Franklin P. Flowers

Frequency of pre‐existing actinic keratosis in cutaneous squamous cell carcinoma

Background Controversy over the rate of malignant transformation of actinic keratosis (AK) into cutaneous squamous cell carcinoma (SCC) has generated considerable debate regarding the importance of treating all such precancers to preclude their transofrmation. Current changes in US healthcare policy will deny many individuals access to certain simple and effective treatment modalities for precancerous lesions.

Toxic epidermal necrolysis: A review

This article reviews the many facets of toxic epidermal necrolysis. Emphasis is placed on the importance of early diagnosis, burn unit placement, supportive care, and avoidance of systemic steroids. Discussion also includes other therapeutic options and the pathophysiology of the disease.

Extensive cutaneous hyperpigmentation caused by minocycline

A 65-year-old man had cutaneous hyperpigmentation that had occurred over the previous 2 1/2 years. The hyperpigmentation was extensive and involved the sclerae, nail beds, and total body; the palms and buttocks were spared. Clinical diagnosis was suggestive of hemochromatosis or heavy metal deposition. Histologic and electron microscopic findings were consistent with lysosomal iron deposition. A careful history showed that minocycline was the cause. Its use was discontinued, and after several years the patients pigmentation is gradually returning to normal.

Skin cancer of the head and neck with incidental microscopic perineural invasion

PURPOSE To address outcomes in clinically asymptomatic patients in whom the unexpected finding of microscopic perineural invasion is noted at the time of surgery. METHODS AND MATERIALS The 35 patients included in this study had skin cancers of the head and neck treated with curative intent between January 1965 and April 1995 at the University of Florida. All patients were without clinical or radiographic evidence of perineural invasion but, at the time of biopsy or surgical excision, had the incidental finding of microscopic perineural invasion. Definitive therapy consisted of radiotherapy alone after lesion biopsy (3 patients) or surgical excision preceded (2 patients) or followed (30 patients) by radiotherapy. All patients had follow-up for at least 1 year, 13 patients (37%) had follow-up for at least 5 years. RESULTS The 5-year local control rate was 78%. The 5-year local control rate for the few patients treated with radiotherapy alone was statistically similar to that for patients treated with surgery and radiotherapy (100% vs. 77%, p = 0.4). Multivariate analysis for factors affecting local control included sex, histology, age, treatment group, clinical T stage, initial histologic differentiation, and previously untreated vs. recurrent tumors, none of which was found to be significant. CONCLUSIONS Both surgery plus radiotherapy and radiotherapy alone provide a relatively high rate of local control for patients with incidentally discovered perineural invasion secondary to skin cancer.

Therapeutic alternatives in cutaneous T-cell lymphoma

Mycosis fungoides and Sézary syndrome, collectively referred to as cutaneous T-cell lymphoma, are non-Hodgkins lymphomas that initially appear in the skin. Early-stage disease, limited to the skin, is best treated with sequential topical therapies such as topical nitrogen mustard, psoralen phototherapy (PUVA), or total-skin electron beam therapy. Photopheresis is the first line of therapy for the patient with erythroderma. Systemic therapy is generally reserved for patients with refractory disease and patients who initially present with extracutaneous involvement. Although there are several treatment options for cutaneous T-cell lymphoma, there have been few randomized comparative trials.

Skin carcinoma of the head and neck with perineural invasion.

PURPOSE The aim of the study was to update the experience treating cutaneous squamous cell and basal cell carcinomas of the head and neck with incidental or clinical perineural invasion (PNI) with radiotherapy (RT). MATERIALS AND METHODS From 1965 to 2007, 216 patients received RT alone or with surgery and/or chemotherapy. RESULTS The 5-year overall, cause-specific, and disease-free survivals for incidental and clinical PNIs were 55% vs 54%, 73% vs 64%, and 67% vs 51%. The 5-year local control, local-regional control, and freedom from distant metastases for incidental and clinical PNIs were 80% vs 54%, 70% vs 51%, and 90% vs 94%. On univariate and multivariate (P = .0038 and .0047) analyses, clinical PNI was a poor prognostic factor for local control. The rates of grade 3 or higher complication in the incidental and clinical PNI groups were 16% and 36%, respectively. CONCLUSIONS Radiotherapy plays a critical role in the treatment of this disease. Clinical PNI should be adequately irradiated to include the involved nerves to the skull base.

NONMELANOMA SKIN CANCER

Nonmelanoma skin cancers encompass a vast array of malignancies: adventitial, vascular, neuroendocrine, hematologic, adnexal, and epithelial. The skin is also a major site for metastasis of internal disease. With an understanding of the frequency of presentation, clinical distribution, and appearance, the clinician is able to provide an accurate diagnosis for most lesions. Because there are so many nonmelanoma skin cancers, the focus here is on those with a high frequency or significant morbidity. The treatment of nonmelanoma skin cancer is constantly evolving; therefore, emphasis is on diagnosis.

The Interferons and Their Use in Condyloma Acuminata

There are three naturally occurring interferons: Alfa, beta, and gamma. Alfa, derived from lymphoblastic tissue, is approved by the Food and Drug Administration for the treatment of condyloma acuminata (genital or venereal warts). Genital warts are caused by human papillomaviruses, of which more than 50 subtypes have been described. Traditional therapies have centered on destruction of the lesions by either cytotoxic or physical modalities. Intralesional interferon exerts its antiviral effects on infected cells without causing damage to the surrounding tissue. In general, success rates with intralesional interferon alfa are comparable to traditional modalities. There is also evidence that interferon alfa might be particularly useful in the treatment of lesions that have failed to respond to other modalities.

Epidermal nevus syndrome: case report and review of clinical manifestations.

Abstract: The epidermal nevus syndrome is a disorder characterized by epidermal nevi and associated neurologic, skeletal, and other abnormalities. We cared for a 3‐month‐old male with multiple epidermal nevi and severe central nervous system involvement.

STEVENS-JOHNSON SYNDROME

The clinical manifestations, including variations, of the Stevens-Johnson syndrome (SJS) are reviewed. Lesions of the skin, eye, and mucous membranes are described and discussed. The potential complications and therapeutic approaches are outlined. Finally, the review discusses the controversy over the use of systemic corticosteroids in this syndrome.