David J. Elpern

Basal cell carcinoma in Kauai, Hawaii: The highest documented incidence in the United States

BACKGROUND In Kauai, Hawaii, we observed an exceedingly high incidence of basal cell carcinoma in an earlier 1-year study. OBJECTIVE Our purpose was to report the incidence of basal cell carcinoma in a defined population in Hawaii. METHODS A prospective 5-year population-based incidence study was conducted on Kauai, Hawaii, between 1983 and 1987 to investigate the frequency of basal cell carcinomas in Caucasian residents. A total of 242 residents, 161 men and 81 women, were identified with an initial episode of basal cell carcinoma during the 5-year period. RESULTS The average annual incidence per 100,000 Kauai Caucasian residents standardized to the 1980 U.S. white population was 576 for men and 298 for women with a combined incidence of 422. The average patient age was 56.5 years, and men had a significantly higher incidence of cancer than women (p < 0.000001). The head and neck was the most common site. The trunk was the second most common site, representing one third of lesions. Subsequent new basal cell carcinomas occurred in 16.9% of patients. Only 3.3% of patients had recurrent carcinomas after treatment. CONCLUSION Kauais incidence rates of basal cell carcinoma are the highest yet documented in the United States. As an unexpected finding, a decreasing incidence trend was noted in the studys later years and may warrant further investigation. Finally, a significant number of basal cell carcinomas developed on the trunk, suggesting and reinforcing the expectation that sun exposure is not limited to the face and neck in this Hawaiian population.

Bowen's disease (squamous cell carcinoma in situ) in Kauai, Hawaii: A population-based incidence report

BACKGROUND The incidence of Bowens disease (squamous cell carcinoma in situ) is rarely investigated. OBJECTIVE Our purpose was to report the incidence of Bowens disease in a defined Caucasian population in Kauai, Hawaii. METHODS We conducted a prospective 5-year population study. RESULTS We found 71 Caucasian residents, 44 men and 27 women, who had an initial episode of Bowens disease during the 5-year period. The average annual incidence rate per 100,000 Caucasian residents of Kauai, standardized to the 1980 U.S. Caucasian population, was 174 for men and 115 for women, with a combined rate of 142. The incidence increased in older age groups. The mean age of the patients was 65.2 years. The most common anatomic site was the extremities. Subsequent Bowens disease occurred in eight patients (11.3%). Recurrence after treatment developed in only one patient (1.4%). Twenty-six patients (36.6%) had concurrent skin cancers, either basal cell carcinoma or squamous cell carcinoma, or both. There was no increased incidence of internal malignancy. CONCLUSION The incidence of Bowens disease is high in Caucasian residents of Kauai and is 10 times higher than that reported from a northern Midwestern community. Kauais intense ambient UV light and greater opportunity for year-round outdoor activities likely contributes to this higher rate.

Nonmelanoma skin cancer in Japanese ethnic Hawaiians in Kauai, Hawaii: An incidence report

BACKGROUND Incidence reports of nonmelanoma skin cancer (NMSC) in Japanese persons are limited. Most studies have relied primarily on hospital records or voluntary reporting systems. OBJECTIVE Our purpose was to determine the incidence of basal cell carcinoma (BCC), squamous cell carcinoma (SCC), and Bowens disease (BD) in a defined Japanese population. METHODS A prospective 5-year population-based incidence study was conducted on the island of Kauai, Hawaii from 1983 through 1987. RESULTS Thirty Japanese Kauai residents, 12 men and 18 women, developed BCC during the 5-year study period. At the same time, 24 Japanese, 6 men and 18 women, were identified with SCC, and 11 had BD, three men and eight women. When standardized to the Japanese population in Japan, the annual BCC incidence rate was 30 per 100,000 Japanese Kauai residents with an average patient age of 75 years. More than 80% of these BCCs were localized to the head and neck. New BCCs developed in four patients with BCC, but none was a recurrence of a previously treated lesion. Five patients with BCC had SCC or BD concurrently or at other times. The SCC incidence was 23 per 100,000 Japanese Kauai residents with an average patient age of 80 years. The head and neck were again the most common anatomic sites. New SCCs subsequently occurred in two patients, in one of whom a localized recurrence also developed. Five patients with SCC had BCC simultaneously or at other times. The incidence of BD was 13 per 100,000 Japanese Kauai residents with an average patient age of 74 years. The extremities were the most common anatomic sites. One patient later had a new BD lesion and a recurrent BD lesion. Two patients had BCC or SCC at other times. CONCLUSION We report incidence rates of BCC, SCC, and BD at least 45 times higher in the Japanese population in Kauai, Hawaii than rates for the Japanese population in Japan. Kauais intense UV radiation and emphasis on outdoor activities may contribute. More Japanese women had NMSC than men, a sex difference not observed in Japan.

Squamous cell carcinoma in Kauai, Hawaii

Background. It is estimated that over 100,000 new cases of squamous cell carcinoma are diagnosed in the United States annually. This number is compounded by an increasing concern over the ozone layer depletion and the continued sunbathing behavior of many individuals. This could be particularly acute in Hawaii, which may have the highest rates of skin cancer in the country. We believe the updated information on skin cancer is essential to address the magnitude of the problem.

Non-melanoma skin cancer and keratoacanthoma in Filipinos : an incidence report from Kauai, Hawaii

Background. Non‐melanoma skin cancer is the most common malignancy in the white population of the United States with an estimated 700,000 new cases each year. Regrettably, data on minority racial groups are either scarce or lacking entirely.

Scabies Epidemiology, Kauai, Hawaii, 1981–1985

ABSTRACT: The demography of scabies was studied in the sole dermatology practice on the island of Kauai, Hawaii, over a 50‐monlh period. Scabies was observed far more frequently in whites and Hawaiians than in Japanese and Filipinos. Within the while ethnic group, scabies was most frequently diagnosed in persons between 15 and 44 years old, while in Hawaiians, the disease was most common in the 0–14‐year age group. It is possible that learned or acquired behavior patterns may play a significant role in contracting the disease.

The human skin microbiome

We generally think of bacteria, fungi, and viruses as pathogens – foreign invaders seeking to harm us. In fact, pathogens are a minority among all of the microbes that populate the Human Microbiome (HM), a term proposed by the well-known geneticist, Joshua Lederberg. By using the term, Human Microbiome, he was referring to all those microbes that are found in and on human beings. Most of these microbes are not only harmless but are in fact beneficial, both in terms of our normal bodily functions as well as protection from other pathogenic microbes. There are several interesting points to consider about the HM. First, the bacteria in our microbiome outnumber us! It is estimated that 100 trillion bacteria live in and on our bodies. Further, only 1% of the cells on our person are human and the other 99% are microbes. To put it graphically, half of our stool is not leftover food but rather microbial biomass. This constitutes 2–5 pounds of bacteria produced by our body each day. David Relman’s opinion is that “We are like coral, an assemblage of life forms living together.” We know that bacteria can harm us. But, do microbes benefit us as well? Consider, for the moment, the use of antibiotics. Besides destroying pathogenic bacteria, antibiotics may disturb the delicate balance of commensals that contribute to our homeostasis. For example, an overgrowth of toxin-producing Clostridium difficile can cause pseudomembranous colitis. What is really impressive, however, is the response to fecal microbial transplants (presumably filled with normal microbe flora) for the treatment of C. difficile colitis refractory to conventional antibiotic therapy. In this case, our health may be more efficiently restored by infusing bacteria, not by infusing additional antibiotics. Significant evidence exists regarding the health benefits of diverse gut flora. By creating free fatty acids and thus lowering the pH of the skin surface, Propionibacterium acnes contributes to making the skin inhospitable for pathogens such as Staphylococcus aureus and Streptococcus pyogenes but allows less virulent coagulase-negative Staphylococcus and Corynebacterium to flourish. In turn, many strains of Staphylococcus epidermidis produce antimicrobial peptides that limit the growth of other microbes on the skin. Pseudomonas aeruginosa, a common skin flora, is well known for producing multiple antimicrobial peptides, including mupirocin. This peptide has been reproduced for topical use as an agent against gram-positive bacteria, including methicillin-resistant S. aureus. The importance of flora on the skin is not limited to its direct effect on other pathogens; there is evidence that the presence of skin commensals, such as Staphylococcus epidermidis, may help prime the immune system and enhance innate immunity. How did we learn about the HM? It was not from the culturing of bacteria from various orifices, as only 1% of the HM can grow in synthetic laboratory, but rather

Dermatoscopic pattern of a cylindroma.

A 65-year-old man presented with an asymptomatic lesion on the left parietal scalp of 6 months’ duration. Three years prior, a cylindroma on the same area was excised by a general surgeon. Physical examination revealed a solitary 6 mm salmon-pink, firm, dome-shaped papule on the left parietal scalp (Figure 1). Dermatoscopic evaluation showed arborizing telangiectasia and several scattered white globules on a white to salmon pink background (Figure 2). The lesion was excised for pathologic evaluation. Histologic evaluation shows multiple irregular lobules in a jigsaw-mosaic pattern diagnostic of cylindroma (Figures 3 and 4).

Granulomatous diseases of the nose

The nose is an almost pyramidal structure with its apex projecting anteriorly and its base attached to the facial skeleton. It is an important respiratory airway structure and also plays an essential role in the perception of smell, a sensation that undoubtedly adds to the quality of life. Furthermore, although the concepts of beauty and the aesthetically ideal face change over time and are somewhat different across cultures, the nose has always had a critical role in these concepts because of its central position in the frontal view of the face and its prominence in the lateral view. As a result of these functional and aesthetic qualities, patients often attach significance to any disease that affects the nose. Indeed, many diseases have a predilection for the nose. Although these diseases may be infectious or noninfectious in origin, they often share a common granulomatous nature (Table 1). Diseases, such as tuberculosis, leprosy, sarcoidosis, Wegener’s granulomatosis, and many other granulomatous diseases with different etiologies, are among the major diseases having a predilection for the nasal structure. The frequency with which they are seen and their etiologies differ with the geographic location of the practitioner. Herein, we present a useful classification of these reactions to assist practitioners in the diagnosis and management of this challenging group of disorders.

KERATOACANTHOMA IN JAPANESE HAWAIIANS IN KAUAI, HAWAII

Background. This is the first incidence report of keratoacanthoma (KA) in a Japanese ethnic population.