Luigi Brunetti

Perineal extramammary Paget disease responsive to topical imiquimod

Extramammary Paget disease (EMPD) is a rare neoplasm that arises in skin rich in apocrine glands, such as the axillae and anogenital region and usually affects the elderly. In most cases, EMPD is an apocrine carcinoma in situ, but it can be associated with internal malignancy spreading to overlying skin. Surgical excision with margin control is the generally accepted standard of care. A 74‐year‐old woman presented with a 1 year history of a pruritic eczematous eruption in perineum which on biopsy was diagnosed as EMPD. Because of the location and extent of the tumor, any surgical approach would have been problematic. Imiquimod 5% cream applied three times weekly for 16 weeks induced complete resolution. Topical imiquimod appears to be a promising treatment option for EMPD, especially when surgery is a challenge, but only a few cases have been reported.

Perinealer extramammärer Morbus Paget: Ansprechen auf topisches Imiquimod

Extramammary Paget disease (EMPD) is a rare neoplasm that arises in skin rich in apocrine glands, such as the axillae and anogenital region and usually affects the elderly. In most cases, EMPD is an apocrine carcinoma in situ, but it can be associated with internal malignancy spreading to overlying skin. Surgical excision with margin control is the generally accepted standard of care. A 74-year-old woman presented with a 1 year history of a pruritic eczematous eruption in perineum which on biopsy was diagnosed as EMPD. Because of the location and extent of the tumor, any surgical approach would have been problematic. Imiquimod 5 % cream applied three times weekly for 16 weeks induced complete resolution. Topical imiquimod appears to be a promising treatment option for EMPD, especially when surgery is a challenge, but only a few cases have been reported.

Successful treatment of localized pyoderma gangrenosum with topical pimecrolimus.

Journal of Cutaneous Medicine and Surgery, Vol 16, No 5 (September/October), 2012: pp 295-297 295 regularly administered for 3 years. The sites of injection of interferon were the abdominal wall and the buttocks. On physical examination, the ulcerative lesion showed bluish, raised, undermined edges with a halo of erythema and a reddish, granulomatous center partially covered by fibrin (Figure 1). The greater diameter measured approximately 4 ern. A biopsy from the border of the lesion showed an epidermis with acanthosis, ulceration, and a diffuse mixed inflammatory infiltrate, with abundant neutrophils in the dermis. The histologic picture was compatible with the clinical diagnosis of PG. A fungal or mycobacterial infection was ruled out by skin cultures and periodic acid-Schiff and Fite stains. Bacteriologic culture was positive for Staphylococcus aureus. Further serologic and instrumental investigations excluded concurrent hematologic or bowel diseases. The patient underwent oral treatment with ciprofloxacin 1 gld for 7 days to eradicate the bacterial infection and gentle debridement of the ulcer with 0.5% silver nitrate baths. Afterward, pimecrolimus cream 1% (Elidel, Novartis Farma, Italy) was applied twice daily into and around the ulcer. After 21 days, significant improvement with a reduction in ulcer size, pain, and perilesional inflammation was evident (Figure 2). Complete healing was observed 6 weeks after starting pimecrolimus (Figure 3). The treatment was well tolerated, without any adverse effect. The ulcer remained healed at 8 months. Although PG is frequently associated with many conditions, the association with multiple sclerosis has up to now been described in only two cases. In one report, the patient presented with PG, ulcerative colitis, multiple sclerosis, and ankylosing spondylitis, whereas in another case, PG was associated solely with multiple sclerosis .9.10 Due to its rarity, this combination may be fortuitous. In addition, it appears unlikely that IFN-~-lb treatment may have enhanced the occurrence of PG in our patient because this drug had been administered for 3 years, and administration continued regularly during the course of PG and after clearing. Recently, there have been several reports on the efficacy of topical tacrolimus in the management of PG.6•7,1114 This agent has been successfully used as monotherapy for early lesions of PG and may be beneficial in combination with systemic immunosuppressants, including corticosteroids and cyclosporine, in the management of more severe and advanced lesions. In addition, topical tacrolimus (with or without occlusion) Successful Treatment of Localized Pyoderma Gangrenosum with Topical Pimecrolimus

Topical tacrolimus in the treatment of granuloma faciale

that distinguishes among the classical, the malignancyassociated, and the drug-induced form of SS. However, there are various atypical forms of SS that have been reported so far. Unusual clinical variants include neutrophilic dermatosis of the dorsal hands and SS with bullous or pustular lesions. Although SS with bullous lesions is well known, SS with pustules is uncommon. To our knowledge, a case with numerous and disseminate plaques accompanying erosion or pustules mimicking vasculitis or bullous disease, which were more numerous on the legs than the face, arms, and trunk, has not been reported yet. In addition, it is also atypical for SS that this patient had been afebrile in his long clinical course despite his extensive skin lesions.

Leg defect reconstruction with double hatchet flaps: report of eight cases

Leg defects not suitable to direct closure can be intriguing to treat, because of the reduced mobility of the skin and paucity of local tissue, especially in the lower third. As the use of local flaps (advancement, rotation, or transposition) is burdened by a significant risk of failure, skin grafts are often utilized to restore moderate or large defects (1). However, grafts require prolonged recovery times and frequently lead to unsatisfactory outcomes. Promising results have been recently described with the use of nontraditional procedures, such as reducing opposed multilobed flaps, opposed bilateral transposition flaps, keystone island flaps, double helix flaps, and others (2–5). However, the advantages of these new techniques need confirmation on larger patient series. We report our experience with the use of double hatchet flaps (DHF) to restore middle to large size defects on the lower extremities.

Oral verrucous carcinoma treated with imiquimod 5% cream and carbon dioxide laser

ejd.2011.1397 Auteur(s) : Roberto Cecchi r.cecchi@usl3.toscana.it, Laura Bartoli, Luigi Brunetti, Mario Pavesi U.O. Dermatologia, Ospedale di Pistoia, V. Matteotti 1, 51100 Pistoia, Italy Oral verrucous carcinoma (VC), also called oral florid papillomatosis, is a rare variant of squamous cell carcinoma, which can affect the oral mucosa, gingiva, tongue, floor of the mouth, and lips [1]. It generally discloses an indolent behaviour, with a slow expanding growth, and minimal metastatic potential. [...]

Micrographic surgery (fresh-tissue Tübingen technique) for treatment of basal cell carcinoma of the head: A single-centre report

Dear Editor, Basal cell carcinoma (BCC) is the most common malignancy in humans. It often arises on sunexposed areas of the head and neck, where it may be locally aggressive and invade vital structures. The biological behavior of BCC depends on its histological pattern and clinical features, including the anatomical site, size and whether it is primary or recurrent. Although a variety of surgical and nonsurgical treatment modalities are available for BCC, micrographic surgery (MS) is one of the most effective methods. The procedure warrants a high cure rate, minimizing healthy tissue sacrifice. It has become the treatment of choice particularly for high-risk BCC. Reported recurrence rates with Mohs’ micrographic surgery (MMS) range 1–3% for primary tumors and 5–7% for recurrent tumors in different studies. A recent prospective study by Leibovitch et al. on a series of 3370 patients with BCC treated with MMS found a 5-year recurrence rate of 1.4% for primary and 4.0% for recurrent tumors. Although standard MMS is the most widely used MS technique, several variants of this procedure have been developed. The common denominator of all these methods is a complete, 3-D control of excised skin tumor margins. The Tübingen technique is a variant of MMS, that was introduced in 1984 by Breuninger and generally uses routine histology on paraffin-embedded sections. This procedure provides a complete microscopic margin control through the use of vertical surface sections of the full perimeter of the excised tumor. In addition, horizontal strips are taken from the tumor base. We report our preliminary experience with this procedure, that has been modified using fresh/ frozen sections in a group of patients with BCC of the head region. All patients had completed a 3-year follow up. A retrospective study of 60 patients (40 men and 20 women; mean age, 65.5 years; median, 64 years; range, 38–87 years) with 60 BCC of the cephalic region, treated by fresh-tissue Tübingen micrographic technique between June 2002 and November 2004 was carried out. The diagnosis of BCC was clinical or in some cases histological. Selection criteria for MS were tumors with ill-defined clinical margins (>90% of cases), recurrent or incompletely excised tumors, high-risk anatomic sites (perioral, nasolabial, periorbital, nasal ala), or biopsy-proven aggressive histological pattern (infiltrating, morpheaform, baso/squamous). Primary BCC were 32 (53.3%) and recurrent BCC were 28 (46.7%). Most of the tumors were located on the nose or perinasal area (45.0%, n = 27), and on the forehead or temporal area (15.0%, n = 9). Mean tumor size was 1.4 cm (range, 0.7–4.6 cm), with 25% of lesions having a diameter of more than 2 cm. The mean number of MS stages required for complete tumor resection was 1.65 (range, 1–4 stages). In 48.3% (n = 29) of cases, BCC were eradicated in one MS stage, while in 41.7% (n = 25) of patients two stages were necessary. Only two patients required four stages of surgery for histologically clear margins. The mean defect size was 2.6 cm (range, 1.0–6.2 cm). None of the patients showed recurrence during a mean follow up of 53.2 months (median, 53 months; range, 39–68 months). Patient characteristics and results of MS are given in Table 1. All procedures were performed under local anesthesia, without any relevant complication. The functional and cosmetic results were quite satisfactory. In conclusion, our experience supports the feasibility and effectiveness of the fresh-tissue Tübingen technique in the treatment of BCC. The method

Topical formulations of delta-aminolevulinic acid for the treatment of actinic keratosis: Characterization and efficacy evaluation

Abstract Actinic keratosis (AK) is a pre‐cancerous disease, with worldwide increasing incidence, which consists in squamous cutaneous lesion caused by excessive exposure to ultraviolet radiation. An established treatment option is photodynamic therapy (PDT), based on light, oxygen and a photosensitizer. The most widely used is 5‐aminolevulinic acid (ALA) which however, being a hydrophilic molecule, has difficultly penetrating the skin to achieve the desired therapeutic effect. To solve this limit, the present study provides for the development of three galenic gel formulations (Natrosol, Sepigel and Carbopol) containing 10% w/w of ALA for the treatment of AK with PDT and their comparison with a lipophilic cream used in the Hospital. The aim of this study is to offer an appealing topical treatment that improves patients’ observance and compliance. Formulations were characterized in terms of chemical, physical and microbiological stability, viscosity and pH. An HPLC‐DAD analytical method was also developed and validated. Sepigel gel resulted the best gel formulation in terms of technological characteristics and stability. A comparative study between this gel and the lipophilic cream was assessed, by evaluating the therapeutic efficacy and the compliance of the patients. Graphical abstract Figure. No caption available.

Repair of a large lateral foot defect with a combination of keystone island flap and V-Y plasty

Reconstruction of foot defects, not possible with primary closure, is often challenging, because the skin at this level is tight and difficult to mobilize. Traditional random pattern cutaneous flaps also have a limited role for the restoration of small and middle-sized wounds, because of the high risk of complications, such as flap necrosis and dehiscence. Skin grafts are widely used to cover large losses in non-weight-bearing sites, although they tend to heal slowly and result in poor outcomes [1]. [...]

The helix flap in the reconstruction of circular skin defects

ejd.2012.1791 Auteur(s) : Roberto Cecchi r.cecchi@usl3.toscana.it, Laura Fancelli, Laura Bartoli, Luigi Brunetti, Michela Troiano, Mario Pavesi U.O. Dermatologia, Ospedale di Pistoia, V. Matteotti 1, 51100 Pistoia, Italy Surgical removal of skin tumours generally originates circular defects, which may be challenging whenever they are not amenable to primary closure. Flap procedures, such as advancement, rotation, interpolation, transposition, skin grafting and combinations thereof can be utilized [...]