John P. Arlette

Increased Melanoma Risk in Parkinson Disease: A Prospective Clinicopathological Study

OBJECTIVE To evaluate the possible association of Parkinson disease (PD) and melanoma in North America. DESIGN, SETTING, AND PATIENTS Thirty-one centers enrolled patients with idiopathic PD. At visit 1, a neurologist obtained a medical history. At visit 2, a dermatologist recorded melanoma risk factors, performed a whole-body examination, and performed a biopsy of lesions suggestive of melanoma for evaluation by a central dermatopathology laboratory. We compared overall prevalence of melanoma with prevalence calculated from the US Surveillance Epidemiology and End Results (SEER) cancer database and the American Academy of Dermatology skin cancer screening programs. RESULTS A total of 2106 patients (mean [SD] age, 68.6 [10.6] years; duration of PD, 7.1 [5.7] years) completed the study. Most (84.8%) had received levodopa. Dermatology examinations revealed 346 pigmented lesions; dermatopathological findings confirmed 20 in situ melanomas (0.9%) and 4 invasive melanomas (0.2%). In addition, histories revealed 68 prior melanomas (3.2%). Prevalence (5-year limited duration) of invasive malignant melanoma in the US cohort of patients with PD (n = 1692) was 2.24-fold higher (95% confidence interval, 1.21-4.17) than expected in age- and sex-matched populations in the US SEER database. Age- or sex-adjusted relative risk of any melanoma for US patients was more than 7 times that expected from confirmed cases in American Academy of Dermatology skin cancer screening programs. CONCLUSIONS Melanoma prevalence appears to be higher in patients with PD than in the general population. Despite difficulties in comparing other databases with this study population, the study supports increased melanoma screening in patients with PD.

Squamous cell carcinoma in situ of the skin: History, presentation, biology and treatment

Squamous cell carcinoma in situ (SCCIS) of the skin is a problem commonly dealt with by dermatologists. The classic presentation, originally described by Bowen, is easily recognized, but presentation on some anatomical surfaces may be associated with less than typical features. Major aetiological factors for this disease are UV light, human papillomavirus infection and immunosuppression. The natural course of SCCIS is usually prolonged, with treatment being appropriate, but not urgent. The choice of therapy requires consideration of the location of the lesion, and a desire for a high cure rate without causing loss of form, function or cosmesis. The immunomodulatory agent imiquimod has offered a significant advance for the topical treatment of SCCIS. Our improved understanding of the underlying biology of SCCIS permits us to make rational choices of treatment. In the future we may be able to determine which of these lesions may progress to invasive disease, and help us select the most effective therapy.

Herpes simplex virus infection of the hand: A profile of 79 cases

Seventy-nine cases of herpes simplex (HSV) infection of the hand were documented by viral culture over a 40-month period. A marked bimodal age distribution was found with 32 cases occurring in adults aged 21 to 30 years and 16 occurring in children less than 10 years old. The infection most commonly occurred on the fingers (69 percent) and thumb (21 percent). All 20 herpes simplex type 2 (HSV-2) isolates came from patients over 20 years old. All of the 13 specimens that were typed after isolation from patients under 20 years old were herpes simplex type 1 (HSV-1). Only seven of the 49 adult cases were identified in health care professionals. In this series, HSV infection of the hand occurred in 2.4 cases per 100,000 population per year. In adults, women with recurrent infections from HSV-2 and a history compatible with genital herpes predominated. In children, a primary HSV-1 infection associated with gingivostomatitis was common.

Comparison of the infrared coagulator and the carbon dioxide laser in the removal of decorative tattoos

A comparative study of the removal of decorative tattoos by the infrared coagulator and the CO2 laser was performed. The comparison was made by following the parameters of length of healing time, postoperative pain, presence of residual pigment, and tendency for scarring. The results showed that the infrared coagulator had the advantages of a more rapid healing time, an easier-to-care-for treatment site, and an equivalent cosmetic result in comparison with the CO2 laser. The CO2 laser had the advantage of total pigment removal in a single treatment, whereas the infrared coagulator often left residual pigment.

Human orf: a diagnostic consideration?

We saw four unrelated cases of human orf infection over a 3-month period. Each patient had a clear-cut history of contact with sheep and developed a characteristic painful pustular lesion on the hand. There were no significant systemic symptoms. Examination of an aspirate by electron microscopy confirmed the diagnosis. The lesions resolved spontaneously within 6 weeks. Human orf infection occurs in North America, and although seldom reported, it should be considered in the diagnosis of cutaneous lesions in patients who have exposure to animals associated with it.

Superficial leiomyosarcoma: a clinicopathologic review and update.

Fauth CT, Bruecks AK, Temple W, Arlette JP, DiFrancesco LM. Superficial leiomyosarcoma: a clinicopathologic review and update.

Anatomic Location of Hyaluronic Acid Filler Material Injected into Nasolabial Fold : A Histologic Study

BACKGROUND Products instilled within or beneath the skin to improve its physical features are known as fillers. The position of the filler within the skin is one determinant of the end cosmetic result. OBJECTIVE The objective was to histologically determine the anatomic location of injected hyaluronic acid (HA) filler within nasolabial fold (NLF) skin. METHODS AND MATERIALS Sixteen patients (12 females, 4 males; median age, 59 years) undergoing Mohs micrographic surgery for basal cell carcinoma of the NLF area consented to injection of Burows triangle or dog-ear redundant skin with HA gel (Juvederm), ex vivo, in vivo, or in vivo with delayed (1–4 weeks) removal. Sections of alcohol-fixed, paraffin-embedded tissue specimens were stained with hematoxylin and eosin and with Hales colloidal iron for detection of acid mucins. Dermal thickness was measured and HA distribution assessed. RESULTS NLF dermal thickness was 1.37±0.27 mm (mean±SD), with a range of 1.04 to 1.86 mm. All 16 patients showed HA filler localized to the subcutis. In 9/16 tissue samples, some HA was present in the deep dermis, but filler was only observed in more superficial dermis in 1 patient. The thickness of injected filler was 2.11±0.63 mm, but filler was often transected at the specimen base. CONCLUSION The predominant localization of injected HA filler is within the subcutis. A relatively thin NLF dermal thickness, typically <1.50 mm, likely precludes accurate injection of filler into dermal collagen. The results suggest that dermal localization of HA filler products is not required for an excellent cosmetic result.

Zinc and the skin.

Zinc is an essential trace element integrally involved in a wide range of metabolic processes required for tissue growth and repair as well as being necessary for maintaining host defences. Zinc deficiency can occur from lack of adequate dietary intake, decreased intestinal absorption, and increased losses in the gastrointestinal tract, urine, and sweat. The clinical signs of zinc deficiency can present in a florid manner with dermatitis, alopecia, and diarrhea, or they can be chronic changes with dwarfism and hypogonadism or, the signs may be barely perceptible with low growth rates and hypogeusia. As with all nutritional deficiencies, the possibility of its existence must be considered before the diagnosis can be made. It is not known how severe zinc deficiency must be or how long it has to be present before the characteristic rash appears. However, as biochemical changes of zinc deficiency occur before any clinical changes do, it is likely that metabolic processes have been affected before the rash heralds the presence of zinc deficiency.

Comparison of outcomes for malignant melanoma of the face treated using Mohs micrographic surgery and wide local excision.

BACKGROUND Mohs micrographic surgery (MMS) is an accepted treatment for nonmelanoma skin cancer and has an evolving role in melanoma. OBJECTIVE To review oncologic outcomes of MMS and wide local excision (WLE) treatments for facial melanoma. METHODS AND MATERIALS A retrospective review of patients with invasive melanoma of the face between 1997 and 2007 identified from the Alberta Cancer Registry (Canada) was performed. Outcome measures were local recurrence (recurrence <2 cm from excision scar), distant recurrence (regional or systemic), and disease‐specific survival. RESULTS One hundred fifty‐one patients were available for analysis (60 MMS, 91 WLE). Median follow‐up time was 48 months. The groups differed in tumor location and mitotic rate. Overall, there was no significant difference in 5‐year local recurrence (7.9% WLE vs 6.2% MMS, p = .58), regional or systemic recurrence (18.8% vs 8.8%, p = 0.37) or disease‐specific survival (82.8% vs 92.4%, p = .59). Breslow thickness was the only consistent predictor of local recurrence or other recurrence and disease‐specific survival on multivariate analysis. Subset analysis of tumors with Breslow thickness less than 2 mm did not reveal any difference in outcomes. CONCLUSION Mohs micrographic surgery has oncologic outcomes of local recurrence, distant recurrence and overall survival similar to those of WLE for invasive facial melanoma.

Deep Tissue Sequencing Using Hypodermoscopy and Augmented Intelligence to Analyze Atypical Pigmented Lesions

Background: Over the past decade, new technologies, devices, and methods have been developed to assist in the diagnosis of cutaneous melanocytic lesions. Objective: Our objective was to evaluate the performance of an augmented intelligence system in the assessment of atypical pigmented lesions. Methods: Nine atypical pigmented lesions on 8 patients were evaluated prior to surgical removal. No lesions had received previous treatment other than a diagnostic biopsy. Prior to surgical removal, each lesion was evaluated by an Augmented Intelligence Dermal Imager (AID) and the assessment parameters reviewed in light of the final histopathological diagnosis. Results: The AID was used to evaluate a limited set of atypical pigmented lesions and showed sensitivity and specificity of 82% and 61%, respectively, based on its internal risk assessment algorithms. Limitations: These cases represent early assessments of the AID in a clinical setting, all prior assessments having been carried out on digital images. The information received from these evaluations requires further validation and analysis to be able to extrapolate its clinical usefulness. Conclusion: The AID combines dermoscopy, hypodermoscopy, and a trained augmented algorithm to produce a diffusion map representing the features of each lesion compared to the learned characteristics from a database of known dermoscopy images of lesions with definitive prior diagnosis. The information gathered from the diffusion map might be used to calculate a malignancy risk factor for the lesion compared to known melanoma features. This malignancy risk factor could be helpful in providing information to justify the biopsy of an atypical pigmented lesion.