Franziska Brehmer

Dynamic Changes in Nevi of a Patient With Melanoma Treated With Vemurafenib: Importance of Sequential Dermoscopy

BACKGROUND Therapy with vemurafenib, an inhibitor of mutated BRAF, yields a response rate of approximately 50% in patients with metastatic melanoma harboring a BRAF V600E mutation. As an adverse effect of vemurafenib, proliferative disorders of keratinocytes, including squamous cell carcinoma, have been described. Low concentration of vemurafenib as present in the epidermis were found to activate wild-type RAF, which, in combination with a preexisting RAS mutation, can promote keratinocyte proliferation. While activating BRAF mutations occur in approximately 50% of melanomas, they are even more frequently observed in melanocytic nevi. OBSERVATION We present the case of a patient with dynamic changes of melanocytic nevi well documented by sequential digital dermoscopy during vemurafenib therapy. A variety of dermoscopic changes were observed. First, nevi involuted, and all of these originally showed a centrally elevated papillomatous and predominant globular pattern. Second, preexisting nevi increased in size, and pigmentation that rendered them atypical. Such lesions were flat and showed a predominant reticular pattern at baseline. Third, multiple new nevi occurred. One example of each of the latter 2 categories was excised and showed wild-type BRAF. CONCLUSION Our findings of changing nevi in a patient treated with vemurafenib highlight the need for sequential skin examinations, including dermoscopy.

When all you have is a dermatoscope— start looking at the nails

Pigmented and non-pigmented nail alterations are a frequent challenge for dermatologists. A profound knowledge of clinical and dermatoscopic features of nail disorders is crucial because a range of differential diagnoses and even potentially life-threatening diseases are possible underlying causes. Nail matrix melanocytes of unaffected individuals are in a dormant state, and, therefore, fingernails and toenails physiologically are non-pigmented. The formation of continuous, longitudinal pigmented streaks (longitudinal melanonychia) may either be caused by a benign activation of matrix melanocytes (e.g., as a result of trauma, inflammation, or adverse drug reactions) or by a true melanocytic proliferation (e.g., in a nevus or melanoma). In general, non-continuous nail alterations, affecting only limited parts of the nail apparatus, are most frequently of non-melanocytic origin. Important and common differential diagnoses in these cases are subungual hemorrhage or onychomycosis. In addition, foreign bodies, bacterial infections, traumatic injuries, or artificial discolorations of the nail unit may less frequently cause non-continuous nail alterations. Many systemic diseases that may also show involvement of the nails (e.g., psoriasis, atopic dermatitis, lichen planus, alopecia areata) tend to induce alterations in numerous if not all nails of the hands and feet. A similar extensive and generalized alteration of nails has been reported after treatment with a number of systemic drugs, especially antibiotics and cytostatics. Benign or malignant neoplasms that may also affect the nail unit include glomus tumor, Bowen’s disease, squamous cell carcinoma, and rare collision tumors. This review aims to assist clinicians in correctly evaluating and diagnosing nail disorders with the help of dermatoscopy.

Strategies for early recognition of cutaneous melanoma—present and future

Cutaneous melanoma is a highly aggressive malignant tumor of skin melanocytes with an increasing incidence in most countries of the world, especially in the fair-skinned populations. Despite all preventive and therapeutic efforts, malignant melanoma is still the most lethal skin cancer. A delayed diagnosis results in an advanced stage and worsened prognosis. Once distant metastases are present, the five-year survival rate is less than 10 percent. At the same time, patients may be cured by an early diagnosis of cutaneous melanoma followed by a wide excision. Therefore, the early detection of melanoma at curable stages is crucial for the patients’ survival. Besides the investigation of pigmented lesions with the unaided eye, a wide range of examination techniques for improved diagnostic accuracy have been developed and validated in clinical trials. However, none of these techniques are able to provide a definite and final diagnosis or to replace an excisional biopsy of suspicious lesions followed by histological analysis. This review provides a concise overview of general principles as well as current and future strategies for an improved early diagnosis of cutaneous melanoma

Repetitive injections of botulinum toxin A continuously increase the duration of efficacy in primary axillary hyperhidrosis: A retrospective analysis in 101 patients

Botulinum toxin type A is an effective, well‐tolerated, albeit temporary treatment for primary axillary hyperhidrosis. However, little is known about the influence of repetitive injections on the duration of efficacy.

Dermatoskopie der Nägel

Pigmented and nonpigmented nail abnormalities often represent a challenge for clinicians because many, and sometimes potentially life-threatening differential diagnoses must be taken into consideration. Although many details of nail diseases can already be assessed with the naked eye, dermoscopy opens up a second microscopic level of inspection, which can be very useful for the diagnostic process. In the last 20 years dermoscopy has made rapid progress in the further development of criteria for the early recognition of melanoma. In addition, the use of dermoscopy has been extended to the examination of cutaneous adnexa, such as hairs (trichoscopy) and nails (onychoscopy). Many, sometimes highly specific criteria for the dermoscopic assessment of nail diseases have been described in a series of recently published articles. This review article provides important diagnostic aids for a well-founded dermoscopic assessment of nail diseases.

Dermoscopy of nails

Pigmented and nonpigmented nail abnormalities often represent a challenge for clinicians because many, and sometimes potentially life-threatening differential diagnoses must be taken into consideration. Although many details of nail diseases can already be assessed with the naked eye, dermoscopy opens up a second microscopic level of inspection, which can be very useful for the diagnostic process. In the last 20 years dermoscopy has made rapid progress in the further development of criteria for the early recognition of melanoma. In addition, the use of dermoscopy has been extended to the examination of cutaneous adnexa, such as hairs (trichoscopy) and nails (onychoscopy). Many, sometimes highly specific criteria for the dermoscopic assessment of nail diseases have been described in a series of recently published articles. This review article provides important diagnostic aids for a well-founded dermoscopic assessment of nail diseases.

Nd:YAG laser epilation to prevent recurrences after pilonidal sinus surgery.

Pilonidal sinus is a common and painful inflammatory disorder of the sacral tissues; it mainly affects men (M:F ratio is 2–4:1) in the 2nd to 3rd decade of life. The disease is found in fairskinned Europeans with an incidence of 26/100 000 people. It rarely occurs in black Africans and Asians [1, 2]. The sinus contains granulation tissue, hairs and cell detritus. The course of disease can be divided in asymptomatic, acute with abscess and chronic exudative. Pilonidal sinuses persist lifelong but can become acute at any moment. In this stage with bacterial superinfection surgical incision and drainage along with antibiotic treatment is recommended. Total excision of the sinus with all its fistula tracts down to the sacral fascia is indicated a noninflamed phase. The optimal treatment after surgical excision is still controversial. Open secondary wound healing, primary wound closure in the centerline or plastic reconstructive flaps are common treatment options. The relapse rate is high and is estimated at 5 % to 20 % [1, 3]. While some authors report the lowest relapse rate after open wound healing [2, 4], others describe best results after wound closure with flaps [5]. Surgical incision and drainage before definitive total excision reduces the longterm recurrence rate [4]. Hairs not only promote relapse but also hamper the process of secondary wound healing after pilonidal sinus surgery (Figure 1). In recent years epilation with different laser systems has successfully reduced the risk for relapse after pilonidal sinus surgery [3, 5–8].

Percutaneous ultrasound-guided drainage of needle aspiration-refractory seromas following lymph node excision.

Lymph node surgery plays an important role in the treatment of cutaneous melanoma. Sentinel lymph node excision (SLNE) is an established procedure according to guidelines worldwide. Clinically enlarged lymph node metastases require complete regional lymph node dissection (CLND). The formation of seromas is a typical complication of lymph node surgery [1]. Apparently, seromas consist of a fibrous (pseudo-) capsule filled with lymphatic fluid, which may [2] or may not [3] have an endothelial lining. Although closed suction drainage is routinely used, seromas have been observed in 10 % of patients after inguinal SLNE and even 57 % of cases following inguinal CLND [4]. After the former, seroma formation is significantly associated with leg edema [5]. Smaller seromas may be asymptomatic, and require no further treatment. However, seromas may cause symptoms such as discomfort, pain, or impairment in mobility. Such cases require repeated needle aspiration. Seromas may be extremely recalcitrant and persist even after repeated aspiration procedures. For cases like this, we would like to present percutaneous drainage as a method that, in our hands, has proven very effective after failed attempts at needle aspiration.

Wiederholte Injektionen von Botulinumtoxin Typ A steigern kontinuierlich die Wirkdauer bei primärer axillärer Hyperhidrose: Eine retrospektive Analyse von 101 Patienten

Botulinumtoxin Typ A ist eine wirksame, gut verträgliche, wenn auch temporäre Therapieoption gegen primäre axilläre Hyperhidrose. Über den Einfluss von wiederholten Injektionen auf die Wirkdauer ist jedoch wenig bekannt.

Rapidly growing blue-red nodule on the cheek of a 4-year-old boy: Case for Diagnosis

Dermatoscopy (Handyscope for iPhone 4, FotoFinder Systems, Bad Birnbach, Germany) revealed a sharply demarcated, symmetric, round tumor with diffuse blue to bluish-red pigmentation (Figure 1c). Macroscopically visible telangiectases disappeared upon compression by the dermatoscopic contact plate. A few lightly colored streaks were visible. Rapidly growing blue-red nodule on the cheek of a 4-year-old boy Case for Diagnosis