Colin J. Fleming

A pilot study of treatment of lentigo maligna with 5% imiquimod cream.

Background  Lentigo maligna (LM) is an in situ form of malignant melanoma, and surgical excision is often unsatisfactory. Imiquimod cream is an immune response modifier and induces a predominantly T‐helper 1 type response.

A randomized, investigator‐masked clinical evaluation of the efficacy and safety of clobetasol propionate 0.05% shampoo and tar blend 1% shampoo in the treatment of moderate to severe scalp psoriasis

The clinical benefit of currently available tar blend shampoos for the treatment of scalp psoriasis is restricted due to their limited efficacy, low cosmetic appeal and potential for carcinogenicity. This 4‐week multicentre, randomized, parallel‐group, investigator‐masked study included 162 subjects and aimed to compare the efficacy, safety and cosmetic acceptability of clobetasol propionate 0.05% shampoo versus a currently marketed tar blend 1% shampoo in subjects with moderate to severe scalp psoriasis. Clobetasol propionate shampoo was superior to tar blend shampoo with respect to all efficacy variables tested (p<0.001): Total and Global Severity Score; erythema; plaque thickening; desquamation; pruritus; total scalp area involved; and the subjects global assessment of clinical improvement. Both treatments were safe and well‐tolerated. Furthermore, more subjects indicated that clobetasol propionate shampoo was more cosmetically acceptable than tar blend shampoo. Clobetasol propionate 0.05% shampoo is a good alternative to tar blend shampoo in the treatment of moderate to severe scalp psoriasis.

Randomized comparison of Mohs micrographic surgery and surgical excision for small nodular basal cell carcinoma: tissue-sparing outcome.

BACKGROUND Mohs micrographic surgery (MMS) is recognized globally as the criterion standard for high‐risk basal cell carcinoma (BCC). The main advantage of MMS over conventional surgery is the chance of complete tumor removal, but it is also thought, based on experience, to be tissue sparing. OBJECTIVE To determine whether MMS leaves smaller surgical defects than standard surgery. METHODS AND MATERIALS This was a randomized trial involving 30 patients with a clinical diagnosis of BCC. Patients were randomly assigned to MMS or standard surgery. In the standard surgery group the BCCs were excised with 4‐mm margins. In the MMS group, tumors were excised with 2‐mm margins and subsequent stages of MMS until the tumor was completely removed. An observer unaware of the treatment allocation calculated the defect size. The main outcome measure was defect size in mm2. RESULTS The median area of the surgical defects in the MMS group was 116.6 mm2, versus 187.7 mm2 in the standard surgery group (95% confidence interval for difference=61‐126, p<.001). CONCLUSIONS This is the first randomized trial demonstrating that MMS is a tissue‐sparing treatment. Trial registration: http://www.clinicaltrials.gov Identifier: NCT00571363.

A randomized study of minimal curettage followed by topical photodynamic therapy compared with surgical excision for low-risk nodular basal cell carcinoma

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Treatment of actinic cheilitis with imiquimod 5% and a retractor on the lower lip: clinical and histological outcomes in 5 patients

Imiquimod 5% (Aldara, 3M Healthcare Ltd.) is a topically applied immune response modifier used in the treatment of superficial basal cell carcinoma, actinic keratosis, and genital warts. We reviewed the casenotes of 5 patients with histologically confirmed dysplastic lower lips who had been treated with topical imiquimod. Each patient was provided with a specially designed lower lip retractor to prevent spread of the cream. Treatment was stopped after 6 weeks or if an acute inflammatory reaction developed. The lower lip was biopsied 4 weeks later, and histologically the dysplastic changes had been reversed in all 5 patients. The lip retractor was well-tolerated, and prevented spread of the cream. Imiquimod 5% cream offers an alternative method to manage dysplastic lips. Our lip retractor is a simple and cost-effective method of isolating the lower lip and allowing application of topical agents. The method could equally well be used for agents other than imiquimod.

Seven years' experience of Mohs micrographic surgery in a UK centre, and development of a UK minimum dataset and audit standards.

Mohs micrographic surgery (MMS) is the gold‐standard treatment for high‐risk basal cell carcinomas and a variety of other cutaneous tumours, including dermatofibromasarcoma protuberans and microcystic adnexal carcinoma. Previous large‐scale case series, audits and reviews have allowed evaluation of MMS outcomes, such as BCC recurrence rates. However, to date there has been no systematic UK MMS audit, and certain important aspects of care, such as postoperative functional outcomes, have not yet been subject to scrutiny.

Trends in dermoscopy use in the UK: results from surveys in 2003 and 2012.

Background: Dermoscopy is a useful tool to aid diagnosis of pigmented and non-pigmented skin lesions, as well as many other dermatological conditions. Use of dermoscopy is increasing worldwide, but to date, there are no reported data on attitudes of dermatologists in the United Kingdom (UK) towards dermoscopy. Objective: To determine current attitudes of UK dermatologists towards dermoscopy and assess how these attitudes have changed over the last decade. Methods: In October 2012, an online survey was sent to members of British Association of Dermatologists over a 12-week period. Data were subsequently compared with data from a similar UK nationwide paper questionnaire distributed to members in 2003. Results: The 2003 survey collected 292 responses (uptake 42%), and in 2012 there were 209 responses (22%), predominantly from consultants and registrars. In 2012, 86% respondents reported increased use of dermoscopy over the previous decade with 98.5% of respondents reporting regular clinical use of dermoscopy, compared with 54% in 2003. Overall, 81% respondents in 2012 had received dermoscopy training, mainly from UK-based courses (62% of respondents) but increasingly via Internet-based resources (30% vs. 7% in 2003). However, 39% respondents lacked confidence when making a diagnosis based on their interpretation of dermoscopy findings. Conclusions: Over the last decade, use of dermoscopy has increased amongst UK dermatologists and the majority of respondents now employ dermoscopy in daily clinical practice. However, the use of dermoscopy in the dermatology community overall is not known and for those individuals there is a continued need for education.

Role of non‐surgical therapies in the management of periocular basal cell carcinoma and squamous intra‐epidermal carcinoma: a case series and review of the literature

Basal cell carcinoma (BCC) and squamous intra‐epidermal carcinoma (IEC) are the most common periocular tumours and can be associated with significant morbidity. Five percent of imiquimod cream and photodynamic therapy (PDT) are popular non‐surgical treatment options but are currently not licensed for periocular use.

Dermatoscopic features of extrafacial lentigo maligna.

The dermatoscopic features of classic lentigo maligna (LM) are well described; however, there is little literature available on extrafacial LM, which is a less frequently reported condition. The skin architecture is especially rich in adnexae on sun‐exposed areas such as the face, relative to other parts of the body, thus it is possible that the dermatoscopic findings of extrafacial LM will differ from the usual findings of LM. We carried out a dermatoscopic study on three patients with extrafacial LM. The dermatoscopic patterns reflected the underlying histological features of the disease, with increased melanocytes seen along the rete ridges and around follicular ostia, which result in a unique pigment network architecture.

Necrolytic migratory erythema in an opiate‐dependent patient

An 18‐year‐old woman presented with severe features of seborrhoeic dermatitis involving her scalp. Subsequently, the toe webs and intertriginous areas became affected by an erythematous, slightly scaly and weepy rash. The groin area was most severely affected, and complicated by intermittent infections with staphylococci and herpes simplex. The patient admitted to smoking heroin and was subsequently enrolled in a methadone programme. A biopsy from the groin area showed a combination of parakeratosis and keratinocyte vacuolar changes, supporting a diagnosis of necrolytic migratory erythema (NME). On completion of methadadone withdrawal, the rash cleared. The rash returned upon recommencing methadone. NME consists of an irregular annular eruption with an erythematous crusted edge. It is often mistaken for intertrigo or seborrhoeic dermatitis. In this patient, a direct effect of heroin and methadone on the epidermal metabolism might be speculated. There could be a variant of the opiate recepter, which is especially sensitive to the effects of opiates. This is the second case occurring in association with opiate dependency and the first case where the patient was rechallenged, although the precise role of the opiates in the aetiology remains somewhat speculative.