this clinical trial. Tacalcitol 20 μg g^?1 ointment was applied once daily to psoriatic lesions of the face over an 8‐week period. Patients were also categorized into three subtypes according to facial lesion distribution. Efficacy was evaluated by the facial Psoriasis Area and Severity Index (facial PASI) and the Physician’s Global Assessment (PGA) score at weeks 2, 4 and 8. The Subjective Global Assessment (SGA) was also determined at the end of the study. Results Thirty‐three patients completed the clinical trial. Mean facial PASI of 33 patients at baseline was 9·58 and after 8 weeks of treatment the mean facial PASI decreased significantly to 3·88. By using PGA, patients showed the following responses to treatment: clearance (n = 1); excellent (6); good (16); fair (4); slight (5); no change (1). The response rate among the three facial psoriasis types showed no difference. Using the SGA, 27 (82%) of the patients presented excellent (15%) or good (67%) effect with tacalcitol 20 μg g^?1 ointment. No serious adverse reactions were observed. Conclusions This is the first clinical study reporting a relevant therapeutic effect and favourable safety profile of tacalcitol 20 μg g^?1 ointment in facial psoriasis. These results suggest that tacalcitol 20 μg g^?1 ointment can be used as the first‐line treatment in patients with facial psoriasis.     

Acrodermatitis Acidemica: Experience of 5 Years in Andalusia

Letters to the Editor are welcomed for publication (subject to editing). Letters must be signed by all authors, and must not exceed two pages of text including references. Letters should not duplicate material submitted or published in other journals. Prepublication proofs will not be provided.