Alvin H Chong

Dermatoscopy aids in the diagnosis of the solitary red scaly patch or plaque–features distinguishing superficial basal cell carcinoma, intraepidermal carcinoma, and psoriasis

BACKGROUND Intraepidermal carcinoma (IEC), superficial basal cell carcinoma (sBCC), and psoriasis are common entities that may all present as well-defined, brightly erythematous plaques. Currently, there are limited data on the dermatoscopic features that differentiate these diagnoses. OBJECTIVE We sought to describe the most significant morphologic findings seen on dermatoscopy of IEC, sBCC, and psoriasis, and formulate a diagnostic model based on these features. METHOD We conducted a retrospective observational study using macrophotography and dermatoscopy to evaluate the presence or absence of dermatoscopic features and formulated diagnostic models for each diagnosis. A convenient sample of 300 lesions was collected from 255 patients from two hospital dermatology clinics and 4 private dermatology practices. These comprised 150 cases of sBCC, 100 cases of psoriasis, and 50 cases of IEC. RESULTS The most significant dermatoscopic features of IEC were a clustered vascular pattern, glomerular vessels, and hyperkeratosis. When all 3 features were observed together, the diagnostic probability for IEC was 98%. sBCCs were characterized by a scattered vascular pattern, arborizing microvessels, telangiectatic or atypical vessels, milky-pink background, and brown dots/globules; the diagnostic probability was 99% if 4 of these 6 features were identified. For psoriasis, the significant features identified were a homogenous vascular pattern, red dots, and light-red background, yielding a diagnostic probability of 99% if all 3 features were present. LIMITATIONS Lack of evaluation of interobserver/intraobserver reproducibility is a limitation. CONCLUSION Dermatoscopy is valuable in the diagnosis and differentiation of IEC, sBCC, and psoriasis because of consistent dermatoscopic morphology.

Solar keratosis: Epidemiology, pathogenesis, presentation and treatment

Solar keratosis is a common problem encountered by dermatologists, particularly in Australia. Solar keratosis is most commonly found on sun‐exposed areas such as the scalp, face and forearms. UV radiation is thought to be the major aetiological factor, with age, immunosuppression and human papillomavirus being important contributing factors. Solar keratosis usually presents as a discrete, variably erythematous and irregular lesion with a scaly surface. Although the exact rate of malignant transformation to squamous cell carcinoma is unknown, the majority of squamous cell carcinomas appear to arise from within solar keratosis. For this reason, solar keratosis is commonly treated and, consequently, an increasing number of therapeutic options is now available. Traditional therapies, such as liquid nitrogen cryotherapy, are still popular, but newer choices, such as photodynamic therapy and imiquimod cream, are now providing further options with similar efficacy and superior adverse effect profiles, albeit at a higher cost.

Retrospective analysis of adult patients with cutaneous leukocytoclastic vasculitis.

A retrospective analysis was conducted on 93 adult patients with cutaneous leukocytoclastic vasculitis from St. Vincents Hospital Melbourne to determine the classification, aetiology, severity and prognosis of this population of patients. We developed a new classification system for the purposes of our study based on modifications to the Chapel Hill Consensus Conference definitions for vasculitic syndromes. The results of our study indicate that an obvious cause was not found in 44.1% of patients. Of the patients with secondary vasculitis, the commonest causes were drugs and infections, accounting for a total of 40.9% of patients. Extracutaneous involvement was found in 39.8% of patients. Patients with symptoms resolving in less than 3 months accounted for 59.1% of the population, whereas 24.8% of patients had either symptoms lasting three or more months or evidence of recurrent symptomatology. There were 6 deaths (6.91%) and the rest were lost to follow up. The majority of patients in this retrospective series were classified as having hypersensitivity vasculitis, which is a relatively benign disorder limited mostly to skin with a low incidence of extracutaneous involvement (15.8%). Nevertheless, evidence of systemic involvement or sepsis need to be excluded as this may have important implications for patient treatment and outcome.

Nephrogenic systemic fibrosis in a gadolinium-naive renal transplant recipient

A 36‐year‐old woman presented with a 2‐year history of multiple, raised, brown papules and indurated skin over her lower legs. She had received a renal transplant 11 years earlier, and had a history of recurrent deep vein thromboses despite a negative thrombophilic screen. The patient had no history of exposure to gadolinium. Histology at this time revealed a light perivascular lymphoid infiltrate, activated fibroblasts and prominent capillary vessels. The patient re‐presented 1 year later with persistence of these lesions, in the setting of worsening renal function requiring haemodialysis. Repeat skin biopsies demonstrated increased dermal collagen and angiogenesis. The dermatopathological findings, in association with renal insufficiency and multiple deep vein thromboses, led to the diagnosis of nephrogenic systemic fibrosis.

Keratosis follicularis spinulosa decalvans and acne keloidalis nuchae.

A 27‐year‐old man presented with a 10‐year history of scarring alopecia on the vertex of the scalp associated with follicular crusting and pustule formation, and a papular eruption on the posterior neck. Additionally, there was keratosis pilaris on the cheeks, eyebrows and thighs. Histology from the vertex showed scarring with a mixed perifollicular inflammatory infiltrate and foci of acute suppurative folliculitis. With clinical correlation, the diagnosis of keratosis follicularis spinulosa decalvans and concurrent acne keloidalis nuchae was made. The association of keratosis follicularis spinulosa decalvans with acne keloidalis nuchae has not previously been described. The patient responded to treatment with oral isotretinoin 20 mg (0.25 mg/kg) daily for 12 months.

Survival After Cutaneous Melanoma in Kidney Transplant Recipients: A Population-Based Matched Cohort Study

Transplant recipients are at elevated risk of melanoma and may have poorer outcomes than nontransplant recipients. We conducted a national, population‐based, matched cohort study of Australian kidney transplant recipients and randomly selected members of the general population matched for age, sex, state and year of diagnosis with invasive cutaneous melanoma (1982–2003). Melanoma histopathological characteristics were extracted from cancer registry notifications and death data were obtained from the National Death Index (1982–2011). Histopathology was compared using conditional logistic regression and overall survival analyzed using Cox proportional hazard models. Compared to melanomas in nontransplant recipients (n = 202), melanomas in transplant recipients (n = 75) had a higher Clarks level (p = 0.007) and higher American Joint Committee on Cancer pathologic stage (p = 0.002), but not Breslow thickness (p = 0.11). Posttransplant melanoma conferred higher risk of death (adjusted hazard ratio 4.26, 95% CI 2.71–6.72, p < 0.001) after adjustment for the matching variables, pathologic stage, histological type and anatomic site. This was not explained by transplantation alone. Melanomas in transplant recipients are more invasive than those in nonrecipients. More aggressive tumor behavior is also supported by a markedly poorer outcome. Treatment algorithms developed for the general population with melanoma may not apply to transplant recipients. A review of patient education and skin cancer screening guidelines is warranted.

Melanoma in organ transplant recipients : The old enemy finds a new battleground

Population registry data and published studies have demonstrated that melanomas in the transplant population occur 1.6–2.5 times more commonly compared with the general population. Studies examining possible risk factors have suggested that in this patient population, there is an increased number of melanocytic naevi. Whether this phenomenon is aetiologically related to subsequent melanoma development is currently unclear. Only one study examined the prognosis of melanomas in this population. The Israel Penn International Transplant Tumor Registry has collated patient data voluntarily submitted by transplant physicians throughout the USA since 1968. Analysis of melanomas in this study found that approximately half were Breslow thickness >1.51 mm. Overall, there was a high rate of nodal and distant metastases, with poorer 1‐, 3‐ and 5‐year survival rates compared with the general population. There is a paucity of good‐quality evidence regarding melanoma in organ transplant recipients. Further research involving international collaborative trials, particularly on risk factors and the prognosis of melanomas in this population, could present a more substantial evidence base from which treatment guidelines based on data could be developed.

Imiquimod 5% cream in the treatment of mycosis fungoides--a pilot study.

Sir, Mycosis fungoides (MF) is the commonest variant of primary cutaneous T-cell lymphoma and is generally associated with an indolent clinical course. MF has been shown to respond to subcutaneous interferon alfa, particularly in patients with early stage disease. Imiquimod is an immune response modifier that induces interferon alfa, tumour necrosis factor and other cytokines that stimulate the cell-mediated immune system. Imiquimod is licensed as Aldara 5% cream for the treatment of external genital warts. Apart from anogenital warts, topical imiquimod has also been shown to be effective in the treatment of molluscum contagiosum, Bowen’s disease, basal cell carcinoma and bowenoid papulosis. To our knowledge, there is only one isolated case report of imiquimod being therapeutically active in MF. We therefore conducted a double-blind placebocontrolled pilot study to evaluate the safety and efficacy of imiquimod cream 5% (Aldara, 3M Pharmaceuticals), once daily, in the treatment of early MF. Ethical approval was obtained from the Cambridge Local Research Ethics Committee. Patients aged 18 years old and above with histologically proven, stable and patch or plaque stage MF were recruited. Four patients, all males, aged 39–61 years old (mean 54 years) with stage 1B MF (T2N0M0) participated in the study. Patients were randomized to receive either imiquimod cream or vehicle. In each patient, a treatment and a distant control area were chosen. Each target area measured approximately 20 cm. The cream was applied daily with a contact time of 8 hours for 16 weeks before being washed off. Telephone follow-up at weeks 7, 9 and 16 assessed tolerability and adverse events. Final clinical evaluation was undertaken at week 32. Clinical assessments and photographs were performed before treatment and at week 32 (Figures 1 and 2). The safety parameters observed incorporate the capture of local skin reactions and adverse events experienced during the treatment period. Symptoms such as irritation, soreness and redness were recorded. Primary efficacy variables were degree of scaling, erythema, thickness and surface area. Treatment and control plaques were outlined on acetates that were subsequently superimposed onto grid paper to calculate surface area. Three patients received treatment with imiquimod (patients 2, 3 and 4). Changes in surface area before and after treatment are shown in Figure 3. In the treatment group, lesions treated with imiquimod demonstrated a mean decrease in surface area of 8.9%, whereas control lesions showed a mean increase in surface area of 39.9%. In the treated lesions, scaling and erythema improved in one patient and thickness in another. No change was observed in the other treated lesion. The patient receiving placebo cream (patient 1) showed an increase in surface area, thickness and scaling, but no change in erythema, of both treatment

Successful treatment of cyclosporine-induced sebaceous hyperplasia with oral isotretinoin in two renal transplant recipients

We present two cases of cyclosporine‐induced sebaceous hyperplasia in renal transplant recipients, successfully treated with isotretinoin. Both patients tolerated isotretinoin well, with no alteration in graft function. These cases provide support for the safe and effective use of oral isotretinoin in the treatment of cyclosporine‐induced sebaceous hyperplasia in the kidney transplant population.

Sweet's syndrome in an Australian hospital: A retrospective analysis

A retrospective analysis was performed of patients meeting the clinicopathological diagnosis of Sweets syndrome identified over a 10‐year period, in a metropolitan hospital. Nine patients met the inclusion criteria. Two patients had preceding streptococcal infection, two had associated inflammatory bowel disease, two had idiopathic Sweets syndrome, and three had an underlying malignancy, one of whom was receiving granulocyte colony‐stimulating factor. Although only three patients were found to have an elevated white cell count, erythrocyte sedimentation rate or C‐reactive protein was elevated in all patients when measured. There was a wide spectrum of clinical presentations, with variations in lesion distribution and the presence/absence of systemic symptoms such as fever and arthralgia. Fever was observed in two‐thirds of cases. Seven patients responded to oral corticosteroids, while one patient cleared spontaneously and one patient was lost to follow up. As erythrocyte sedimentation rate or C‐reactive protein was elevated in all cases when measured, it may be a useful diagnostic tool.