Mark L. Welch

Confluent and reticulated papillomatosis: Response to minocycline

BACKGROUNDnConfluent and reticulated papillomatosis (CRP) of Gougerot and Carteaud is an uncommon disorder of unknown cause for which a variety of treatments have been proposed.nnnOBJECTIVEnWe attempted to evaluate the effectiveness of oral minocycline.nnnMETHODSnNine patients with CRP were treated with oral minocycline, 50 mg twice a day, for 6 weeks. The average follow-up period was 11 months. Recurrence rate, side effects, and effectiveness of therapy were assessed.nnnRESULTSnAll patients except two had a 90% to 100% response to therapy. Recurrences were noted in three patients, all of whom responded to re-treatment with minocycline. None of the nine patients had an adverse reaction.nnnCONCLUSIONnMinocycline, 50 mg twice a day, is safe and effective for CRP.

5-Fluorouracil iontophoretic therapy for Bowen's disease

BACKGROUNDnTopical 5-fluorouracil (5-FU) is an accepted therapy for Bowens disease. Recurrences with this method have been attributed to deep follicular involvement and poor patient compliance because of the prolonged treatment time required.nnnOBJECTIVEnWe sought to determine whether iontophoresis of 5-FU is an effective therapy for Bowens disease.nnnMETHODSnTwenty-six patients with biopsy-proven Bowens disease received eight 5-FU iontophoretic treatments in 4 weeks. Local excision was done 3 months after the last treatment. The specimens were step-sectioned and evaluated for any histologic evidence of bowenoid changes.nnnRESULTSnOnly 1 of 26 patients showed histologic evidence of Bowens disease 3 months after treatment.nnnCONCLUSIONn5-FU iontophoresis appears to be a safe, effective, and well-tolerated therapy for Bowens disease.

Syringolymphoid hyperplasia with alopecia. A case report.

Syringolymphoid hyperplasia with alopecia is an uncommon skin disorder described in 1969 by Sarkany. Since then only three additional cases have been reported, all in the European literature. We present a 59‐year‐old man with two persistent hyperpigmented hairless patches of 13 years duration. Biopsy specimens revealed characteristic hyperplastic changes of the eccrine glands and ducts and a dense lymphocytic infiltrate surrounding eccrine structures with “syringotropism”. Perifollicular lymphocytic infiltration and changes consistent with follicular mucinosis and mycosis fungoides were also present. Imunophenotyping and gene rearrangement studies showed I he cells to be primarily of the T helper phenotype with rearrangement of I he surface receptor gene.

Histologic and immunohistochemical features in biopsy sites in which bovine collagen matrix was used for hemostasis.

BACKGROUNDnBovine collagen matrix (Helistat and Helatene), which is used primarily for hemostasis, decreases wound contracture in skin biopsy sites and promotes wound granulation.nnnOBJECTIVEnOur purpose was to evaluate excision specimens of previous biopsy sites to determine whether there are histologic differences between cases in which bovine collagen matrix was used for hemostasis and those in which it was not used.nnnMETHODSnThirty-two diagnostic punch biopsies were done with hemostasis obtained with bovine collagen matrix in 24 biopsies and by pressure alone in eight. The biopsy sites were reexcised at various time intervals, and the histologic and immunohistochemical features were evaluated and compared.nnnRESULTSnIn specimens in which collagen matrix was used, migration of stromal and epithelial cells along the bovine collagen matrix was evident by 2 days and had progressed rapidly by 4 days. Around and within the matrix hyaluronic acid increased during the first 8 to 10 days. Initially stromal cells stained with CD34 and reticulum fibers were present at 8 to 10 days. AT 12 to 15 days, factor XIIIa+ stromal cells were present within the matrix, and host collagen fibers were present and well-oriented within the degenerating matrix. Biopsy specimens allowed to heal without the matrix showed a delayed and an uneven increase in hyaluronic acid. Furthermore, the granulation tissue within the dermis showed no organization with a persistent acute inflammatory infiltrate and increased muscle actin-positive stromal cells as scar formation proceeded.nnnCONCLUSIONnBovine collagen products appear to provide a matrix that promotes thrombosis. The collagen matrix also promotes migration and attachment of stomal and epithelial cells, thereby organizing and accelerating wound healing.

Immunohistochemical features in inflammatory linear verrucous epidermal nevi suggest a distinctive pattern of clonal dysregulation of growth

BACKGROUNDnWe studied biopsy material from four patients with inflammatory linear verrucous epidermal nevi (ILVEN) that had a psoriasiform appearance histologically and seven cases of linear epidermal nevi (LEN). Of the seven LEN, five showed hyperkeratosis, papillomatosis, and varying degrees of acanthosis; two had features of epidermolytic hyperkeratosis. Because these lesions have distinctive histologic patterns, we wanted to determine whether we could also demonstrate a distinctive pattern of immunohistochemical markers.nnnMETHODSnOn all 11 cases we performed immunohistochemical stains for PCNA, factor XIIIa, MAC-387, UCHL-1, and OPD-4. In addition, on one case of ILVEN we performed ICAM-1, ELAM-1, and HLA-DR stains.nnnRESULTSnThe pattern of staining of PCNA, factor XIIIa, MAC-387, UCHL-1, and OPD-4 was distinctly different in ILVEN and LEN. Staining for ICAM-1 was present on keratinocytes, and ELAM-1 was present on endothelial cells in two cases of ILVEN. HLA-DR in these same two cases of ILVEN stained mainly dendritic cells in the epidermis.nnnCONCLUSIONnThe different pattern of staining of PCNA, factor XIIIa, MAC-387, UCHL-1, and OPD-4 in LEN and ILVEN indicates a different mechanism of growth dysregulation. Stains for ICAM-1, ELAM-1, and HLA-DR in ILVEN suggest that an inability to down-regulate the inflammatory infiltrate may be important in the growth dysregulation in ILVEN. In addition, the onset of ILVEN at the time of HIV-1 infection in one patient suggests that HIV-1 infection may be one of many factors that initiates ILVEN in a susceptible person.

How Many Nonmelanoma Skin Cancers Require Mohs Micrographic Surgery

background Cost containment in health care is currently a subject of much debate. The rapid spread of managed care is an attempt to influence practice trends and contain costs. Although seldom directly stated, it is implied that some physicians may perform high‐cost procedures when not necessarily indicated, an example being Mohs micrographic surgery (MMS). objective There are little data in the literature indicating what percentage of skin cancers treated by MMS would be appropriate. For such data to be meaningful, a model would have to exist wherein there is no financial incentive or disincentive for performing the procedure. Military medicine provides this unique environment. methods In a retrospective review, the counted the total number of basal cell carcinomas and squamous cell carcinomas diagnosed at Brooke Army Medical Center (BAMC) over a 5‐year period. We then determined the number of MMS cases performed on these cancers. results A total of 5193 nonmelanoma skin cancers (NMSC) were diagnosed at BAMC and 1701 of these were treated by MMS. Overall, the percentage of NMSC treated by MMS was 32.7% for the 5‐year period. conclusion This information may serve as a framework for physicians and health delivery systems as they negotiate managed care contracts for the management of skin cancer.

WIDESPREAD NEVUS SPILUS

Case 1: A forty-year-old white man had a generalized spotty pigmentation for over 20 years. All lesions consisted of a background of tan macular pigmentation, which was studded with small dark brown macules and papules. An area of the back (Fig. 1) and abdomen (Fig. 2) was covered with a large confluent lesion. The back was involved bilaterally, while the abdominal lesion was unilateral with an abrupt respect for the midline. In addition, morphologically identical lesions were present on the posterior neck extending into the hairline (Fig. 3), and a third lesion involved the face unilaterally. In his early twenties the patient had been diagnosed, based solely on the presence of this nonfamilial pigmented lesion, as having neurofibromatosis. A review of a biopsy done at that time revealed basilar hyperpigmentation in the light tan area and junctional nests of nevus cells at the base of elongated rete ridges in the dark brown areas. The diagnosis was changed to a widespread nevus spilus.

Allergic contact dermatitis and reactivation phenomenon from iontophoresis of 5-fluorouracil*

Iontophoresis uses direct electrical current to drive chemical agents through the skin. 1 It has been used to treat epithelial neoplasms with cisplatin, 2 bleomycin, and vinblastine. 3 To our knowledge, there have been no adverse systemic reactions reported. We report a cutaneous allergic reaction with subsequent reactivation at a distant site resulting from the iontophoretic administration of 5-fluorouracil (5-FU). CASE REPORT A 78-year-old white man entered into a protocol of iontophoretic administration of 5-FU for the treatment of Bowens disease. After the sixth treatment a 2 x 6 crn, erythematous, eczematous plaque on his left scapula developed at the treatment site. This responded to topical triamcinolone cream and was believed to be an irritant reaction to the electrode adhesive. Within 24 hours after his next treatment 7 days later, a 6 x 10 cm pruritic eczematous plaque accompanied by an annular erythematous urticaria-like reaction involving most of his back appeared. The patient was treated with antihistamines and topical betamethasone cream. It was unclear whether this eruption was caused by the preservative-free 5-FU or to some component of the delivery electrode. To elucidate this, the patient agreed to iontophoresis of normal saline solution to one forearm and the 5-FU solution to the other. At 24 hours the 5-FU-treated site showed moderate erythema and the previously described reaction on the patients back flared severely, requiring administration of systemic cordcosteroids. The saline treatment site was normal. Biopsy specimens from the forearm and back showed spongiotic dermatitis with numerous eosinophils consistent with an acute allergic contact dermatitis. DISCUSSION 5-FU is widely used to treat a variety of neoplasms. 4 Adverse cutaneous reactions to systemic

EVALUATION AND MANAGEMENT OF NONMELANOMA SKIN CANCER: The Military Perspective

As the incidence of melanoma skin cancer continues to increase in this country, so does the need for early detection and treatment of these tumors. This article discusses a military skin cancer screening clinic that encourages patient participation and the criteria and statistics regarding the different treatment modalities we employ to treat these skin cancers.

Pretreatment with intralesional hyaluronidase prior to excision of dermatofibrosarcoma protuberans

Dermatofibrosarcoma protuberans (DFSPs) are an uncommon malignancy that commonly recur, but rarely metastasize. The origin of DFSPs is controversial; however, they stain with the progenitor marker CD34. DFSPs usually show increased stromal mucin, mainly hyaluronic acid (HA). HA increases cellular proliferation, delays differentiation and increases cellular motion. We evaluated the pretreatment of DFSPs with intralesional injections of hyaluronidase (HD) prior to the surgical excision. Five of nine cases of DFSPs were pretreated with HD. In HD-pretreated cases the margins for excision of the residual tumor were reduced. HD pretreatment also decreased CD34 staining and increased polarizable collagen in the residual tumor.