Maria M. Tsoukas

Surgical treatment for dermatofibrosarcoma protuberans: the Dartmouth experience and literature review.

Introduction:Dermatofibrosarcoma protuberans (DFSP) is an invasive soft tissue tumor with asymmetric pattern of growth and propensity for recurrences, thus warranting systematic treatment planning at onset. We conducted a retrospective analysis of 25 patients with DFSP that received either wide excision, modified wide excision (with horizontal processing), Mohs micrographic surgery (MMS), or combination surgery. Follow-up ranged from 15–133 months, with a median of 68 months. Results/Conclusions:Fourteen patients were treated with wide excision, 4 with modified wide excision, 6 with MMS followed by modified wide excision, and 1 with MMS. No recurrences were reported. Patients with lesions arising from “cosmetically sensitive” areas (head and neck) most often underwent MMS or modified wide excision. Our study supports that all 4 surgical treatment methods were successful in achieving recurrence-free survival, but emphasis on presurgical planning and patient selection for each surgical approach is key to allow for the least complicated repair while maximizing tissue preservation.

Dietary and other risk factors in the aetiology of cholelithiasis: a case control study.

We studied the effect of dietary factors and a variety of other risk factors on the development of cholelithiasis through a case control study. The study involved 96 cases and 118 age and sex matched controls. All cases and controls were interviewed with regard to a variety of risk factors and frequency of consumption of over 100 food items. Analysis was done both by chi square and a multiple logistic regression model. From all the dietry factors the only ones that showed a positive statistically signficantly (p<0.05) association was consumption of animal fat as expressed by eating all visible fat on the meat and using butter on the table. Interestingly high consumption of olive oil had a negative (protective) association with the disease. A negative association was also found with smoking and holding a job demanding hard labor.

Light-based therapies in acne treatment

The use of light and laser in the treatment of acne is increasing as these modalities are safe, effective, and associated with no or minimal complications when used appropriately. These light and laser sources are also being used in combination with pharmacological and/or physical measures to synergize their effects and optimize the therapeutic outcome. This review focuses on optical devices used in treating acne and serves to delineate the current application of various methods, including their utility and efficacy.

Genital warts and other HPV infections: Established and novel therapies

Wart therapies involve methods of targeted lesion destruction, as well as selective immunologic modification. While there are several therapeutic options, no treatment has been proven to be superior in terms of clinical clearance or recurrence. Controlled trials comparing treatments are currently lacking. Many factors are used in the selection of treatment. Variables that should be taken into account include but are not limited to the morphology of the lesions such as thickness and size, quantity, anatomic location, human papilloma virus (HPV) classification, immunocompromized or immune competent status, as well as the preferences of the patient and the provider, cost and availability. No current treatment completely eradicates the human papillomavirus virus. The availability of vaccinations against HPV infection is contributing to the decreasing incidence of this disease. This contribution highlights conventional therapies, off-label treatment strategies including combination therapies, and prophylaxis for condylomata acuminata.

The Role of Photodynamic Therapy in Acne: An Evidence-Based Review

BackgroundAcne vulgaris is a highly prevalent skin disorder that affects almost all adolescents and can persist into adulthood. Photodynamic therapy (PDT) is an emerging treatment for acne that involves the use of a photosensitizer in combination with a light source and oxygen.MethodsWe performed a systematic review of the literature and critically evaluated the studies. Sixty-nine clinical trials, four case reports, and two retrospective studies met the inclusion criteria, and seven of the studies were high quality.ResultsThe most common photosensitizers used were 5-aminolevulinic acid and methyl aminolevulinate, and both showed similar response. Red light was the most frequently used light source, followed by intense pulsed light, and showed comparable results. Inflammatory and non-inflammatory lesions both responded to treatment, with inflammatory lesions showing greater clearance in most studies. Adverse events associated with PDT for acne were mild and included pain on illumination and post-procedural erythema and edema. PDT has been safely used in higher Fitzpatrick skin types (III–IV), although these patients had a higher risk of transient hyperpigmentation.ConclusionThis review supports PDT as an efficacious treatment for acne and a good adjunctive treatment for mild to severe acne, especially in patients who have not responded to topical therapy and oral antibacterials, and are not great candidates for isotretinoin. Further studies are warranted to evaluate the optimal photosensitizers, light sources, incubation times, and number of treatments for PDT use in acne.

Clinicopathologic challenge. Neutrophilic dermatosis of the dorsal hands--a variant of localized Sweet's syndrome.

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Compliance and phototherapy

When beginning a phototherapy regimen for a patient, consideration of compliance rates is important. Compliance to phototherapy can be affected by several factors, including the grade of discomfort and side effects from therapy, failure of previous therapies, accessibility and convenience to reach the phototherapy center, grade of improvement during phototherapy, patient relief due to light therapy, and rapport with staff. Understanding how these factors can affect patient adherence can allow for phototherapy regimens to be tailored in a manner that optimizes health outcomes and allows for proper patient selection.

Minimally invasive eyelid care in dermatology: medical, laser, and cosmetic therapies.

There is a high demand for facial aesthetic enhancement, and the periorbital region is one of the first areas to show signs of aging. Many nonsurgical therapies exist to tackle these problems. These therapies are becoming more efficacious while reducing postprocedural recovery time. The goal is to restore the natural youthful appearance rather than to create an effect that differs from the patients appearance earlier in life. Eyelid care, and cosmetic dermatology in general, intends to restore balance and symmetry. We discuss the initial consultation, relevant anatomy for the dermatologist, and medical, laser and cosmetic therapies.

Borderline sebaceous neoplasm in a renal transplant patient without Muir-Torre syndrome

Borderline sebaceous neoplasms are rare tumors that can be challenging to diagnose because of their admixture of histopathologic features. Most such tumors have been described in patients with Muir‐Torre syndrome (MTS). We report the case of an immunosuppressed, 82‐year‐old African‐American woman without MTS who developed a rapidly growing lesion on the left cheek. Histopathology revealed a borderline sebaceous neoplasm with predominant features of sebaceous adenoma and with focal features raising concern for the possibility of an evolving, well‐differentiated, low‐grade sebaceous carcinoma with a high mitotic index. In the setting of immunosuppression, borderline sebaceous neoplasms may occur outside of MTS; careful evaluation and conservative treatment are recommended in managing such tumors.

Treatment of Actinic Keratoses: A Randomized Split-Site Approach Comparison of Sequential 5-Fluorouracil and 5-Aminolevulinic Acid Photodynamic Therapy to 5-Aminolevulinic Acid Photodynamic Monotherapy

BACKGROUND Actinic keratoses (AKs) are skin lesions resulting from sun exposure and carry a risk of developing into squamous cell carcinoma. Current therapies for AK eradication include topical 5-fluorouracil (5-FU) and photodynamic therapy (PDT) with topical 5-aminolevulinic acid (ALA). However, sequential therapy with 5-FU-ALA-PDT may offer improved outcome compared to ALA-PDT alone. OBJECTIVE The purpose of this study is to compare the long-term efficacy of AK clearance by sequential therapy with 5-FU-ALA-PDT versus ALA-PDT alone. MATERIALS AND METHODS This is a single center, randomized split-site approach study on equivalent anatomical and clinical sites. Seventeen patients were enrolled with one half of the site randomized to receive sequential 5-FU-ALA-PDT and the other side with ALA-PDT monotherapy. Total AKs were counted at baseline, 6 and 12 months. RESULTS Median percentage reduction in AK number at 6 months for 5-FU-ALA-PDT versus ALA-PDT was 100% for 5-FU-ALA-PDT (N = 21) and 66.7% for ALA-PDT (N = 21), p = .001. Median percentage reduction in AK number at 12 months for 5-FU-ALA-PDT versus ALA-PDT was 100% for 5-FU-ALA-PDT (N = 22) and 82.6% for ALA-PDT (N = 22), p = .0002. CONCLUSION Sequential therapy with 5-FU-ALA-PDT is more effective at AK clearance at 6 and 12 months compared to ALA-PDT monotherapy.