Leonard H. Goldberg

Effect of a Low-Fat Diet on the Incidence of Actinic Keratosis

BACKGROUND Actinic keratoses are premalignant lesions and are a sensitive and important manifestation of sun-induced skin damage. Studies in animals have shown that dietary fat influences the incidence of sun-induced skin cancer, but the effect of diet on the incidence of actinic keratosis in humans is not known. METHODS We randomly assigned 76 patients with nonmelanoma skin cancer either to continue their usual diet (control group) or to eat a diet with 20 percent of total caloric intake as fat (dietary-intervention group). For 24 months, the patients were examined for the presence of new actinic keratoses by physicians unaware of their assigned diets. RESULTS At base line, the mean (+/- SD) percentage of caloric intake as fat was 40 +/- 4 percent in the control group and 39 +/- 3 percent in the dietary-intervention group. After 4 months of dietary therapy the percentage of calories as fat had decreased to 21 percent in the dietary-intervention group, and it remained below this level throughout the 24-month study period. The percentage of calories as fat in the control group did not fall below 36 percent at any time. The cumulative number of new actinic keratoses per patient from months 4 through 24 was 10 +/- 13 in the control group and 3 +/- 7 in the dietary-intervention group (P = 0.001). CONCLUSIONS In patients with a history of nonmelanoma skin cancer, a low-fat diet reduces the incidence of actinic keratosis.

Fractional photothermolysis for the treatment of surgical scars: A case report

Background. Surgical scars are a challenging condition to treat. Fractional photothermolysis provides a promising new modality for treatment. Case report. A 55‐year‐old white female patient with a surgical scar on the chin was treated with fractional photothermolysis (1550 nm FraxelTM SR laser). A single treatment session was performed at pulse energy of 8 mJ (MTZ) and a final density of 2000 MTZ/cm2. The treatment response was assessed by comparing pre‐ and 2‐week post‐treatment clinical photography. Results. A greater than 75% clinical improvement of scarring was achieved at 2 weeks after a single treatment based on independent physician assessment. No significant adverse effects were noted. The improvement was persistent at 1‐month follow‐up. Conclusion. Fractional photothermolysis offers a new, effective, and safe modality for the treatment of surgical scars.

Expanded access study of patients with advanced basal cell carcinoma treated with the Hedgehog pathway inhibitor, vismodegib.

BACKGROUND Vismodegib, a first-in-class Hedgehog pathway inhibitor, was US Food and Drug Administration (FDA) approved for advanced basal cell carcinomas (BCCs) based on a single, nonrandomized, phase-II trial. Consequently, additional clinical data are critical to confirm the efficacy and safety of vismodegib. OBJECTIVE We sought to assess efficacy and safety of vismodegib, while providing early drug access to patients with advanced BCC and limited treatment options. METHODS This was an open-label, multicenter study in patients with advanced BCC inappropriate for radiotherapy or surgery. Patients received 150 mg vismodegib daily until disease progression or intolerable toxicity. Tumor response was assessed via Response Evaluation Criteria in Solid Tumors version 1.0. RESULTS A total of 119 patients with advanced BCC took vismodegib for a median of 5.5 months. Objective responses occurred in 46.4% of locally advanced BCC and 30.8% of patients with metastatic BCC. Response was negatively associated with prior systemic therapy in patients with locally advanced BCC (P = .002). Mean follow-up for safety was 6.5 months, with muscle spasms (70.6%), dysgeusia (70.6%), alopecia (58.0%), and diarrhea (25.2%) as the most common adverse events. LIMITATIONS Abbreviated follow-up time because of study termination upon FDA approval was a limitation. CONCLUSION This study provides important clinical data supporting the efficacy and safety of vismodegib. Larger studies are underway to assess predictors of response and long-term outcomes.

Microcystic Adnexal Carcinoma

background. Microcystic adnexal carcinoma is a slow-growing, nondescript, locally aggressive, deeply infiltrating neoplasm histologically characterized by an infiltrative pattern of basaloid or squamous cells, a desmoplastic stromal reaction, keratin-filled cysts, and glandular structures. objective. Microcystic adnexal carcinoma is uncommon and may be mistaken microscopically for other benign and malignant entities. Perineural or intraneural involvement by tumor cells is characteristic and extension into underlying structures including muscle, fat, and bone are frequently encountered. Although local recurrences are common after standard surgical excision, metastases have not been reported. Extensive resections of lesions may be necessary to extirpate widespread tumor, particularly those that are long standing or recurrent. Because significantly increased morbidity is associated with recurrent disease, surgical and histopathologic techniques that stress examination of all margins are advantageous. methods. We review the course of 10 patients with microcystic adnexal carcinoma of the face (six primary and four recurrent lesions) and their treatment by Mohs micrographic surgery.

Effectiveness of isotretinoin in preventing the appearance of basal cell carcinomas in basal cell nevus syndrome.

Fig. 1. Number of lesions in identical twins with basal cell nevus syndrome during isotretinoin therapy. REFERENCES 1. Haustein UF, Herrmann K, Bohme HJ. Pathogenesis of progressive systemic sclerosis. Int J Dermatol 1986;25:28693. 2. Cipoletti HF, Buckingham RB, Barnes EL, et al. Sjogrens syndrome in progressive systemic sclerosis. Ann Intern Med 1977;87:535-41. 3. Fong PH, Chan HL. Systemic lupus erythematosus with pemphigus vulgaris. Arch Dermato1 1985;121:26-7. 4. Vetters JM, Saikia NK, Wood J, et al. Pemphigus vulgaris and myasthenia gravis. Br J Derrnatol 1973;88:437-41. 5. Katz AL, Nashel DJ, Goard PG, et al. Pemphigus vulgaris and lymphoma in a patient with scleroderma. South Med J 1979;72:1463-6. 6. Heyden W. Pemphigus Seborrheicus bei progressiver Sklerodermie. Z Hautkr 1984;59:1336-9. pathogenetic mechanisms, or the association might be merely a coincidence. A larger series of patients should be reported and more should be learned about the pathogenetic mechanisms of these diseases before further conclusions are reached.

Laser eradication of pigmented lesions: a review.

BACKGROUND Pigmented lesions include solar lentigines, seborrheic keratoses, dermatosis papulosa nigra, ephelides, café‐au‐lait macules, nevus spilus, Beckers nevus, postinflammatory hyperpigmentation, melasma, nevocellular nevi, congenital nevi, junctional and compound melanocytic nevi, nevus of Ota and Ito, Horis nevus, and blue nevi. Advances in laser technology have resulted in the ability to treat pigmented lesions with greater safety and efficacy. OBJECTIVE To review the literature on the use of cutaneous laser treatments for pigmented lesions using Medline. RESULTS The literature cited the use of various lasers to treat pigmented lesions, including argon, carbon dioxide, erbium‐doped yttrium aluminum garnet, Q‐switched, long‐pulsed ruby, alexandrite, diode, and fractional lasers. For each lesion, we describe the efficacy of laser treatments, treatment intervals, and settings used for a variety of diagnoses. CONCLUSION The treatment of pigmented lesions continues to evolve as new laser technology emerges and improvements in existing devices are made. The ability to treat pigmented lesions with greater efficacy and safety has resulted from recent advances in laser technology. The authors have indicated no significant interest with commercial supporters.

Microcystic adnexal carcinoma: Ten cases treated by Mohs micrographic surgery

BACKGROUND Microcystic adnexal carcinoma is a slow-growing, nondescript, locally aggressive, deeply infiltrating neoplasm histologically characterized by an infiltrative pattern of basaloid or squamous cells, a desmoplastic stromal reaction, keratin-filled cysts, and glandular structures. OBJECTIVE Microcystic adnexal carcinoma is uncommon and may be mistaken microscopically for other benign and malignant entities. Perineural or intraneural involvement by tumor cells is characteristic and extension into underlying structures including muscle, fat, and bone are frequently encountered. Although local recurrences are common after standard surgical excision, metastases have not been reported. Extensive resections of lesions may be necessary to extirpate widespread tumor, particularly those that are long standing or recurrent. Because significantly increased morbidity is associated with recurrent disease, surgical and histopathologic techniques that stress examination of all margins are advantageous. METHODS We review the course of 10 patients with microcystic adnexal carcinoma of the face (six primary and four recurrent lesions) and their treatment by Mohs micrographic surgery.

Mohs tissue mapping and processing: A survey study

BACKGROUND Mohs micrographic surgery (MMS) is the most reliable, conservative, and tissue-sparing approach to the management of cutaneous malignancies. The concept of MMS is simple, but its technique, which involves a series of suboperations, is complex. OBJECTIVE To define which techniques of Mohs tissue mapping and processing are presently employed by members of the American College of Mohs Micrographic Surgery and Cutaneous Oncology. METHODS Five hundred eighty surveys of eight questions regarding different techniques used in Mohs tissue mapping and processing were mailed out to Mohs micrographic surgeons registered with the American College of Mohs Micrographic Surgery and Cutaneous Oncology. A total of 310 responses (53%) were collected between October and December 2002. The results were tabulated and analyzed. RESULTS Most Mohs micrographic surgeons personally prepare the map of the tissue in relationship to the patient (66.5%). A hand-drawn picture with standard orientations is most frequently used to map and orient a tissue specimen (69.4%). Histotechnicians usually prepare the tissue specimen for cryostat processing (63.5%). A heat extractor and/or tissue cuts or “slits” are the preferred methods used to flatten tissue by 52.9% of respondents. Hematoxylin and eosin is the stain that is most commonly used (82.6%). Approximately 50% of Mohs micrographic surgeons cut the excised specimen from the first stage into two separate pieces. Each tissue piece is then commonly processed into three to six representative serial sections per glass slide (68.1%). These sections are most commonly cut at 5 to 6 μm (53.9%) and less frequently at 4 μm (21.9%). CONCLUSION There is variability in mapping and processing techniques employed Mohs micrographic surgeons and their histotechnicians. As long as the integrity of each step of Mohs tissue mapping and processing is preserved, the high cure rate of the technique should be maintained.

High rate of malignant transformation in hyperkeratotic actinic keratoses

BACKGROUND Controversy exists over the rate of malignant transformation of actinic keratoses (AKs) and, therefore, which treatment is indicated. Furthermore, it is not known to what degree each of the separate clinical subtypes of AKs become malignant. OBJECTIVE Our purpose was to examine clinically diagnosed hyperkeratotic AKs and classify them histologically. METHODS Fifty papular hyperkeratotic AKs on the dorsum of the hand, wrist, and arm, less than 1 cm in diameter, were identified in 43 patients. Histologic evaluation was conducted in a blinded fashion by two observers. RESULTS Histologic examination showed 18 lesions (36%) to be invasive squamous cell carcinoma, whereas another seven (14%) were squamous cell carcinoma in situ. Proliferative AKs were the next most common lesion identified (26%), followed by hypertrophic (10%) and lichenoid (4%) AKs. Basal cell carcinomas (4%) and other benign lesions (6%) comprised the rest of the biopsy specimens. CONCLUSION It is possible to predict clinically, with greater certainty than previously realized, which AKs have a greater tendency toward malignant change. Clinical hyperkeratotic AKs less than 1 cm in diameter on the dorsum of the hand, wrist, or forearms of white patients have a malignancy rate of 50%. Lesions with this clinical description should be removed by shave biopsy, then by 35% trichloroacetic acid, then liquid nitrogen to a width and depth of 3 mm.

Treatment of melasma using fractional photothermolysis: a report of eight cases with long-term follow-up.

BACKGROUND Melasma on the face is difficult to treat and is often refractory to multiple treatment modalities. OBJECTIVES To investigate the safety and efficacy of fractional photothermolysis (FP) for the treatment of melasma and to determine recurrence rates with this treatment method. MATERIALS AND METHODS Eight female patients (Fitzpatrick skin type II–IV) with clinically diagnosed melasma on the face were treated using FP (1,550 nm Fraxel SR laser). Two to seven treatments were performed at 3‐ to 8‐week intervals. Treatment levels ranged from 3 to 10, corresponding to 9% to 29% surface area coverage (8–10 passes per treatment). Energies used ranged from 6 to 40 mJ. Physician and patient assessments were recorded at each visit and at a follow‐up visit 7 to 36 months (mean 13.5 months) after the last treatment session. RESULTS At the last treatment, assessments revealed greater than 50% clinical improvement in melasma in five of eight patients. Follow‐up assessments by the evaluating physician revealed sustained efficacy in five patients. Recurrence was reported in three patients. No significant adverse effects were noted. CONCLUSIONS FP is a safe and effective treatment for refractory melasma, with long‐term remission. The authors have indicated no significant interest with commercial supporters.