Loretta S. Davis

Effects of selenium supplementation for cancer prevention in patients with carcinoma of the skin. A randomized controlled trial. Nutritional Prevention of Cancer Study Group.

OBJECTIVE To determine whether a nutritional supplement of selenium will decrease the incidence of cancer. DESIGN A multicenter, double-blind, randomized, placebo-controlled cancer prevention trial. SETTING Seven dermatology clinics in the eastern United States. PATIENTS A total of 1312 patients (mean age, 63 years; range, 18-80 years) with a history of basal cell or squamous cell carcinomas of the skin were randomized from 1983 through 1991. Patients were treated for a mean (SD) of 4.5 (2.8) years and had a total follow-up of 6.4 (2.0) years. INTERVENTIONS Oral administration of 200 microg of selenium per day or placebo. MAIN OUTCOME MEASURES The primary end points for the trial were the incidences of basal and squamous cell carcinomas of the skin. The secondary end points, established in 1990, were all-cause mortality and total cancer mortality, total cancer incidence, and the incidences of lung, prostate, and colorectal cancers. RESULTS After a total follow-up of 8271 person-years, selenium treatment did not significantly affect the incidence of basal cell or squamous cell skin cancer. There were 377 new cases of basal cell skin cancer among patients in the selenium group and 350 cases among the control group (relative risk [RR], 1.10; 95% confidence interval [CI], 0.95-1.28), and 218 new squamous cell skin cancers in the selenium group and 190 cases among the controls (RR, 1.14; 95% CI, 0.93-1.39). Analysis of secondary end points revealed that, compared with controls, patients treated with selenium had a nonsignificant reduction in all-cause mortality (108 deaths in the selenium group and 129 deaths in the control group [RR; 0.83; 95% CI, 0.63-1.08]) and significant reductions in total cancer mortality (29 deaths in the selenium treatment group and 57 deaths in controls [RR, 0.50; 95% CI, 0.31-0.80]), total cancer incidence (77 cancers in the selenium group and 119 in controls [RR, 0.63; 95% CI, 0.47-0.85]), and incidences of lung, colorectal, and prostate cancers. Primarily because of the apparent reductions in total cancer mortality and total cancer incidence in the selenium group, the blinded phase of the trial was stopped early. No cases of selenium toxicity occurred. CONCLUSIONS Selenium treatment did not protect against development of basal or squamous cell carcinomas of the skin. However, results from secondary end-point analyses support the hypothesis that supplemental selenium may reduce the incidence of, and mortality from, carcinomas of several sites. These effects of selenium require confirmation in an independent trial of appropriate design before new public health recommendations regarding selenium supplementation can be made

Telemedicine evaluation of cutaneous diseases: a blinded comparative study.

BACKGROUND Numerous telemedicine programs have been created in the United States, but studies documenting the fidelity and effectiveness of telemedicine for evaluation of skin diseases are lacking. OBJECTIVE We attempted to determine the percentage of encounters in which two different dermatologists, one using telemedicine and one on-site, could independently arrive at the same primary diagnosis. METHODS Two clinical telemedicine sites linked through the Georgia Statewide Telemedicine Program were used in this study of 60 patients with skin problems. One dermatologist evaluated the patients on telemedicine (interactive television) and a second then took the patients into a separate examination room and evaluated them on-site. Each investigator recorded their diagnoses with no discussion with each other. As a control group, the investigators independently and in a blinded fashion (to each others diagnoses) recorded diagnoses for a group of patients from a third dermatologists clinic. Raw data were evaluated and classified by this third dermatologist who assigned diagnoses to categories of complete agreement, partial agreement, or disagreement. RESULTS There were no significant differences with regard to disagreement. However, there was a higher probability of complete agreement between the two dermatologists when each examined the patient on-site and in person than when one evaluated the patient on telemedicine and one examined the patient on-site and in person. CONCLUSION Our results suggest that telemedicine is an effective means of diagnosing cutaneous diseases. However, because partial interobserver agreement on diagnoses was greater for the telemedicine group than for the control group (p < 0.05), it is likely that optimum use of medical assistants at the remote site will be necessary to increase the likelihood of complete agreement on diagnoses among dermatologists using interactive television.

Ocular rosacea : Signs, symptoms, and tear studies before and after treatment with doxycycline

OBJECTIVE To examine ocular signs, symptoms, and results of tear analysis in patients with cutaneous rosacea before, during, and after doxycycline therapy. DESIGN Before-after trial. SETTING General community. PATIENTS OR OTHER PARTICIPANTS Thirty-nine patients with cutaneous rosacea underwent dermatologic and ocular examinations, testing of tear break-up time, and Schirmer testing at baseline and 4, 8, and 12 weeks. Six patients did not complete the study. Baseline tear break-up time and results of Schirmer test were compared with those of 13 patients without rosacea who were matched for age and sex. INTERVENTION Patients with rosacea were given doxycycline, 100 mg daily for 12 weeks. MAIN OUTCOME MEASURE Statistically significant (P, .05) improvement in tear break-up time. RESULT The most frequent ocular symptoms were dryness, itching, blurred vision, and photosensitivity, all of which improved significantly with treatment. All patients had signs of ocular disease, most commonly erythema and telangiectasia, meibomian gland dysfunction, and ciliary base injection. Significant improvement (P,.05) for scales, erythema and telangiectasia, ciliary base injection, bulbar injection, papillary hypertrophy, and punctate epithelial erosions was seen. Average tear break-up time for the patients with rosacea was 5.7 seconds, which improved to 10.8 seconds after 12 weeks of treatment (P = .007). Baseline tear break-up time was significantly lower than for the comparison group of normal subjects (P = .001). There was no correlation between severity of cutaneous disease and ocular disease. CONCLUSIONS All patients with cutaneous rosacea had some degree of ocular involvement. Tear break-up time is abnormal in patients with rosacea. Ocular erythema and telangiectasia, meibomian gland dysfunction, and short tear break-up time in patients with cutaneous rosacea are indicators of ocular rosacea. Doxycycline, 100 mg daily, will improve ocular disease and increase the tear break-up time.

Relationship Between Age of Ear Piercing and Keloid Formation

Objective. Keloids occur commonly after trauma to the skin, with ear piercing being a well-known inciting event. We surveyed 32 patients with keloids resulting from ear piercing, to examine a potential relationship between age of piercing and keloid formation. Methods. A total of 32 consecutive patients completed a survey about ear-piercing and keloid formation. Fishers exact test was used for data analysis. Results. Fifty percent (n = 16) of surveyed patients developed a keloid after their first piercing. Twenty surveyed patients developed keloids with subsequent piercings. Those who had piercings at ≥11 years of age were more likely to develop keloids (80%) than were those who had piercings at <11 years of age (23.5%). Conclusions. Keloids are more likely to develop when ears are pierced after age 11 than before age 11. This observation holds true for patients with a family history of keloids. Given the difficulty and cost of treating keloids, prevention remains the best approach. Patients with a family history of keloids should consider not having their ears pierced. If this is not an option, then piercing during early childhood, rather than later childhood, may be advisable. Primary care physicians and pediatricians should educate children and their parents about the risk of keloid formation.

Rapidly progressive CD8-positive cutaneous T-cell lymphoma with tongue involvement

Cutaneous T-cell lymphoma rarely involves the oral cavity. We describe the histological and immunological findings of a rapidly progressive CD8+ cutaneous T-cell lymphoma involving the tongue. Involvement of the oral cavity usually indicates a poor prognosis. Cases of cutaneous T-cell lymphoma with oral involvement as reported in the English-language literature are reviewed and discussed.

Paraneoplastic Autoimmune Multiorgan Syndrome (Paraneoplastic Pemphigus) in a Child: Case Report and Review of the Literature

Paraneoplastic autoimmune multiorgan syndrome, also known as paraneoplastic pemphigus, has been observed only rarely among children. We describe a 10-year-old boy with typical clinical and histologic findings of paraneoplastic pemphigus associated with Castleman’s disease. His disease was refractory to resection of the tumor and aggressive combination immunosuppressive therapies. The patient died 1 year after presentation, as a result of complications of bronchiolitis obliterans. This case is unusual because of the young age of the patient.

Treatment of scleromyxedema with 2-chlorodeoxyadenosine

Scleromyxedema is an unusual skin disease that is characterized by a proliferation of fibroblasts and an accumulation of mucin. Despite experience with multiple forms of therapy, no single agent has proved uniformly beneficial in this condition. We describe a patient with scleromyxedema who was treated successfully with 2-chlorodeoxyadenosine (2-CdA), a purine analog used mainly in the treatment of lymphoproliferative disorders.

Familial cutaneous collagenoma

Address for correspondence: Marianne E. Dawn, MD, Department of Dermatology, University of Maryland School of Medicine, 419 West Redwood Street, 6th Floor, Baltimore, MD 21201 E-mail: marianne.dawn@gmail.com A 41-year-old woman presented to our dermatology clinic in February 2005 with a chief complaint of numerous fleshcolored nodules on her back and abdomen. She initially noticed the lesions at age 17 years. The plaques had increased in size and number over time, but remained asymptomatic. The patient reported multiple similar lesions on a maternal uncle and a cousin. Her family history was also notable for cardiomyopathy, resulting in the death of her mother. The patient’s past medical history was notable for poorly controlled type I diabetes, currently managed with an insulin pump; and coronary artery disease. The patient had undergone multiple cardiac procedures before the age of 40 years, including quadruple coronary artery bypass grafting surgery and placement of 9 cardiac stents. Her ejection fraction on cardiac catheterization in November 2004 was 65% with no wall motion abnormalities. On physical examination, numerous spongy, discrete, flesh-colored plaques and nodules were seen concentrated across the upper part of her back between the scapulae as well as underneath the breasts and across the flanks (Figure 1). All lesions were asymptomatic. Prior workup of this patient had included plain films of the long bones and hands, which were within normal limits. A biopsy from lesional skin on the back highlighted by trichome stain showed an increased number of markedly thickened and eosinophilic dermal collagen bundles compared with adjacent normal skin. Immunohistochemical studies with anticollagen type I and type III antibodies confirmed that the increased collagen material consisted of type I collagen fibers, which is the same type of collagen found in normal dermis. The elastic fibers, highlighted by Verhoeff-van Gieson stain (Figure 2), were diminished and haphazardly arranged. No increased cellular component or inflammatory infiltrate was observed. These findings were consistent with a collagenoma. Further analysis of the lesional tissue by electron microscopy revealed that the ultrastructural appearance of the collagen fibers, including arrangement and diameters, were not significantly different from that of the normal tissue (Figure 3).

Cutaneous draining sinus tract of odontogenic origin: unusual presentation of a challenging diagnosis.

A 44-year-old woman presented with a chronically draining lesion on her cheek just lateral to the nasofacial sulcus. The lesion was refractory to treatment with oral antibiotics. Physical examination revealed poor dentition, and a panoramic radiograph demonstrated periapical abscesses in the maxillary right lateral incisor and canine. A diagnosis of cutaneous fistula of odontogenic origin was made, and the patient was treated with tooth extraction. The cutaneous fistula subsequently resolved. Intraoral examinations and radiographs are critical for making the diagnosis of cutaneous draining sinus tract of odontogenic origin. Many patients undergo unnecessary surgical therapies before having the correct diagnosis made, but root canal therapy or surgical extraction is the treatment of choice. A dental origin must be considered for any chronically draining sinus of the face or neck.

Mohs Surgical Treatment of a Granular Cell Tumor on the Toe of a Child

Abstract:  Granular cell tumors are uncommon, usually benign tumors of neural origin. They are most often diagnosed in the third to sixth decades of life and are infrequently seen in the pediatric population. Although they can be found in a wide distribution throughout the body, more than half occur in the oral cavity and other head and neck sites such as the larynx. We report a granular cell tumor on the distal toe of a 5‐year‐old child, removed with Mohs surgery. Review of the English language literature revealed four previously reported granular cell tumors treated with Mohs micrographic surgery, none of which was in a child.