Christopher J Quirk

Two‐year interim results from a 5‐year study evaluating clinical recurrence of superficial basal cell carcinoma after treatment with imiquimod 5% cream daily for 6 weeks

Imiquimod 5% cream is approved in the USA, Europe and Australia to treat superficial basal cell carcinoma, using a regimen of once daily, 5 times per week for 6 weeks. Vehicle‐controlled, phase III clinical trials show that imiquimod is safe and effective for treating superficial basal cell carcinoma with dosing 5 or 7 times per week for 6 weeks. This phase III, open‐label study evaluates the long‐term (5 years) clinical efficacy and safety of dosing once daily, for which this manuscript reports the 2‐year time point in the follow‐up period. For the 169 enrolled subjects, the tumour selected for treatment was assessed clinically to determine initial clearance at the 12‐week post‐treatment visit. If clinically clear of superficial basal cell carcinoma, subjects entered a 5‐year, long‐term follow‐up period. Subjects were evaluated for recurrence at the 3‐, 6‐, 12‐ and 24‐month follow‐up visits. The initial clearance rate at 12 weeks post treatment was 94.1%. The proportion of subjects who were clinically clear at the 2‐year follow‐up visit was estimated to be 82.0%. Imiquimod was tolerated when applied daily, with erythema reported for all subjects participating in the study. The recurrence rate observed suggests that once daily dosing and 5×/week dosing yield similar clearance rates, but daily dosing increases local skin reactions.

Toward the discrimination of early melanoma from common and dysplastic nevus using fiber optic diffuse reflectance spectroscopy

We describe a study of the discrimination of early melanoma from common and dysplastic nevus using fiber optic diffuse reflectance spectroscopy. Diffuse reflectance spectra in the wavelength range 550 to 1000 nm are obtained using 400-microm core multimode fibers arranged in a six-illumination-around-one-collection geometry with a single fiber-fiber spacing of 470 microm. Spectra are collected at specific locations on 120 pigmented lesions selected by clinicians as possible melanoma, including 64 histopathologically diagnosed as melanoma. These locations are carried through to the histopathological diagnosis, permitting a spatially localized comparison with the corresponding spectrum. The variations in spectra between groups of lesions with different diagnoses are examined and reduced to features suitable for discriminant analysis. A classifier distinguishing between benign and malignant lesions performs with sensitivity/specificity of between 6469% and 7278%. Classifiers between pairs of the group common nevus, dysplastic nevus, in situ melanoma, and invasive melanoma show better or similar performance than the benign/malignant classifier, and analysis provides evidence that different spectral features are needed for each pair of groups. This indicates that multiple discriminant systems are likely to be required to distinguish between melanoma and similar lesions.

Brachioradial pruritus and cervical spine manipulation

Brachioradial pruritus (BRP) causes significant morbidity in the majority of patients for whom no effective treatment is found. Chronic ultraviolet radiation exposure has usually been cited as the cause, but nerve damage from cervical spine disease has also been implicated. We report on a small retrospective exploratory study, conducted by questionnaire, of a group of patients who were treated with a specific cervical spine manipulation. Ten of 14 patients reported resolution of symptoms following manipulative treatment. All six patients who had had previous cervical spine disease responded to manipulation, as did half the remaining eight patients who had no previous history of neck symptoms. Although patients with BRP, by definition, share similar symptoms, the aetiology is almost certainly multifactorial. Prospective studies looking for cervical spine disease, as well as assessment of this particular method of cervical spine manipulation as a treatment modality for BRP, should be considered.

Topical applications and perioral dermatitis

Perioral dermatitis (POD) is a common dermatosis and is considered by most dermatologists to be increasing in incidence. An Australia‐wide, questionnaire‐based study investigating the aetiology of POD was conducted, with particular emphasis on the significance of cosmetic use. One hundred and thirty‐three cases were obtained from dermatologists across Australia and were compared with 99 randomly selected controls who were matched for age and sex. Application of foundation, in addition to moisturiser and night cream resulted in a 13‐fold increased risk for POD (odds ratio 13.5; P <0.001). The combination of moisturiser and foundation was associated with a lesser but significantly increased risk for POD (odds ratio 2.9; P = 0.017). Moisturiser alone was not associated with an increased risk of POD. These findings suggest that cosmetic preparations play a vital role in the aetiology of POD, perhaps by an occlusive mechanism. In 83% of cases, topical steroid application to the face occurred after the development of a facial rash.

Epithelioid sarcoma. A diagnostic problem.

Twelve cases of epithelioid sarcoma have been reviewed, illustrating the diagnostic problems for which this rare tumor has become notorious and demonstrating varied rates of tumor progression. The histological features most helpful to the distinction of epithelioid sarcoma from other nodular skin lesions, including benign conditions such as rheumatoid nodule and granuloma annulare, are discussed. The ultrastructural appearances of two cases were similar to immature mesenchymal tissue.

Hypertrophic lichen planus mimicking squamous cell carcinoma

An 87‐year‐old female presented with a 3 month history of hyperkeratotic nodules on her left shin. An initial clinical and histological diagnosis of multiple squamous cell carcinomas on the left shin was made. Review of the biopsy, however, showed hypertrophic lichen planus with pseudoepitheliomatous hyperplasia. Typical lichen planus was seen affecting the oral mucosa, nails and skin elsewhere.

Successful treatment of in‐transit melanoma metastases using topical 2‐4 dinitrochlorobenzene

A 78‐year‐old woman presented with multiple histologically proven in‐transit melanoma metastases involving the lower half of the left leg. Initial therapy with liquid nitrogen cryotherapy had some short‐lived success but was not tolerated by the patient. As further lesions began to develop, daily topical application of 2% 2‐4 dinitrochlorobenzene to the lesions was commenced. During the first 2 years of therapy a partial response was achieved, with treated lesions regressing while new lesions developed. Eventually a long‐term remission of almost 2 years with no clinical evidence of cutaneous melanoma deposits was achieved. This treatment did not prevent metastatic lymph node and ultimately fatal liver involvement. Topical immunotherapy can be a useful adjunct in the treatment of cutaneous melanoma metastases, particularly in those patients who are unable to tolerate other destructive modalities of therapy.

Inverted follicular keratosis simulating malignant melanoma.

A 93‐year‐old woman was noted to have a single pigmented lesion on the posterior aspect of her neck. Clinical examination revealed a 12 × 8‐mm flat lesion, with an irregular border and variegated pigmentation. Dermatoscopic examination revealed a lesion with multiple colours, featureless areas and black dots, suggestive of malignant melanoma. With a presumed clinical diagnosis of malignant melanoma, an elliptical excision was performed, with a 1‐cm margin. However, histological examination revealed the unexpected diagnosis of pigmented inverted follicular keratosis.

MULTICENTRIC RETICULOHISTIOCYTOSIS: A LIGHT AND ELECTRON MICROSCOPIC STUDY

Multicentric reticulohistiocytosis (MR) with typical skin lesions and arthritis developed in a 51 year old woman. The cutaneous papules and nodules contained a dermal infiltrate of histiocytes and giant cells with ground‐glass cytoplasm. Invagination of elastin and collagen by MR cells was demonstrated by both light and electron microscopy. The patient responded well to treatment with chlorambucil but was subsequently found to have a rapidly disseminating carcinoma of the breast.