R. Viraben

Histological evolution of recurrent basal cell carcinoma and therapeutic implications for incompletely excised lesions.

Background  It has been proposed that the management of incompletely excised recurrent basal cell carcinomas (BCCs) should depend on their histological appearance, and that nonaggressive recurrent BCCs may not require re‐excision.

Bullous and mucous membrane pemphigoid show a mixed response to rituximab: experience in seven patients.

Editor Rituximab, a chimeric monoclonal antibody directed against the cell-surface glycoprotein CD20, was originally developed to treat B-cell malignancies. Recently, rituximab, alone or in combination with intravenous immune globulins, has been shown to induce remission in up to 86% of patients with pemphigus refractory to oral steroids. However, there is limited information regarding the efficacy and safety of rituximab in auto-immune bullous disorders other than pemphigus. Herein, we report on a retrospective study of seven patients with refractory bullous pemphigoid (BP) or mucous membrane pemphigoid (MMP) who underwent treatment with rituximab. We performed a retrospective study on patients treated with rituximab for an auto-immune bullous disease other than pemphigus. Patients were selected between August 2007 and August 2009 at Toulouse and Limoges University Hospitals. During this period, seven patients (four men and three women) had received rituximab treatment. Five had BP and two had MMP (Table 1). The decision to initiate rituximab treatment was a multidisciplinary therapeutic decision. The median age at diagnosis was 70 years (range 33–85). Most patients had a history of comorbidities, including cardiac disease (four), pulmonary disease (one), renal disorder (one) and cutaneous cancers (two). All patients had previously not responded to topical corticosteroids or to at least one systemic immunosuppressive regimen (systemic corticosteroids, methotrexate, mycophenolate mofetil, cyclophosphamide, dapsone, azathioprine, etanercept). On physical examination, all patients had cutaneous lesions and four of the seven patients had erosions of the mucous membranes: oral (three patients), genital (three patients), ocular (two patients) and nasal (one). Direct immunofluorescence showed linear IgG and complement C3 deposits at the dermoepidermal junction of perilesional skin in six patients. Using indirect immunofluorescence analysis, antibasement membrane zone antibodies were detected in the serum of five and anti-BP-180 autoantibodies were detected by ELISA (Euroimmun, Lubeck, Germany) analysis in six patients. Six patients received four infusions of rituximab at weekly intervals at a dose of 375 mg ⁄ m. In one patient with BP, four additional rituximab infusions were given 11 months after the first dose, due to relapse of the disease. All patients received concomitant immunosuppressive medications. Four patients experienced complete remission on therapy, while two patients had partial remission. The median time to improvement in skin lesions was 4 months. Four patients are still in maintained remission, but one patient relapsed after 4 months of complete remission. The average duration of follow-up was 8 months (0.25; 27). Concerning clinical adverse events, one 85year-old patient with BP suddenly died 10 days after introduction of the first infusion of rituximab. The patient had a previous history of cardiac disease (ischaemic cardiopathy, atrial fibrillation and abdominal aortic aneurysm). In this retrospective review, rituximab appears to be an interesting therapeutic option, alone or in association with other systemic immunosuppressants, to treat BP and MMP that is resistant to conventional immunosuppressive treatments. Rituximab has shown promise in several case reports and cohort studies in treating paraneoplastic pemphigus, refractory cases of pemphigus vulgaris and foliaceus. There are also case reports for other autoimmune bullous skin disorders, where rituximab therapy successfully treated four patients with MMP and nine with refractory BP (Table 2). At present, rituximab treatment may be proposed in patients with autoimmune bullous diseases who are resistant to at least two conventional treatment regimens, including systemic glucocorticosteroids and immunosuppressants. However, further studies are needed to assess the role of rituximab in autoimmune bullous diseases other than pemphigus.

Secondary syphilis simulating oral hairy leukoplakia

We describe a case of secondary syphilis of the tongue in which the main clinical presentation of the disease was similar to oral hairy leukoplakia. In a man who was HIV seronegative, the first symptom was a dryness of the throat followed by a feeling of foreign body in the tongue. Lesions were painful without cutaneous manifestations of secondary syphilis. IgM-fluorescent treponemal antibody test and typical serologic parameters promptly led to the diagnosis of secondary syphilis. We initiated an appropriate antibiotic therapy using benzathine penicillin, which induced healing of the tongue lesions. The differential diagnosis of this lesion may include oral squamous carcinoma, leukoplakia, candidosis, lichen planus, and, especially, hairy oral leukoplakia. This case report emphasizes the importance of considering secondary syphilis in the differential diagnosis of hairy oral leukoplakia. Depending on the clinical picture, the possibility of syphilis should not be overlooked in the differential diagnosis of many diseases of the oral mucosa.

Histological regression in primary melanoma: not a predictor of sentinel lymph node metastasis in a cohort of 397 patients

Background  Regression has been proposed as a potential marker of dissemination in thin melanomas. Previous studies have shown conflicting results.

Prevalence and prognostic value of cutaneous manifestations in patients with myelodysplastic syndrome

Background  Skin manifestations associated with myelodysplastic syndrome (MDS) may reveal bone marrow transformation into acute myeloid leukaemia.

Topical methyl aminolevulinate photodynamic therapy for management of basal cell carcinomas in patients with basal cell nevus syndrome improves patient’s satisfaction and reduces the need for surgical procedures

Background  In basal cell nevus syndrome, basal cell carcinomas occur in early life. The treatment of basal cell carcinomas requires surgical excisions and may lead to unaesthetic scars. Photodynamic therapy (PDT) is a validated treatment of skin cancers, with good cosmetic outcomes.

Sentinel lymph node biopsy for melanoma is becoming a consensus: a national survey of French centres involved in melanoma care in 2008

Background  The role of sentinel lymph node (SLN) biopsy in melanoma care remains controversial and is not included in most guidelines for the management of melanoma in Europe.

Losartan-associated atypical cutaneous lymphoid hyperplasia

Summary Drug hypersensitivity reactions can induce an atypical lymphoid infiltrate ranging from a benign condition to a malignant lymphoma. Here we describe two patients in whom atypical cutaneous lymphoid infiltrates developed while they were receiving losartan, an angiotensin II inhibitor.

Double‐positive CD4/CD8 mycosis fungoides: a rarely reported immunohistochemical profile

Mycosis fungoides (MF) represents the most common epidermotropic cutaneous T‐cell lymphoma (CTCL), and tumor cells typically express a mature T‐helper memory phenotype. A minority of MF patients display an unusual phenotype, which may be either CD4(−)/CD8(+) or double negative. Herein, we report a case of biopsy‐proven MF in a 31‐year‐old woman who presented with infiltrated plaques involving photoprotected areas of the skin. Immunohistochemical study combined with confocal microscopy revealed co‐expression of CD4 and CD8 in a subset of atypical T lymphocytes. To our knowledge, this is the second report of a CD4/CD8 dual‐positive MF.

First case of “bubonulus” in L2 lymphogranuloma venerum

Since 2003, an ongoing lymphogranuloma venereum (LGV) proctitis outbreak has been reported in industrialised countries with a new variant designated L2b. Only men who have sex with men (MSM) are affected and most are HIV co-infected; delayed or incorrect diagnoses are frequent. We report a rare clinical case of LGV primary stage called “bubonulus” with penile adenopathy and secondary local acute lymphoedema in an MSM seropositive man. This is the first case described of this clinical presentation with a L2b genovar strain, occurring immediately after use of a sex toy. It suggests that this presentation is favoured by host immunity and behavioural factors. These factors may also play a part in the new outbreak of LGV.