Marian Northington

Giant basal cell carcinoma associated with human papillomaviruses infection

Abstract:  Different criteria have been used to define giant basal cell carcinoma (BCC). However, the majority of tumors of 10 cm or greater in diameter have a characteristic clinical and histopathologic presentation. As a group, these tumors often show metastatic spread as opposed to all other BCCs that rarely metastasize. We present an additional patient with a giant BCC greater than 100 cm2. This tumor had a characteristic location and infiltrative growth pattern. Unusual features of this tumor included a lack of expression of BCL‐2 with a greater proportion of cycling tumor cells expressing proliferation markers than conventional BCC, as well as expression of anogenital human papillomaviruses (HPV) subtypes with oncogenic potential. The association of HPV with BCCs has rarely been studied and may not be identical to HPV‐induced genital squamous cell carcinomas. However, the findings in this patient suggest that HPV may play a role in the development of some chronic giant BCCs.

Interest in cosmetic improvement as a marker for tanning behavior: a survey of 1602 respondents

Dermatologists see many patients interested in improving their physical appearance through cosmetic procedures or medical means. Dermatologists frequently counsel patients on sun protection as well, particularly those with a personal or family history of skin cancer, sun‐sensitive dermatoses or those with obvious sun damage. Our objective in this study was to identify novel markers of skin cancer risk, which may aid dermatologists in targeting extra sun protection counseling for certain groups. A 16‐question survey was distributed to subjects 19 years of age and older in public areas of downtown Birmingham, Alabama in August and September of 2008. Overall, about 40% of both genders reported that they were highly concerned that current sun exposure could cause skin cancer. Participants interested in at least one appearance‐related questionnaire item were significantly more likely than those not interested to rate tanned skin as highly important (31.6%vs. 17.5%, P < 0.001), and to report regret for previous sun exposure (12.5%vs. 3.6%, P < 0.001). Subjects who thought tanned skin was important were significantly more likely to report interest in improving their appearance through cosmetic procedures and medical means. We conclude that individuals with an interest in improving their physical appearance through cosmetic procedures or medical means may be especially in need of sun protection counseling.

Patient selection for skin-tightening procedures

Noninvasive skin‐tightening devices have become increasingly popular over the last decade to improve skin laxity with minimal risk and recovery time. Proper patient selection improves patient outcomes and satisfaction. There are many devices available for tightening including monopolar radiofrequency, bipolar radiofrequency, fractional radiofrequency devices, infrared devices, combined light and bipolar radiofrequency devices, and intense focused ultrasound devices. There have been shortcomings with tightening devices including inconsistent clinical outcomes. The question arises, why are there inconsistent results and variability among patient outcomes? Variability could be related to different devices, treatment protocols, body area treated, and patient selection. Patient age, degree of laxity, history of smoking, ethnicity, body mass index, and individual patient pain threshold could all possibly contribute to patient response to tightening devices. The literature does not elucidate consistently, which variables are the most important in predicting best patient response. Included is a review of the literature discussing skin tightening and patient selection.

Successful treatment of refractory Hailey-Hailey disease with a 595-nm pulsed dye laser: A series of 7 cases

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OnabotulinumtoxinA Unmasking Myasthenia Gravis

Our patient was a 64-year-old woman with a history of psoriasis and psoriatic arthritis (treated with methotrexate since 2008), melanoma, hypothyroidism, thymus irradiation as a child (due to enlarged thymus), and fatigue (attributed to fibromyalgia). She had been a long-term dermatology patient and had been treated for many years with neurotoxins and soft tissue fillers at our institution and outside providers. When she was seen in October 2009, her glabellar rhytides were treated with BTX-A (25 U) without complications. During a different visit in October 2009 and in December 2009 and February 2010, her face and neck were treated for photodamage and scars with NFR without complications. She returned to clinic in May 2010 for her fourth treatment with NFR to the face as neck and BTX-A to the glabella, forehead, and crow’s feet (58 U). Within 1 week of this treatment, she started to complain of binocular horizontal diplopia. We were concerned that this was a side effect of BTX-A. Neuro-ophthalmology evaluated her and noted the absence of ptosis, normal acuity, pupillary function, and normal ductions but comitant 12-diopter esotropia. MG was a consideration, and a MG panel was ordered, in addition to a thyroid function panel and contrasted cranial and orbital magnetic resonance imaging (MRI). A 12-diopter-base-out Fresnel prism was prescribed for the left lens with good results. The MRI and thyroid panel were negative, but the acetylcholine receptor and modulating antibodies were positive, supporting a diagnosis of MG.

Utility of Wood's light in margin determination of melanoma in situ after excisional biopsy

BACKGROUND Margin evaluation of melanoma in situ (MIS) is difficult because of its ill-defined clinical borders. Woods light examination is commonly used to help delineate MIS margin before excision. OBJECTIVE To prospectively study the accuracy of preoperative Woods light examination for margin assessment of MIS. MATERIALS AND METHODS The authors evaluated 60 patients before excision of MIS under white light and Woods light. Staged excision was performed using the square procedure technique. After achieving clear margins, they compared final wound size with expected wound size if surgical margins had been based on Woods light examination. RESULTS Seven patients (11.7%) had Woods light enhancement beyond the visible margin of the biopsy site. In all 7, increased wounding would have occurred if the surgical margins had been based on Woods light examination. In 1 of the 7, use of the Woods light examination would have reduced the surgical stages needed by 1 stage but would have increased the wound size by 83.3%. CONCLUSION Woods light examination has limited utility if complete excisional biopsy of MIS is performed before treatment. In this study, surgical margin based on the Woods light examination would have resulted in an increased average wound size and would not have reduced the number of stages needed when performing the square procedure.

Rationalizing Outcome Measures in Dermatologic Surgery

Dermatologic surgery, including cancer surgery, cosmetic surgery, and laser and energy device procedures, is a well-established branch of dermatology known for minimally invasive, effective, and safe solutions to patient problems. Over time, clinical research pertaining to dermatologic surgery has improved in terms of methodologic rigor, with dermatologic surgery accounting for a large proportion of the comparative effectiveness studies and randomized controlled trials in dermatology. Further improvements in the quality of studies examining dermatologic surgery therapies will require understanding and overcoming several remaining challenges.