Sabina Vaccari

Generalized psoriasis induced by topical treatment of actinic keratosis with imiquimod.

Generalized psoriasis induced by topical treatment of actinic keratosis with imiquimod Dear Sir, Imiquimod cream (Aldara, 3M Pharmaceuticals, St Paul, MN), an immune response modifying drug which demonstrates potent antiviral and antitumorous activity, has been used for the treatment of several skin conditions. Clinical trials have shown efficacy in the treatment of precancereous lesions such as actinic keratoses, Bowen’s disease, and inflammatory skin diseases. Efficacy has been reported in the treatment of other cutaneous or mucosal malignancies like lentigo maligna, squamous cell carcinoma, and VIN; hence, no controlled clinical trials have yet been published on applications of the drug. A 77-year-old man presented with seven actinic keratosis localized at the parietal region of his balding scalp. The clinical history revealed that the patient had psoriasis. This dermatological pathology had been stable for the past 7 years, during which time he had not received any topical or systemic treatment for psoriasis. No evidence of psoriasis was shown on clinical examination. The patient’s laboratory examinations showed no abnormalities and he was otherwise healthy. Topical treatment with Imiquimod 5% cream was prescribed once daily 3 times/week for 6 weeks for the actinic keratosis. After the second week of treatment the patient developed moderate psoriasis from changes at the sites of application of the imiquimod cream (Fig. 1). A 4-day rest period from application of the drug was advised, after which the treatment was restarted. After the fourth week, the patient was referred to our clinic showing a severe psoriatic reaction of the scalp and widespread small erythemato-scaling plaques over the trunk, face and limbs (Fig. 2). We interrupted the treatment of the imiquimod cream and prescribed no therapy after the psoriatic flare-up. No systemic disorders were noted by our patient and his blood analysis showed no change, demonstrating no systemic absorption. At a 10-day review, the patient and the lesions of the scalp had improved. At the 4-week post-treatment follow up the generalized psoriatic eruption had resolved. The clinical examination of the scalp showed clearance of the actinic keratosis. A biopsy was performed at the scalp area where the lesions were previously localized and showed no signs of actinic keratosis on histologic examination after only 12 applications. Psoriasis is a chronic multifactorial inflammatory disease. Its onset has reportedly been triggered or exacerbated by a few exogenous factors such as the weather, emotional stress, drugs and infections. Drugs may result in exacerbating a preexisting psoriasis, or by inducing psoriatic lesions on clinically uninvolved skin in patients with psoriasis. Imiquimod [1-(2-methylpropyl)-1, H-imidazo(4,5-c), quinolin-4-amine] is an immune response modifier which activates immune cells via toll-receptor (TLC) 7, initiating a cascade that leads to the induction of cytokines such as IFN-alfa, gamma and IL-12, which promote a Th-1 immune response. These cytokines are capable of inducing psoriasis. Evidence that psoriasis is an immune-mediated disorder comes from laboratory studies, clinical observation, and use of targeted therapies. Lately there have been immunohistochemical studies offering the hypothesis of a predominance of Th-1 cytokines in psoriatic skin. Figure 1 Localized psoriasiform eruption in the scalp area following imiquimod application

Partial excision of matrix and phenolic ablation for the treatment of ingrowing toenail: a 36-month follow-up of 197 treated patients.

BACKGROUND Several options for the treatment of ingrowing toenails are available, ranging from simple conservative approaches to extensive surgical procedures. OBJECTIVE To evaluate in a long‐term follow‐up (36 months) the efficacy of chemical matricectomy with phenol for the treatment of ingrowing toenails. METHODS AND MATERIALS A total of 197 phenol ablations were performed in 139 patients with stage 2 and 3 disease. Each patient was examined weekly until full wound healing was achieved and was followed for 36 months to assess the long‐term efficacy of the treatment. The healing period after surgery ranged from 2 to 4 weeks; few postoperative complications were seen. RESULTS Only three recurrences were observed (after 2, 4, and 11 months). Short‐term results were excellent. No severe complications occurred during the 36‐month follow‐up period. Cosmetic results were remarkable. The success rate was 98.5%. CONCLUSIONS Phenol cauterization is an excellent surgical method for the treatment of ingrowing toenails, being simple and associated with low morbidity and a high success rate, even over the long term (36 months). The authors have indicated no significant interest with commercial supporters.

Mohs surgery for squamous cell carcinoma of the nail: report of 15 cases. Our experience and a long‐term follow‐up

Background  Subungual squamous cell carcinoma (SSCC) is the most common malignancy of the nail unit. Mohs micrographic surgery (MMS) is a microscopically controlled surgical technique that has a high cure rate for skin cancers despite allowing narrow surgical margins.

Contact sensitization to sunscreens

BACKGROUND Para aminobenzoic acid (PABA) derivatives and cinnamate are chemical sunscreens that protect against UVB (290 to 320 nm). They may occasionally produce contact and photocontact sensitization. OBJECTIVE To report a sensitization to octyl-dimethyl-PABA and photosensitization to 2-ethylhexyl-p-metossicinnamate in a 31-year-old man. METHODS A patient with a 3-year history of a relapsing dermatitis involving the face, neck, legs, and knees is reported. The eruption had recurred every summer after sunlight exposure. Patch tests with International Contact Dermatitis Research Group (IC-DRG) standard series and the photopatch series (Hermal-Trolab, Reinbek, Germany) using Finn chambers on Scanpor (Norgesplaster A/S, Oslo, Norway) were carried out. RESULTS We found a positive reaction to Balsam of Peru, fragrance mix, Escalol 507, and Parsol MCX (Hermal-Trolab, Reinbek, Germany). Photopatch test revealed a positive reaction only for Parsol MCX. CONCLUSION The incidence of allergic contact dermatitis to sunscreens is considered low. Recently sunscreens patch test concentrations have been increased from 2% to 10%. These higher percentages will probably permit the identification of more cases of sunscreens allergy in the near future.

Mohs Surgery for Squamous Cell Carcinoma of the Nail Unit: 10 Years of Experience.

BACKGROUND Squamous cell carcinoma (SCC) is the most frequent malignant tumor of the nail unit. OBJECTIVE The aim of this study was to review the long-term outcome of patients affected by SCC of the nail who underwent Mohs surgery. MATERIALS AND METHODS Patients affected by nail SCC were enrolled, including cases where x-ray examination had revealed bone changes. The tumor was completely excised and the defect filled with a skin substitute based on hyaluronic acid where bone involvement was not observed. Where Mohs sections indicated bone involvement, the distal phalanx was disarticulated and the remaining end of the digit repaired using a volar/plantar flap. Follow-up was performed every 6 months for 5 years. RESULTS Mohs technique was performed in 43 cases. Microinvasive SCC was diagnosed in 5 cases, in situ SCC in 7 cases, and invasive SCC in 45 patients. Recurrences were observed in 2 patients (3.5%). Disarticulation was performed in both of them, and no further tumor recurrences were observed in 4 to 5 years of follow-up. CONCLUSION Mohs surgery provides the highest cure rate for the treatment of nail SCC. It allows the evaluation of periosteal invasion and therefore bone invasion to be reliably distinguished from inflammation or compression. This technique reduces the number of unnecessary amputations, a critical consideration for patients quality of life.

Nail apparatus melanoma: Is trauma a coincidence? Is this peculiar tumor a real acral melanoma?

Nail Apparatus Melanoma (NAM) is rare, particularly in Caucasians. Understanding its pathogenesis and collecting epidemiologic data may be difficult due to its location and the exiguity of the case series of this cancer. Cutaneous melanoma has been thought related to UV radiation, and NAM is considered an acral variant of melanoma, even if the nail presents a specific anatomy. Little is reported about pathogenesis, except reports suggesting traumatic injuries as a causal factor. UV exposure is debated in nail melanoma because of its structure. The nail is, in fact, a unique structure with sun-exposed and non exposed melanocytes. NAM arises from the nail melanocytes, located in the nail matrix, which is the germinative part of the nail and composed of a proximal and distal portion. The proximal nail matrix lays under the proximal nail fold that covers it and is non-sun exposed, while the distant nail matrix, clinically visible as the lunula, is sun-exposed, though lying underneath the nail plate. According to these anatomical data, NAM is a distinct melanoma type, and studies need to classify it as acral melanoma or as a particular type of melanoma with its own pathogenesis and prognostic criteria. This study investigates potential risk factors of NAM, emphasizing (i) trauma and (ii) UV exposure among our NAM patients.

Causal relationship between exposure to chemicals and malignant melanoma? A review and study proposal.

Malignant melanoma (MM) is a significant cause of morbidity and mortality worldwide. The MM-related incidence and mortality have been increasing at an alarming rate over at least the past four decades. Malignant melanoma has been thought to be related mainly to exposure to the sun or UV radiation. A review of the scientific literature reveals many significant correlations between chemical exposure in the workplace and the occurrence of malignant melanoma, particularly in cutaneous areas that have never been exposed to sunlight. Discrepant findings are reported by independent studies concluding that MM is causally related to employment-related chemical exposures and to investigators with industry affiliations. More studies are needed to define a correlation of chemical exposure as a co-factor on the pathogenesis in some melanoma patients. We propose further investigation by dermatologists working in Melanoma Centers, using a simple questionnaire on chemical exposure among patients, that have previously been diagnosed and are followed up for melanoma comparing with appropriate matched controls. Collecting the data and results from the questionnaire will help us understand the initiation events in melanoma and prevention health issues.

Successful treatment of pyogenic granulomas following gefitinib therapy with partial matricectomy and phenolization

A 72-year-old woman was referred to us because of the occurrence of painful toenail lesions, which had been present for 1 month. The patient had been on gefitinib (Iressa®, AstraZeneca Pharmaceuticals LP, Wilmington, DE, USA) therapy for 13 months for the treatment of lung metastatic neoplasia. Clinical examination revealed mild paronychia and three erythematous nodules surrounding the lateral nail fold of both toenails (Figure 1). Patient history revealed folliculitis on the lower limbs and a papular eruption on the upper chest and back at the beginning of treatment with this drug (fourth and sixth months of therapy). Both of these inflammations were successfully treated by her oncologist with topical antibiotics (erythromycin 3% cream). She denied exposure to microtraumas. No other drugs had been prescribed by her physician or oncologist. Pyogenic granulomas, Kaposi’s sarcoma, angiosarcoma and metastasis from her cancer were considered on differential diagnosis. Biopsy of one of the nodules was performed and histologic examination showed angiomatous tissue composed of a variable dilated network of blood-filled capillary vessels embedded in an edematous stroma containing inflammatory neutrophylic infiltrate (Figure 2). A diagnosis of pyogenic granuloma was performed on the basis of clinical and histological presentation. Topical therapy with corticosteroids and antibiotics (clobetasol propionate cream 0.05% and mupirocine ointment) was prescribed for a 2-week period, with a reduction of the symptomatology related to paronychia but persistence of pyogenic granulomas. Therapy with gefitinib was not interrupted. Partial matricectomy and phenolization was performed on both toenails, leading to healing of the lesions (Figure 3). Gefitinib and other drugs that block epidermal growth factor receptor have been associated with a large and interesting pattern of cutaneous adverse effects, including acneiform eruptions, xerosis, desquamation, seborrheic dermatitis, chronic paronychia, and hair texture changes (1,2). Another case of pyogenic granuloma associated with this drug has been described (3). The mechanism underlying these cutaneous manifestations is yet to be determined. Pyogenic granuloma is a common, acquired, benign vascular lesion of the skin and mucous membranes, which may occasionally present intravascularly or subcutaneously. Drug-induced pyogenic granulomas have often been reported, especially after chemotherapy, systemic retinoids and antiretroviral agents (4,5). The aim of this letter is to underline that pyogenic granulomas may occur during treatment with gefitinib and though the related discomfort may compromise compliance, no discontinuation of chemotherapy is needed. Literature data report recurrence and a scarce control of these kinds of lesions after surgical therapy but amelioration on gefitinib discontinuation (6). To our knowledge, there are no cases of pyogenic granulomas treated with partial matricectomy and phenolization. No recurrence of the pyogenic granulomas or paronychia was observed in our patient at a 12-month follow-up, and hence treatment with gefitinib was continued.

Dermoscopic findings of vulvar intraepithelial neoplasia: a series of four cases

Vulvar intraepithelial neoplasia (VIN) is a subtype of in situ squamous cell carcinoma (SCC). The diagnosis is clinical and histopathological. Dermoscopy of VIN has been scarcely reported. Herein we describe the dermoscopic features in 4 female patients. This article is protected by copyright. All rights reserved.

The Role of Photodynamic Therapy in the Treatment of Vulvar Intraepithelial Neoplasia

Background: vulvar intraepithelial neoplasia is a non-invasive precursor lesion found in 50–70% of patients affected by vulvar squamous cell carcinoma. In the past, radical surgery was the standard treatment for vulvar intraepithelial neoplasia, however, considering the psychological and physical morbidities related to extensive surgery, several less aggressive treatment modalities have been proposed since the late 1970s. Photodynamic therapy is an effective and safe treatment for cutaneous non-melanoma skin cancer, with favorable cosmetic outcomes. Methods: in the present paper, the results of selected studies on photodynamic therapy in the treatment of vulvar intraepithelial neoplasia are reported and discussed. Results: Overall, complete histological response rates ranged between 20% and 67% and symptom response rates ranged between 52% and 89% according to different studies and case series. Conclusions: the real benefit of photodynamic therapy in the setting of vulvar intraepithelial neoplasia lies in its ability to treat multi-focal disease with minimal tissue destruction, preservation of vulvar anatomy and excellent cosmetic outcomes. These properties explain why photodynamic therapy is an attractive option for vulvar intraepithelial neoplasia treatment.