R.J. Barlow

U.K. guidelines for the management of cutaneous melanoma

Summary  These guidelines for management of cutaneous melanoma present evidence‐based guidance for treatment, with identification of the strength of evidence available at the time of preparation of the guidelines, and a brief overview of epidemiological aspects, diagnosis and investigation. To reflect the collaborative process for the U.K., they are subject to dual publication in the British Journal of Dermatology and the British Journal of Plastic Surgery.1

Treatment of proliferative haemangiomas with the 585 nm pulsed dye laser.

Summary Haemangiomas usually develop within the first few weeks of life, most regressing spontaneously before the age of 7 years. Some may ulcerate or compromise a vital function, in which case systemic corticosteroids, surgery or radiotherapy may be helpful. Ail of these treatment modalities are associated with significant morbidity. Treatment with the 585 nm flash lamp pulsed dye laser is safe and effective in the management of superficial vascular malformations. We report seven patients, under 12 months of age, who presented with proliferative haemangiomas, causing functional impairment. Ulcerated lesions were present in four patients. The patients were treated with the 585 nm pulsed dye laser (fluences 7·0–9·25J/cm2), at intervals of 4–8 weeks. All of the lesions showed a significant reduction in size, together with improvement in the colour and integrity of the overlying skin. Treatment with the 585 nm pulsed dye laser should be considered in the management of infants with early proliferative haemangiomas, in whom intervention is indicated.

Adhesion molecule expression and the inflammatory cell infiltrate in delayed pressure urticaria

We have investigated the kinetics of the leucocyte infiltrate in delayed pressure urticaria (DPU) in relation to the in vivo expression of the cytokine‐regulated cell surface adhesion molecules. E‐selectin (endothelial adhesion molecule‐1. ELAM‐1). intercellular adhesion molecule‐1 (ICAM‐1), and vascular adhesion molecule‐1 (VCAM‐1). Immunohistochemical analysis was performed on biopsies taken from unchallenged skin, and at 0, 2, 6, 24, 48 and 120 h after weighted rods had been applied to 13 patients with DPU. There was moderate to marked upregulation of E‐selectin at 6 and 24 h after application of pressure. At 24 h, more patients showed expression of VCAM‐1 on perivascular cells than before pressure. Moderate expression of ICAM‐1 was present in some biopsies from both unchallenged and pressure‐challenged skin, but there was no clear trend. In DPU, there was a significant increase in the neutrophil count at 2 h after a pressure challenge, with further increases at 6 and 24 h. The median cell counts per high‐power field of eosinophils and monocyte/ macrophages increased significantly at 24 h after pressure. Biopsies from four normal controls subjected to an identical pressure challenge showed no detectable changes in adhesion molecule expression or in the cell infiltrate. The findings in four patients with chronic idiopathic urticaria not associated with DPU were qualitatively similar to (but intermediate in severity between) the findings in DPU weals at 6 and 24 h.

Increased interleukin 6, but reduced interleukin 1, in delayed pressure urticaria

Interleukin 1 (IL‐1) and interleukin 6 (IL‐6) were measured by bioassays in suction‐blister exudates from lesional skin, from skin immediately following a pressure challenge, and from control skin (not subjected to pressure) of patients with delayed pressure urticaria. IL‐6 activity in lesional exudates was significantly higher than in exudates from the other two sites. IL‐1 activity in lesional exudates was not significantly higher than in the control exudates, but significantly less IL‐1 activity was found immediately after pressure challenge than from the control site.

Dermatofibrosarcoma protuberans: 35 patients treated with Mohs micrographic surgery using paraffin sections.

Background  Dermatofibrosarcoma protuberans (DFSP) has conventionally been treated with wide local excision. More recently Mohs micrographic surgery (MMS) has been advocated.

Early Cure Rates with Narrow-Margin Slow-Mohs Surgery for Periocular Malignant Melanoma

BACKGROUND Staged excision with rush-processed paraffin-embedded tissue sections (Slow-Mohs) is an effective treatment for periocular melanoma. Although there is no consensus on initial margins of excision, narrower margins in the eyelids have the functionally and cosmetically important consequence of smaller postoperative wounds. OBJECTIVES To report early cure rates for periocular melanoma using Slow-Mohs surgery with en-face margin sectioning. METHODS Retrospective, multicenter, noncomparative case series. Slow-Mohs surgery in 14 patients with periocular melanoma from 2000 to 2006. RESULTS Fourteen patients underwent 14 Slow-Mohs procedures for eight lentigo maligna, one nodular, and one superficial spreading melanoma, and four lentigo maligna, 12 primary, and two recurrent tumors. The most common site was the lower eyelid (8/14, 57.1%). Breslow thickness ranged from 0.27 to 1.70 mm, with four cases less than 0.76 mm and one case greater than 1.5 mm. Five cases were a Clark level II or greater. Complete excision was achieved with one level (6 cases) or two or three levels (8 cases), with 2- to 3-mm margins at each level in all but one case. With median follow-up of 36 months, there were two local recurrences (2/14, 14.3%). CONCLUSION Slow-Mohs with en-face sections achieves similar early cure rates to previously published margin-controlled excision techniques. Narrow margins of excision can optimize tissue preservation without compromising outcome.

Objective assessment of port-wine stains following treatment with the 585 nm pulsed dye laser.

Previous studies assessing the treatment of port‐wine stains (PWS) with the 585 nm pulsed dye laser have relied on either subjective clinical assessment or in vivo measurement of skin colour alone. The aim of the present retrospective study was to develop an objective method of assessing available pre‐ and post‐treatment photograph pairs. Port‐wine stains depicted in photographs of 23 patients following six or more treatment sessions were assessed for changes in colour (ΔH*) and PWS size by computer image analysis and were compared with a subjective assessment of PWS reduction by a ‘blinded’ physician examining the same images. The post‐treatment mean reduction in the PWS assessed by the physician was 39.7%. A global assessment score incorporating values of ΔH* and PWS size by computer analysis showed a mean reduction of 12%, with a more significant correlation with the physician assessment (Spearman’s rank correlation coefficient 0.627; P = 0.001) than changes in size or colour alone.

The effects of topical corticosteroids on delayed pressure urticaria

Six patients with delayed pressure urticaria (DPU) applied clobetasol propionate (0.05%) ointment or its base to predetermined test sites on the right and left thigh as part of a randomized, double-blind study. A pressure challenge was administered to each test site at the initial visit and repeated after 3 days and 6 weeks of treatment and at between 4 and 8 weeks after treatment. The areas of pressure-induced weals were measurd 6 h after each challenge. At the 6-week visit, a 4-mm punch biopsy was taken from pressure-challenged skin on each test site. Sections were stained for mast cells and immunohistochemical labelling was used to demonstrate neutrophils (neutrophil elastase), eosinophils (eosinophil cationic protein), monocytes/ macrophages (EBM 11), cells expressing the beta-2 integrins (CD11/18) and the vascular adhesion molecules, E selectin and intercellular adhesion molecule-1 (ICAM-1). In the steroid-treated sites, there was a significant decrease (P<0.05, Wilcoxons matched-pairs test) in the size of the pressure weals compared with baseline at 3 days, 6 weeks and at follow-up. Demonstrable mast cells were significantly decreased (P=0.059) in the pressure-challenged areas in the steroid-treated sites compared with the base-treated sites. The histological response to pressure was minimal in both sites perhaps demonstrating an active pharmacological effect of the ointment base. In conclusion, the application of potent topical steroids significantly reduced the clinical response to pressure in patients with DPU, possibly through a reduction in mast cells.

Microcystic adnexal carcinoma: a case series treated with mohs micrographic surgery and identification of patients in whom paraffin sections may be preferable.

BACKGROUND Microcystic adnexal carcinoma (MAC) is a rare cutaneous tumor characterized by aggressive local infiltration, including a high propensity for perineural invasion (PNI). OBJECTIVES To report our experience in treating MAC using Mohs micrographic surgery (MMS) with frozen sections and to identify patients in whom that technique may have limitations. MATERIALS & METHODS A review of records between 1992 and 2008. RESULTS Nine patients with MAC were identified. All tumors were located on the face. PNI was noted in the diagnostic biopsies of two patients with periocular MAC, in both of whom tumor persisted after MMS. The mean duration of follow‐up was 5.4 years. CONCLUSIONS MMS with frozen sections is reliable for treating primary MAC in which PNI is not present on a diagnostic biopsy. Previous surgery and PNI were associated with greater risk of persistence in periocular MAC. In these patients, it may be appropriate to consider MMS with paraffin‐embedded sections, possibly as a layer after apparent clearance on frozen sections. Further excision of orbital contents should be considered in periocular MAC that infiltrate the deep orbital fat or are noted to have PNI.

Hypertrophic scar formation following carbon dioxide laser ablation of plantar warts in cyclosporin‐treated patients

We present four renal transplant patients who developed hypertrophic scars following carbon dioxide laser ablation of recalcitrant plantar warts. All of the patients were on long‐term treatment with cyclosporin, which we believe to be responsible. We discuss several possible mechanisms by which cyclosporin may influence wound healing and scarring.