Evelien Verhaeghe

Inter-observer variation in the histopathological diagnosis of clinically suspicious pigmented skin lesions

When a biopsy is taken of a suspicious pigmented skin lesion, histological examination is expected to establish the definitive diagnosis. This study evaluated the inter‐observer variation of 20 pathologists in the histological diagnosis of a randomly selected set of suspicious pigmented skin lesions (PSLs), by comparing their diagnoses to a reference diagnosis. Overall sensitivity for melanoma was 87%, ranging from 55% to 100% between the observers. Sensitivity was significantly lower for thin (Breslow thickness <1 mm) than for thick melanomas (83% versus 97%, p=0.005). Overall melanoma specificity was 94%, ranging from 83% to 100% between observers. Dysplastic naevus was the most important source of false‐positive diagnoses, mainly in situ melanomas. Positive and negative predictive values in the given test set were 75% and 97%, respectively. In the case of melanoma, there was quite some variation in measured Breslow thickness. This would have led to a different therapeutic approach in 12% of the readings. Some of the variation seemed to be due to a different interpretation of the presence of a co‐existent naevus. In 9% (3/35) of the readings, participants did not agree on the presence of ulceration. These results reflect a tendency to overdiagnose mainly thin melanomas in general histopathological practice. They also demonstrate variation in the assessment of major prognostic factors of melanoma. Copyright

New insights in segmental vitiligo: case report and review of theories

Segmental vitiligo and generalized vitiligo are in general considered to be separate entities. The aetiopathogenesis of segmental vitiligo remains unclear, although several hypotheses have been put forward including mainly neuronal mechanisms. The typical association with other autoimmune diseases, as seen in generalized vitiligo, seems to be significantly less in segmental vitiligo, although recent insights point towards a possible immune‐mediated overlap between the two subtypes. In this article, we describe a case with simultaneous presence of segmental vitiligo, alopecia areata, psoriasis and a halo naevus. To our knowledge, this is the first case with this exceptional combination. This concomitant presence could support the involvement of a shared autoimmune‐mediated process, and may provide new insights into the pathogenesis of segmental vitiligo and direct future research. In the light of this remarkable case, different possible aetiopathogenetic mechanisms leading to the clinical presentation of segmental vitiligo are discussed and a new three‐step theory is proposed.

Long‐Term Evaluation of Donor‐Site Morbidity after Radial Forearm Flap Phalloplasty for Transsexual Men

INTRODUCTION Phalloplasty using the radial forearm flap is currently the most frequently used technique to create the neophallus in transsexual men (formerly described as female-to-male transsexual persons). Although it is considered the gold standard, its main disadvantage is the eventual donor-site morbidity in a young, healthy patient population. AIM The study aims to examine the long-term effects of radial forearm flap phalloplasty in transsexual men and to evaluate aesthetic outcome, scar acceptance, bone health, and daily functioning. MAIN OUTCOME MEASURES Scars were evaluated with the patient and observer scar assessment scale, the Vancouver Scar Scale, and self-reported satisfaction. Bone health was assessed using dual X-ray absorptiometry and peripheral quantitative computed tomography, and daily functioning using a physical activity questionnaire (Baecke). These measurements were compared with 44 age-matched control women. METHODS This is a cross-sectional study of 44 transsexual, a median of 7 years after radial forearm flap phalloplasty, recruited from the Center for Sexology and Gender Problems at the Ghent University Hospital, Belgium. RESULTS We observed no functional limitations on daily life activities, a pain-free and rather aesthetic scar, and unaffected bone health a median of 7 years after radial foreram flap phalloplasty. Over 75% of transsexual men were either satisfied or neutral with the appearance of the scar. CONCLUSIONS Transsexual men, despite scarring the forearm, consider the radial forearm flap phalloplasty as worthwhile.

Early Treatment of Hemangiomas with Lasers

Hemangiomas can present a difficult problem in management. Much controversy exists over whether it is better to watch and wait for natural involution or to be more aggressive and attempt to prevent some of the potential negative sequelae. Different modalities have been employed in the treatment of hemangiomas, including systemic therapy – antiangiogenic drugs, i.e. systemic corticosteroids and α-interferon – and local therapy – surgical procedures, arterial embolization and cryotherapy. Overall, a very conservative approach to therapy has been recommended because of treatment risks, treatment inadequacy and lack of evidence showing superiority over natural involution. Recently laser treatment has been used in the therapeutic approach of hemangiomas. This review discusses the pros and contras of early laser treatment of hemangiomas. For superficial hemangiomas, the flashlamp pumped pulsed dye laser in particular has proven itself in numerous studies. In the treatment of hemangiomas with subcutaneous components, the Nd:YAG laser is the treatment of choice.

Time delays and related factors in the diagnosis of cutaneous melanoma

Delay in melanoma diagnosis was investigated in a population-based sample of 130 patients. The median time elapsing from the first notice of the lesion to excision was 110.5 days. There was no linear correlation between total delay time and Breslow-thickness of the diagnosed melanomas (P=0.19). Patient delay, defined as the time from first notice of a (change in a) lesion to the first observation by a physician, exceeded 2 months in half of all patients. Only 41% of the patients consulted a doctor because they were worried about the lesion. Colour change and itch were associated with a longer patient delay. There was no correlation with age, gender, socio-economic factors, localisation of the lesion and the person who first noticed the lesion. In one quarter of all patients, the time from first observation by a physician to excision of the lesion exceeded 2.5 months. This physician delay seemed to be attributed to misdiagnosis and to a delay occurring during referral.

Short‐ and Long‐Term Clinical Skin Effects of Testosterone Treatment in Trans Men

INTRODUCTION Our knowledge concerning the effects of testosterone (T) therapy on the skin of trans men (female-to-male transsexuals) is scarce. AIM The aim of this study was to evaluate the short- and long-term clinical effects of T treatment on the skin of trans men. METHODS We conducted a prospective intervention study in 20 hormone naive trans men and a cross-sectional study in 50 trans men with an average of 10 years on T therapy. MAIN OUTCOME MEASURES Acne lesions were assessed using the Gradual Acne Grading Scale, hair patterns using the Ferriman and Gallwey classification (F&G), and androgenetic alopecia using the Norwood Hamilton Scale. RESULTS T treatment increased facial and body hair growth. The F&G score increased progressively from a median value of 0.5 at baseline to a value of 12 after 12 months of T administration. After long-term T treatment, all but one trans man achieved an F&G score indicative of hirsutism in women, with a median value of 24. Only one trans man acquired mild frontotemporal hair loss during the first year of T treatment, whereas 32.7% of trans men had mild frontotemporal hair loss and 31% had moderate to severe androgenetic alopecia after long-term T therapy. The presence and severity of acne increased during the first year of T therapy, and peaked at 6 months. After long-term T treatment, most participants had no or mild acne lesions (93.9%). Dermatological outcome was not demonstrably related to individual serum T or dihydrotestosterone levels. CONCLUSIONS T treatment increased facial and body hair in a time-dependent manner. The prevalence and severity of acne in the majority of trans men peaked 6 months after beginning T therapy. Severe skin problems were absent after short- and long-term T treatment.

Current Guidelines in Melanoma Treatment

This article focuses on the actual management of cutaneous melanoma, dealing both with established, internationally well-accepted standard procedures and interventions which are still being investigated. It wants to offer a global picture to the dermatologist of what is currently available in the therapeutic arsenal against melanoma.

Pyoderma gangrenosum as an Early Revelator of Acute Leukemia

Bullous pyoderma gangrenosum is an atypical, more superficial variety of the classical pyoderma and is often associated with myeloproliferative disorders. We present the case of a patient who presented initially with subcutaneous nodules and who developed bullous lesions afterwards. Histological evaluation showed the presence of neutrophilic infiltrates in both lesions. A few months after the diagnosis of bullous pyoderma gangrenosum, an underlying leukemia was revealed. Our case illustrates the importance of regular blood and bone marrow examinations in patients with atypical bullous pyoderma gangrenosum, resulting in a rapid diagnosis of the underlying disease.

Intrapatient Comparison of 308-nm Monochromatic Excimer Light and Localized Narrow-Band UVB Phototherapy in the Treatment of Vitiligo: A Randomized Controlled Trial

Background: Limited data are available about the use of 308-nm monochromatic excimer light (MEL) and localized 311-nm narrow-band ultraviolet B (NB-UVB) in the treatment of vitiligo. The aim of this study was to evaluate the efficacy of 308-nm MEL versus localized 311-nm NB-UVB in vitiligo patients. Methods: Eleven patients participated in this prospective intrapatient placebo-controlled randomized trial. In each patient, 3 lesions were selected and treated with NB-UVB, MEL and placebo during 24 sessions, respectively. Repigmentation was evaluated clinically and by objective surface measurement. Results: Twenty percent of the lesions treated with NB-UVB achieved repigmentation scores above 50%. None of the lesions treated with MEL achieved a repigmentation higher than 50% after 24 sessions. Conclusion: Localized 311-nm NB-UVB is effective in the treatment of vitiligo. It should be considered for localized vitiligo as it is easily accessible. In this study the efficacy of localized 311-nm NB-UVB was superior to 308-nm MEL.

Under-registration of melanoma in Belgium: an analysis.

The overall underestimation of incident cancer cases in the Belgian National Cancer Registry is estimated at about 20-25%, with a probable larger under-registration among males. Melanoma incidence is suspected to be underestimated even further because of the hospital-based reporting system of the National Cancer Registry. To investigate the suspected underestimation of melanoma in Belgium, the official data were compared with international data on melanoma incidence and the results of a melanoma registration programme launched in the province of East Flanders. The Eindhoven Cancer Registry, which covers a registration area near the Belgian border, was used as a reference to calculate the expected number of melanomas in East Flanders for 1995. The results indicate an ongoing under-registration of melanoma cases by the National Cancer Registry. Based on the Eindhoven Cancer Registry data, the under-registration in East Flanders is estimated at 43% for males and 36% for females. The East Flanders registration programme apparently obtains a better registration in females. This is mainly due to a higher registration in the younger age groups. In these groups a higher proportion of in situ melanomas and a thinner median Breslow thickness of the invasive melanomas is observed.